Getting ready to start a cardiac clinical, or just landed a job on a cardiac unit? Let’s go through my top tips to succeed in your new unit!
Top Tips For the New Cardiac Nurse
Stepping into the cardiac unit can feel nerve-wracking and exciting all at the same time. What should you expect, and how do you even prepare for this new job?
In this guide, I’ll share the most important things you’ll need to know as a new cardiac nurse. These are things that will make all the difference in your job. The cardiac unit is different than the med-surg floor.
1. Know Your Cardiac Patient’s Potassium Level
If you have a patient with a cardiac issue, it’s crucial to know their latest potassium level.
Neuro docs always want to know the sodium level; cardiac docs want to know the potassium level.
The reason potassium is so important for cardiac patients is because when it is out of normal range, it can prevent the proper electrical signals in the heart from firing, which tell it to beat properly. This can lead to arrhythmias.
Many cardiac patients will get potassium replacement to aggressively ensure the patient is well within normal limits. Your normal potassium level is 3.5-5.0, but if your patient who just had cardiac surgery resulted in a 3.5 K on their am BMP or CMP, chances are that the provider will still want to replace to prevent them from getting below normal.
Your unit may have a potassium replacement protocol, which enables the bedside nurse to order the potassium replacement based upon their lab and a few other factors. These cut down significantly on provider calls early in the shift for this pretty straight forward order.
2. Know The Different Kinds of Cardiac Providers
Physicians specializing in the care of cardiac patients don’t just come from cardiologists. There are quite a few cardiac sub-specialties… and if you’re working at a large hospital, you’re probably going to be dealing with many of them.
It can be a foot-in-mouth situation to page the wrong kind of provider for your patient (IE calling the cardioVASCULAR surgeon instead of the cardioTHORACIC surgeon).
Here’s a brief non-inclusive list of the different kinds of cardiac sub-specialties you may encounter:
- Cardiovascular surgeon
- Cardiothoracic surgeon
- Interventional cardiologist
- Adult congenital cardiologist
- Preventive cardiologist
- Heart failure and transplant cardiologist
If you’re on orientation and need to call a physician, but not sure who – always check with your preceptor first. The last thing you want to do is interrupt a cardiac surgery only to find out they’re not the right provider to ask!
3. Know Your Hemodynamic Parameters
Whether you’re in a cardiac ICU, stepdown, or floor, it’s really important to know what your parameters are for vital signs – especially for blood pressure and heart rate. And not only do you need to know them, but you must also make sure your alarm parameters are set appropriately as well. Don’t assume the previous nurse had the bedside monitor (or telemetry monitor on cardiac floors) set correctly.
You can blow freshly placed grafts with a BP that’s too high. Conversely, you can risk ischemia or other complications if their pressure isn’t high enough. If we’ve got someone in afib with an HR over 100, we’re significantly increasing our risk for strokes.
Also, if you’ve got nursing assistants or patient care technicians who take care of getting the vitals for you – make sure you’re looking at the vitals. Don’t just assume the assistant intuitively knows what blood pressures are too high and what is not. This is especially true if your patient has a lower BP limit than most.
For example, let’s say your patient as an order to keep the systolic BP less than 160 on your patient who had a fem-pop 19 hours ago. You’ve got a PRN order to give hydralazine for an SBP greater than 160, and another order requiring you to call if you’ve had to give it more than twice in a shift. Clearly, this is important.
Let’s say your CNA is responsible for getting vitals and toileting 15 people in the span of 1.5 hours. That’s a lot of patients, all who have their own parameters. They may be going so fast to get things done that they don’t remember to notify you of the 165/88 BP … then, on the next round of vitals 4 hours later, the BP is 171/92 …. And finally, during their last sweep of BP’s, they’re at 177/93. They’ve gone all day with an untreated high BP and a fresh graft. Maybe that CNA assumes the nurses always look at their vitals. Or, maybe it’s a float CNA who doesn’t realize the culture on your unit is to notify nurses of BPs over a certain threshold. Regardless of the reasons (justifiable or not) or who actually took the vitals, it’s ultimately your responsibility as the nurse to monitor their vitals and treat them promptly.
(If that example seemed very specific – it’s because it happened to me!)
