MGMR

We also use filters at the end of each line, using Alaris pumps. The infusion pump lines don't have them, so we add a small one on at the end, but the syringe pump tubing automatically has the filter in the line. The only thing we don't filter that I can think of is albumin, and lipids have their own special filter.

I work in peds cardiac ICU, so the environment is obviously different than with adults. But we have open visitation 24/7. Technically only two family members are allowed into the room at a given time, no children under 7(?) are allowed without showing their vaccination records, and they're allowed food and drink (even though nurses can drink water at the computers lol). People usually come in for short bursts of time and then leave anyway, so it usually isn't a problem - especially for night shift. Since it's a pediatric floor, we have security at the front allowing people in and keeping tabs on how many family members are at the bedside. If family members are not cooperating with the bedside or charge nurse, we can ask security to escort them out. Although this has never been needed in the years I've worked there.

I completely agree. I think that one of the main downfalls of the CNS profession was that it tried to be too "flexible" as a general APRN able to perform in many roles, including provider. I think the CNS degree in itself is a flexible APRN role, and didn't need to muddy the waters by creating confusing with the NP degree.

I have this same problem in terms of choosing between the two degrees, except I still do want to perform patient care at the bedside. Without a doubt, there are many more job opportunities for Nurse Practitioners than for Clinical Nurse Specialists. Even in areas that utilize CNS's, there is usually only one per unit at most, or one per specialty service. For example, there might be one neonatal CNS for the entire NICU, but they may also employ a handful of NNP's. Also in areas of the country or hospitals that don't use CNS's, they typically will fill those roles with NP's (or anyone with a MSN) because most people feel that the NP degree is a catch all: provider, educator, etc. It's a shame because I believe in getting the education for the job you want to perform in, and getting your NP teaches you how to be a provider, but it might not prepare you well for roles in education, leadership, etc. But if the jobs don't exist, people are going to just get their NP because they don't want to waste their time and money.

If you're interested in CLABSI/CAUTI prevention and best practice implementation, CNS would be a great choice for your APRN degree. You can get your Adult/Geriatric, Pediatric, or Neonatal CNS degree, but you don't sub-specialize further than that at the academic level. I would say specialty practice beyond your degree is determined by the job you take after graduation and the training they provide you in that specialty, and also any knowledge and expertise you bring from your RN practice previously. If you're interested in invasive procedures, but little to no patient care, you could also become an NP working in IR. My friend does this. She was a SICU nurse while getting her NP, got a job in IR after. Her day consists of placing CVLs/PICCs, chest tubes, etc. Very little patient contact beyond the line or tube placement as they go back to the unit immediately after.

You also have to think about the type of lifestyle and environment you want to work in. Do you want to do ICU or acute care? Inpatient or outpatient? With your NNP, you'll almost always be working in hospitals in some type of ICU or step down environment. It may require weekends, holidays or nights. Some people get their NP to escape that schedule. PNP gives you more flexibility depending on your state and local hospital's use of PNPs. You could work primary care, outpatient specialty clinics, and some even allow them in NICUs and PICUs depending on the person's RN experience - although that is a fading trend. I would also look to see how your local hospitals use PNPs.

I hope that the CNS role is making a comeback because it is probably the route I will take for my advanced degree in the future. It seems like in NYC (where I'm located) it is getting more popular, but slowly. If you are set on not going the NP route, I think that a CNS degree would be a good fit as it fills many roles - not only CNS positions (obviously), but also positions such as unit educators, service line providers such as wound care clinical nurse specialists, etc. But maybe I'm too biased/optimistic.

Sorry to hear PICU isn't working out, but better to try and find out than to never know! I think you should talk to your ANM even if she isn't approachable, or maybe your ANM along with your NM together. At my institution, they usually help the nurse find a place in another unit if it isn't working out since the hospital spent money in training you. The sooner the better in my opinion, so they aren't wasting time and money on your orientation.

I would say your PCU deals with more acuity than many units that are considered intensive care. I'd say to put "yes." You can elaborate more about your experience during the actual face to face interview.

My hospital will reimburse your exam fee, and then you get a $2000/year bonus put into your normal paycheck in December.

It's pretty common, at least for my unit, to get a relatively inexperienced nurse for your night shift preceptor. Unfortunately there's not enough of a balance of experienced nurses on night shift to give all the incoming nurses on orientation, so they typically settle for the most experienced among the inexperienced. But I definitely echo what NotReady4PrimeTime and SICUMurseCCRN said. It's important that the educators know because you need to ensure you're getting the best orientation as possible. It's also important because if nothing is said, they'll start giving that nurse more and more orientees since, as far as they know, it went so well with you. If you phrase it as a safety issue to your manager and educator, I think it will go over best.

You can see the actual amount each medline tubing is on the package before you open it. The ones we use are about 0.8cc, plus the very small amounts in the back check valves on either end (each being about 0.05cc maybe). So, if the medication is 1cc or less, we push that entire amount into the line and run the flush to deliver the medication over the correct amount of time. The flush is 1cc to ensure the entire line is flushed through.

