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CICU, Telemetry
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CCU BSN RN has 7 years experience and specializes in CICU, Telemetry.

5 years in Cardiac Surgery Stepdown 1.5 years in Cardiac Intensive Care

CCU BSN RN's Latest Activity


    Removing Foley’s on intubated patients

    As far as I'm concerned it's a great idea in MICU, not as often in CVICU. First 12-18 hours postop- decreased UOP is often a sign that my CI/CO are falling, especially now that we're using less swans (or rather, it's the sign that motivates our providers to take action). Imagine if I had to wait 6-8h to find out instead of getting that data in real time... Then the foley really would be in all week. If my IABP migrates south and occludes the renal arteries...do you want your nurse to find out in an hour or two, then get an interventional doctor to adjust it in another hour or two, or shall I wait until my patient doesn't void for 6-8h, then another hour or two to get the device repositioned, and then I guess we'll keep them in ICU a few more days to 'watch' their AKI, but without accurate UOP... PureWicks are great when they work. If your patient is wiggling/moving about the cabin or doesn't have enough girth/bonus skin on their labia...you can be SOL. I had one last week who couldn't bring herself to use the purewick. psychologically. too afraid she'd wet the bed. Was in tears in pain rolling onto a bedpan, still couldn't pee, had to lie flat for 6h (probably longer after I left, since her groin started bleeding while rolling about to get on the bedpan). I wound up straight cathing her 5 minutes before shift change because she was howling in pain, her doctor hadn't paged me back for 3 hours, and I'd spent the better part of 3 hours trying everything I could think of to extricate urine from her bladder. Men with urinals when they have any device where they aren't supposed to move/sit up/etc.....I've had more than a handful of patients with IABPs that go from CDI to oozy as all get out because my patient was using a urinal. I've literally given blood transfusions because my patient doesn't have a foley. Cardiorenal? CHF? Intubated patient on max vent settings with sub-optimal oxygenation? Yeah, let's throw some lying flat and rolling onto a bedpan into the mix. I'm sure they'll recover real quick after, too. That SpO2 of 53 is totes not real. They've always looked kinda blue. They just come from the Avatar planet. There are exemptions to every rule, I'll be the first to admit. Most nurses DO try to get CVC/ETT/Foley/Restraints out/off as soon as it's safe and appropriate. Most patients in our CVICU are here for 2-4 days before we transfer them out. Very few have marathon, months-long ICU stays. Our management recently started pushing docs on rounds to DC femoral central lines w/in 48h of admission. Their solution? Pull the line, but don't replace with a more appropriate site.
  2. I really like Marino's The ICU Book Also have a copy of hemodynamic monitoring made incredibly easy or incrediblly visual...I find those books have decent sketches/illustrations of concepts for more visual learners If your EKG interpretation/rhythm identification is weak, I'd pick up some kind of resource- I don't have a particular one that I feel is better than the rest, just that this is a pretty important skill and you'll see some weird rhythms. For Pharm I just use whatever resource the hospital is paying for- there's always one. Reviewing your drips (epi, levo, vaso, neo, milrinone, nipride, dopamine/dobutamine, amio/lido, cardizem, nitro) will save you time and errors later

    How long before turning?

    I usually turn 'em within an hour. I basically admit, get report from anesthesia, send labs/ABG, check CT outputs and titrate drips for 20-30 minutes to get a handle on their vitals/how labile they're going to be, then turn. If they've been bleeding and my CTs seem to be patent and are all draining...I'm less likely to turn them right away, mostly because I'm busy with other interventions If their CTs dump when they turn...better out than in. I'd rather quantify their blood loss and be able to give cryo/products if necessary than have the patient tamponade and be doing an emergent resternotomy in their room. I know that's an extreme example, but still... As to the post-op CHG bath and removing OR linen...All the patients are on clean beds/sheets when they come from the OR (except the pools of blood in their neck/hair/OR sheet from line placement), but when moving from the OR table to the bed, they are slid over on the OR sheet, onto the ICU bed with clean linen. You just tip them side to side to remove the sheet from the OR, then things look neat and pretty again, and you know any pool of blood you find from then out is from your own time. CHG bath is our protocol within 6h postop, and I'd rather do it while they're intubated on a fent gtt because I get a lot more pushback once we've extubated and are nonstop c/o pain, dry mouth, and the like.