Similarly, in the ICU if you’ve got monitors that automatically take the vitals for you and you just have to verify them – make sure they’re accurate before finalizing them to be in the chart.
Providers will look at these vitals and make clinical decisions based on them. They work under the assumption that the nurse would not enter them into the medical chart if they were not accurate. So, if your arterial line isn’t leveled correctly, or if your BP cuff is way too big or small, or if it’s no longer snuggly attached to the patient’s arm – they have no clue. Please, don’t mindlessly verify. Do your rounds, check your equipment, and make sure those vitals truly are accurate before signing off on them.
Don’t be that nurse who highlights 6 hours of vitals and verifies them without actually looking at them first… or that nurse who never looks at the cuff or art line except for that first assessment at the beginning of the shift… remember, providers are looking at these to make decisions about medications and treatment plans. We’ve got to ensure they’re accurate and we’re promptly treating anything out of range.
4. EKGs – What You Really Need to Know As a New Cardiac Nurse
Alright, this is a HUGE topic for cardiac nurses. Many feel they’ve got to take a comprehensive EKG review course before starting on the unit, have the information memorized, and then they’re competent to care for these patients.
However, the reality is that a lot of the information from these highly technical EKG courses are tough to retain and recall at the moment when your patient has flipped into a new rhythm and you’ve got to respond appropriately very quickly.
A lot of these EKG courses go very far in depth on non-urgent or emergent situations, which is great to know – but as the newbie, it’s my opinion to focus on those moments in which you’ve got to drop everything and urgently deal with the EKG change. Yes, the mechanisms behind a 2nd degree AV block and WPW are both really important to know – but I really want you to get afib with RVR, SVT, symptomatic bradycardia, vtach, vfib, PEA, and asystole and what you do for all of them down first.
We tend to assume that it’s our job as the bedside nurse to notice when things have changed, analyze the 6-second EKG strip with impeccable accuracy, call the physician, and spout off our findings and our recommended treatment plan on day one. Truly, that is the mark of a highly experienced nurse – not the newbie who just got through their first EKG course post-nursing school.
At this point, you should be able to:
- Notice when their EKG changed
- Assess the patient
- Notify promptly; answering the provider’s follow-up questions succinctly
- Implement any new orders they’ve given
- Monitor appropriately
You also must be able to know when we’ve got a life-threatening situation and start BLS immediately. As you get more comfortable in the role and see more situations, then you dive deeper into the ins and outs of those stable (but still actionable) rhythm changes so you can chat with the provider about the best course of action with confidence.
I wrote a blog post of the highlights that I really recommend being 100% sound on as a cardiac nurse, and you can find that here.
While we can quickly figure out how to respond in codes, we also need to figure out how to act quickly in urgent situations… you know, the patient isn’t coding, but they’ve got some acute changes that need to be addressed ASAP.
One of the most common situations that you’ll see on a cardiac unit is atrial fibrillation with a rapid ventricular response. I’ve got a free download that walks you through the process of dealing with it at the moment as the bedside nurse that you can sign up for here.
5. Notice Subtle Cardiac Changes
So, what about those times when the patient’s decline is not so obvious? While we all want to be prepared to respond by heroically the coding patient (and that does happen from time to time), but what’s much more common and every day are much more subtle signs of a patient’s decline that we are just as responsible for noticing and addressing.
Here are some signs your cardiac patient is de-compensating:
- Increasing ectopy (also called ectopic beats, basically premature beats or a disturbance in the electrical conduction of the heart like increased PVCs or PACs)
- Increasing need for oxygen
- Decreasing urinary output
- Decreasing bowel sounds and abdominal distention
- Increased work of breathing
Paying attention to these changes and not only intervening, but asking why this is happening is an important aspect of your development as a successful and safe cardiac nurse.
Getting ready to have patients on telemetry, but need a little refresher first?
Telemetry Basics Brush-Up from FreshRN is a self-paced mini-course where we walk through the basics of cardiac electrical conductivity and how that is reflected on your telemetry strips, discuss rhythms based on the level of urgency you should have, go over insider tips and tricks, and more.
New Cardiac Nurse Tips: Final Thoughts
I hope these tips helped you out. When you learn the lingo and terms and know what to check for on your rounds, your time as a new cardiac nurse will be so much better and easier.