At this moment, I don't think there actually is a certification exam for a CNS in Women's Health. I think that the Association of Women's Health Obstetric & Neonatal Nurses have proposed that curriculum for a hopeful certification exam, but have not been successful in approving it officially.

While I agree about the huge difference in turning an intubated preemie and adult, that still doesn't explain the rest of the OP's situation: not being able to start a peripheral IV, titrate Dopamine, or check a blood sugar on your own is extremely restrictive. Especially for an ICU nurse.

I've only worked peds cardiac ICU, but from talking to many of the nurses who have come to my unit from adult ICU, it appears that there is huge difference in nursing autonomy in pediatric versus adult ICUs. I think the NICU has the least autonomy out of the three units at my hospital (NICU, PICU, PCICU), and that PCICU has the most. And that's not saying much because I feel like I don't have much autonomy most days. I titrate anti-hypertensive drips like Nitroprusside and Nicardipine to stated BP goals, and some sedation like Precedex as needed. But we typically need to ask to go up on Fentanyl drips (even though we bolus as much as we need), and we never touch Epi drips without an order. Obviously we don't titrate Milrinone, and we don't use Dopa or Dobutamine on my unit. The adult ICU nurses told me that they could titrate pretty much any drip, and give fluid up to a certain amount before calling the provider. We would never be allowed to give fluid boluses on our own, even if their pressures are 40s/30s with a CVP of 2. I think it's ridiculous you can't start an IV on your own, and don't get me started on giving intermittent IV meds sterilely or NICU's lack of sedation/pain management. Even our NICU isn't THAT bad. Yours sounds particularly stifling. I think that if you love the specialty, stay and get the experience you need and go elsewhere. I have many friends who have come to my unit from a NICU background where the nurses re-taped tubes on their own without asking the medical team, went to deliveries and put in their own PICC lines. So it definitely can be done. I also believe that, sometimes, if you earn the respect over time, you gain more and more independence to do things as long as they're correct things to do. For example, even if it isn't your unit culture to check a glucose, I think it would not make your resident explode in anger if you did it with sound clinical judgment. Something like, "Hey, I noticed that the blood sugars have been trending down, so I checked and their sugar is 20. Do you want to give a D10 bolus?" Or something along those lines. It shows you have an idea of what's going on, and they can't be mad really because, well, you're right.

Our pediatric floor is 4:1, very very rarely 5:1 and mostly at night if ever that high. PCTs do vitals, I/Os, cares, and some help with labs. Our PICU and PCICU has a max of 2:1.

In a clinical setting (unlike in academia), calling yourself Dr. ___ is misleading to the general public - or anyone for that matter. Unless you are a physician (MD/DO), it isn't appropriate to address yourself as Doctor because it is assumed that you are a physician. There are RNs working at the bedside with DNPs, should they introduce themselves as Doctor ____ to their patient, even though they are working as a bedside nurse? There are OTs and PTs with doctorates, what about them?

I saw that too MurseJJ. I actually am interested in going per diem in their new cardiac NICU - seems right up my alley and a great learning experience. They said they only wanted full time staff at this time unfortunately. MSK and Morgan Stanley seem to be the only hospitals I've noticed that actively hire CNSs. Maybe if I ever get over there I could talk to the CNSs in the PICU/NICU/PCICU and really see their role in action. I did have the opportunity of reaching out and talking with our new neonatal CNS in the NICU. She was very excited about her role and reiterated the joy she felt working in a true advanced practice nursing role. She said she took the same courses as the NNPs until about 3/4th of the program and split off for a few courses and obviously clinicals. That sounds perfect for me. I plan on asking to shadow her sometime to get a better "in the life" picture of what she does. I do also see her at the bedside when sick patients arrive to the unit. ECMO is becoming bigger in our pediatric units, and the NICU nurses have been the most weary of it. She's been teaching hour long classes to the ICU nurses in pediatrics about her experiences with ECMO as a bedside NICU nurse. That's something I definitely could see myself doing in the future if I went the CNS route as well.

Really interesting/good discussion. I've been having a hard time deciding what I want to do for the future as well regarding the CNS vs NP routes. I work in a pediatric cardiac ICU, and I honestly really love being a bedside nurse in this environment - granted I work in a great unit and hospital. I have a good amount of autonomy and am always in the discussion of the medical decisions being made for my patients. My ideal job for the future would be exactly what i'm doing now, with advanced knowledge and slightly more autonomy - I would love the ability to start PICCs, arterial lines, and even intubate. I know flight/transport nurses in some NICUs for example do these things, so I don't need to be an NP to do this. Honestly, the NP role is not appealing to me outside of the procedural advantages like intubation/CVL insertions. I like managing my patient, their lines, titrating sedation at the bedside, etc. I work very closely with NPs on my unit and have a very good understanding of their role. Have nothing but respect for them and their knowledge/role, but it doesn't seem like the direction I want to go. The CNS role was very appealing to me because, like everyone here mentioned, it seems like an advanced practice "nursing" role. The problem for me is that it doesn't seem as clinically based in practice or in its education, like the NP education is. I'm also in the NYC metro area, and there are no CNSs at my hospital. The NICU just hired one recently, and no one seems to know what she does or what she is. And (my worst nightmare) she seems to be completely removed from the bedside - she's off the unit in meetings and committees constantly. I do see their importance, but I also think it's essential to remain current with bedside practice as well. It seems like I can't find a role that fits my ideals outside of what I'm currently doing at the bedside. The CNS role seems great for education (I love to teach), remaining in nursing practice, and advancing my education. The NP seems good because I can learn to intubate, place invasive lines, etc. What's worse is that every nurse I talk to seems completely shocked as to why I'm interested in possibly pursuing the CNS route, which is also discouraging. Sorry for rambling and not really saying much - just trying to add to the discussion.