    Target temperature management initiation.

    Our TTM policy is to initiate within 6h of ROSC- gives you time to get a head CT and make your docs line your patient before they're cold and it's more difficult. Of course we try to cool people asap, but our policy is within 6h. That said, I've seen it started as much as 12h post-arrest. Not sure how much good it's doing at that point, but if the doc is insistent, they are allowed to override the general policy. I'd see if you guys have a TTM or hypothermia policy at your institution

    new staffing laws in mass? CA nurses

    Does anyone have a link to the exact wording/actual bill/law being passed? Our nurse manager couldn't find it, and has hoped we'd forget that we asked for it, because this week we're back to scare tactics. Last night the grapevine said we'd lose our IV Therapy RNs and our designated RRT RNs. Anyone know if they constitute 'ancillary personnel'? I've also been told we'd only be able to work 8h shifts instead of 12h. Again, no one wants us to find or read bills before we vote on them? Or is the hospital just trying to keep our noses out of it and it's super easy to find?

    Did I cause this rapid response?

    It's a bit unclear from your post how much you were in touch with your preceptor from 11a-4p, and/or how much/little time she's spending with you/in your patient rooms. If you're a new nurse with 3 weeks of orientation under your belt, I'm impressed you can locate a nasal cannula and check a blood sugar (I'm exaggerating, of course, but the point is that you require and DESERVE more careful supervision t this point in your training. Others have brought up good points, but I'll reiterate them for fun: 1. Sepsis. If your guy was septic, there's only a roughly 50% chance of him living through it anyway, in case that helps you to not feel so bad when things go south for them. 2. Anyone acting weird gets their sugar checked. Always. 3. Any change in mental status gets your preceptor in the room. Always. Until you're off orientation, then replace 'preceptor' with 'charge RN' or 'trusted experienced RN'. Altered mental is a great thing for them to teach you about: How to tell a CVA from seizure activity from detox from hypoglycemia from acid/base disorder'. 4. My guess is that the overnight nurse assumed his disorientation/AMS was from dementia/sundowning/infection. Let's venture a guess and say he has sleep apnea and is either undiagnosed or noncompliant with his CPAP. Anyway, gets moderately hypercarbic overnight, then severely so for you. 5. Your guy's hypoglycemia was not entirely because he got insulin and didn't eat. That contributed, don't get me wrong. Look into what sepsis and its associated processes do to blood sugar. Not always, but has been known to cause severe hypoglycemia. 6. Your preceptor needs to know when your systolic drops by 40 points. But your guy has HTN and chest pain. You probably gave an AM dose of a beta blocker and/or other antihypertensives. They could easily be the culprits. So could sepsis. You have a preceptor, their job is literally to be asked a million mildly annoying questions and deliver advice and guidance. Take advantage. Lastly, You did way better than I'd expect anyone less than 6 weeks into their first job to do. Sounds like you need to work on communicating with your preceptor and getting a little more supervision. I've seen way more preventable RRTs from way more seasoned nurses. I wouldn't have been anything but proud that you prevented a death if I were the RRT nurse that night .

    Stepdown / IMU

    Our levels of care that I'm aware of : Critical Care: q1h or more frequent interventions. Ratio 1:1 or 1:2 depending on acuity. Stepdown/PCU: Vitals q2h, labs q2h prn, q2h neuros if needed. Can take Cordis/Introducer but not swan ganz catheters, can titrate low-dose neo, nitro, dopa, insulin, cleviprex gtts, can have arterial lines. Everyone absolutely on continuous telemetry and pulse oximetry. Ratio is a strict 1:3 (my point here is there is HUGE variation between hospitals about what type of tubes/lines/drains/drips are taken on units so a simple ratio/what your intermediate care happens to be called isn't necessarily enough for comparison) Telemetry: Vitals q4h or q8h, depending on patient/their orders. All on telemetry, can be on continuous pulse ox if ordered, can have heparin/amio/diltiazem/nitro (for CP only, not titrating to BP), neuros/labs/interventions cannot be required more often than q4h. These floors tend to be more loose about letting patients remove heart monitor or other equipment for walks, bathroom trips, etc. Ratio is ideally 1:4, usually 1:5-6 on day shift and 1:7-8 on nights

    Preparing to Apply to ICU

    If you are itching to get off your current unit and into the ICU after a mere 6-7 months after your first nursing job, it makes you look like a prospective CRNA hopeful. In manager speak: I can hire this person with zero critical care experience, pay through the nose to orient them and in 2 years when they're finally getting good, they're going to abruptly leave to enter an academic program that will flat out refuse to let them work for 3 years while they're in school. Also, and please don't take this the wrong way, you're coming across as pretty over confident. You may not like your current floor or level of care, but there's no way you've learned all you can at your current floor. You're still very task-oriented (which is safe and prudent at your experience level), but your entire argument is essentially that since you've changed a few DSDs and given Amio and insulin gtts, you've learned all you can out of med/surg. You've got to learn how to tell when a patient is going to crump, have to figure out why, what you think they need, and do it all before they get massively unstable and/or code. Just my .02

    Orientation length for ICU

    I had tele/stepdown experience but no critical care experience I got 5 weeks on days and 1 week on nights, roughly. It wound up being a little longer because I got pulled off of orientation multiple days to take a stable patient assignment (patients who after AM rounds were declared telemetry or stepdown patients, and could thus be assigned to me, freeing up an ICU RN to take OR cases) and they did at least give me those days back. I also had to complete ECCO modules on my own time. I would find out what kind of educational preparation/support they provide. ECCO modules weren't perfect but I learned the necessary content, they were definitely a huge time suck. The other 2 major hospitals in my area offer an ICU course, which is a few weeks long, full time, to give you in depth pharm, patho, etc. I'd be wary of entering ICU nursing without something of that nature. Expecting every preceptor to have all of the necessary knowledge and ability to teach is unrealistic. Mind you a floor educator meeting with you to answer questions, or a few hours a week in the research library could probably make up for this; it's just something to consider.
  10. CCU BSN RN

    What is your opinion on calling in "sick"

    If you can't bring your best self (or her close cousin, your almost best self) to work, you have no business being there. Just like I don't want you coming in with the flu and spreading that plague amongst the patients and staff while whining about how crappy you feel all night, I also don't want you walking in the door already dreading the day, or when your mind is clearly elsewhere. Whatever you call it: a sick day, a personal day, a mental health day- TAKE IT IF YOU NEED IT. ALWAYS. Like with any illness, if you take so many that your boss wants to talk about the attendance policy with you, then your illness is impacting your day to day life, and needs professional treatment. Or you need a new job. I think most of us have some kind of a code, or set of guidelines, about times it is absolutely not okay to do this. Some of mine include: 1. I won't take a personal day if I know we have a critical staffing situation already (e.g. floor is full, we are going to be short 4 nurses already and everyone will have unsafe assignments even if we get every float nurse in the hospital.) 2. I won't take a personal day on a holiday or the days before/after holidays 3. I won't take a personal day on an overtime shift that I signed up for recently 4. I'll do my due diligence when taking a personal day in the summer during vacation/wedding season (double check staffing or census) 5. I won't call out if I'm in charge and there is no one else scheduled to work who has been trained as a charge RN, unless I can get a buddy to pick up a shift and cover for me. It's not safe or fair to expect someone to be in charge of a busy CICU with no training
  11. CCU BSN RN

    PVC's, APC's No Treatment?