Age does not determine acuity here, and I think that if you were given the teenager, that was their most stable, appropriate patient. It may make you uncomfortable, but you're always going to be uncomfortable floating. That isn't your unit, not your specialty, you don't know where the supplies are, you don't know the medical team or the nurses. In my opinion, their job isn't to make you comfortable, it's to keep their patients safe - and that was probably their safest assignment to give you. The example of giving pediatric nurse a 23-weeker is misleading because here, gestational age CAN determine acuity. And something like the management of a 23-weeker in the NICU would never even be mentioned in nursing school whereas the general principles of a teenager are covered. If you are uncomfortable, always ask the nurse you get report from the vital sign ranges that they want and what the big things are to watch out for. I like to ask something along the lines of, "What could make this patient sick today/tonight, and how will I know?" You should also know who the charge RN is, because he or she is there to help with any questions or concerns you may have. You're NOT expected to be an expert, but you're expected to keep that patient safe. And as an ICU, regardless of patient population, you should be able to pick up on big changes in patient status.

Monitors are not perfect, so sometimes the patient's rhythm will register as a PVC or Vtach, etc. to the monitor when that's not the case. Always look back to make sure and assess the patient of course, but most of the time it's obvious. I'm not sure if all monitors have this, but the ones I use have an option under "arrhythmia" that you can click called "re-learn arrhythmia" or "re-learn rhythm." You can click that so the monitor will register the patient's rhythm as NSR and not continue to call normal beats as PVCs or Vtach etc.

Hm, that's a real shame. And definitely not the role I envision myself doing in the future. The neonatal CNS in our hospital's NICU does a lot more patient care at the bedside. She helps insert lines in babies who are difficult sticks, helps to change aspects of the unit that are not streamlined and are frustrating for nurses, and does a lot of education for the staff. For example, ECMO is becoming much bigger at our hospital - previously all patients on ECMO, neonatal or not, would be housed in the PICU or PCICU. But she has created protocols and education sessions so that the NICU staff can house their own patients requiring ECMO. These are just a few things that I could see myself doing as a CNS in the PCICU. The CNS roles that you're describing sound like my own personal nightmare though, which makes me a bit worried.

Hey all, Just wondering what your experiences have been with clinical nurse specialists working in your PICU/PCICU/NICU. We currently do not use any in my PCICU, but the NICU just hired a neonatal CNS and the job seems very interesting - possibly something I'd like to pursue. What have your experiences been like? What were their job responsibilities? Did they still take patient assignments from time to time? How much hands on patient care did they perform (inserting lines, dressing changes, etc.)?

I just had a topic I need clarification on. I work in a peds cardiac ICU where we use "carriers" of a patient's maintenance fluid at rates of mostly 1cc/hr (sometimes 3-5cc/hr for non-neonates or for RA lines). I'm confused as to the purpose of the carriers. First, I thought that the carriers were to "carry" the drips to the patient faster. But if you program a pump to infuse a drip at a certain rate, it will only push the med through the line at that rate, and changing the rate of the carrier fluid would only change the rate of the fluid at the very end of the line near the patient (through the ultrasite white cap, which is an extremely small amount of fluid). My second answer when researching my question was that the rate of all the fluids together must be at least 1cc/hr to keep the small lines patent, and since neonates' weights are so tiny the fluid infusing over an hour can be very small. Is this thinking correct about carrier fluids used to keep lines patent mainly? It's hard to find an answer to this specifically for pediatric/neonates because the answers I found came mostly from adult ICU nurses who use adult tubing, with y-sites etc. With our patients, we mostly use small 1cc med tubing with filters that each attach to its own port, and not the adult tubing with y-sites etc. Thanks for the help!

Thanks for the info! I know I know, I think I'll just have to suck it up and do the PNP program and take the "across the lifespan" stuff as just broadening my knowledge further. I think it's just hard for me because I'm not fully committed on actually performing in the NP role, more so on advancing my education. I know I don't want to be a CRNA, and going through an NP program opens up so many roles in the future for me like education, NP, clinical nurse resources, management, etc. Good thing I have plenty of time to figure this all out.