    Yes, I was speaking of critically ill patients with advanced heart failure. Sorry. My viewpoint is colored by my experience, just like yours. Ibutilide is wonderful in an EP lab, but do you really want a first year medical resident ordering it and overseeing its use overnight in an ICU? I believe only our EP attendings are even allowed to place orders for Ibutilide at our institution, given that it carries a black box warning and 2.5% of those treated will develop Torsades. I wouldn't accept that a relatively young and healthy patient is having prolonged periods of ventricular bigeminy, esp associated with ANY symptoms. If we're talking outpatients and Holter monitors, which I somehow missed the first time around, I'd be looking for causes in their lifestyle. In the hospital setting, we control quite a few variables. In the real world, your patients are smoking cigarettes, using cocaine and other drugs, drinking 15 shots of espresso a day, mixing up their medications, being dehydrated, eating poorly or drinking ETOH causing electrolyte imbalances, etc. There are a TON of variables to consider here before we start talking about one, definite course of treatment. I'm not saying I wouldn't do any further workup of an outpatient, but I'd be putting it in context and discussing lifestyle modifications, especially in a hemodynamically stable patient without significant symptom burden. So, I don't disagree with you, for the subset of patients who require EP involvement, and have an electrical conduction issue of unclear etiology. Ablation, Ibutilide, these are good options there.
  12. CCU BSN RN

    New Grad starting in CVICU SOS

    The best thing you can do to prepare...study hard and pass your last semester of nursing school and your boards. You don't need your soul saved over a job you don't even have yet, and won't even have the necessary qualifications for for probably close to 8 or 9 months. Wasting brain space on PA pressures and IABP management when they won't be covered on your boards doesn't necessarily seem like the best choice. Come back and ask this again once you've graduated, passed your boards, and secured a job offer. And again, best of luck with those things, but don't jump the gun.
  13. CCU BSN RN

    PVC's, APC's No Treatment?

    With advances in medicine, heart failure patients are living longer. They have a lot of ectopy because their hearts suck. I'm not saying you shouldn't get lytes, and EKG, and keep your K>4 and Mg>2, and give your BB if it's indicated. Consider a few things about Lidocaine: can put your patient into VT and literally cause a code while you're pushing it. Also, lidocaine toxicity isn't too fun when they've been on a gtt for too long. Amio instead? Well, that's toxic to literally every organ, blows veins quicker than you can demand a central line, and has a half life of approximately 4 nuclear winters. A few ectopic beats (or even sustained bigeminy) in a mentating patient with otherwise stable vitals? Kind of seems like asking for trouble to aggressively treat that, don't you think?
  14. CCU BSN RN

    Shortages r/t Puerto Rico

    Puerto Rico has manufacturing plants for literally every major Pharma company. These plants don't have power, they all have generators but often not the gas to run them, not to mention that their employees can't physically get to work in the rugged terrain. we're already having critical shortages of several meds, products, and supplies, and given the dismal timeline for restoring the power grid in PR, I have no doubt that we'll be dealing with more shortages every day for awhile. The minibags of D5W and NS were a loss, but I could cope. The shortage of Morphine and Dilaudid have been particularly rough for my patients in the last few weeks, as they're recovering from cardiac surgery and obviously in need of IV pain management. The shortage of IV KCl is presenting serious challenges. So what shortages are hurting you guys the most? How do you think our hospitals are going to compensate for them? Just curious how everyone else is being impacted and what your thoughts are
  15. CCU BSN RN

    Am I too small to be a nurse?

    Funny how we don't demonize overweight nurses who smoke and are in terrible shape (like myself, I can't do more than 2 minutes of chest compressions effectively), but it's societally okay to suggest that you're 'too small'. I've known plenty of nurses who were barely 5 feet tall and scrawny. A lot of them wound up in NICU, where their patients typically weigh 1-7 pounds. Honestly other than needing a stool for CPR and being moderately irked when I can't reach the top shelf of the Pyxis, my limited height has never posed any issue that I'm aware of.
  16. CCU BSN RN


    I've floated within other telemetry floors (our float cluster, if you will) several times in the 5ish years I was a telemetry nurse. I've cried at least 50% of those shifts. I hate floating, I don't even know where to find a flush or how to access the Pyxis, and why the heck are all my CHF patients seemingly about to flash? And what is the RT's number on these floors? How does their intern/resident/PA/NP structure work? Who is covering them? Do they have an NP for stupid crap but you call the hospitalist for everything else? And what's the code to the med room again? No one has time to answer these questions, that's why you were floated here in the first place, because they're absurdly short-staffed. So, if an experienced nurse gets unbelievably overwhelmed floating to floors very similar to her own...can we all extrapolate from that how awful it could potentially be for someone to float to a care area completely foreign to them? Because I can, and it sounds like a terrible idea.