Top Tips for Cardiac Nurses: An Interview with Nurse Nacole

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Who You’ll Hear

Kati Kleber, MSN RN – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, and speaker.

Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.

Nacole Riccaboni, MBA MSN APRN AGACNP-BC FNP-BC CCRN-CMC is a critical care advanced registered nurse practitioner (ARNP) in Orlando, Florida. Check out her website here, or follow her on Instagram here.

Top Tips for Cardiac Nurses: An Interview with Nurse Nacole

If you are a new grad that is not taking accountability for his or her learning and mistakes, it is a huge red flag. You will mess up and be clunky and inefficient; this is normal. Please lean into learning about your mistakes and not pretending they never happened in the first place. If you want to learn more about something, you’ll have to do that at home.

Often, there isn’t enough time to do that while providing care simultaneously. At work, you’ll be focused on getting things done. At home, you can reflect on why and look up information to solidify your knowledge and understanding.

Clinical focal points

• First, focus on understanding the anatomy of the heart
  • Our course Cardiac Confidence simplifies this
• Second, focus on learning ECG interpretation
  • Our blog post on ECGs touches on it
  • Our mini course Telemetry Basics Brush-Up discusses basics
  • Our comprehensive ECG Rhythm Master dives deep
• Next, ensure you focus on the patient – not just the numbers on the monitor
  • Patients don’t always present like the textbook

Cardiac history and procedures

• Blood pressure and heart rate parameters can be different depending on the different surgeries, procedures, or history
  • Know the parameters and look at your nursing orders before calling and treating
• Be aware of important cardiac-related aspects of their medical history, including procedures
  • MI (with or without stents), CABG, AVR, MVR, cardiomyopathy, afib, heart failure, etc.

Most recent potassium level

• Cardiothoracic and vascular surgeons, and cardiologists care a lot about this lab (much like neuro docs really care about sodium levels)
• Be diligent and proactive to supplement potassium
  • Your body doesn’t hang on to potassium if your magnesium is low
  • If you have to replace both, replace magnesium first then do your potassium
  • Even if the lab is within normal range, they may proactively order supplementation to keep it there rather than reacting when it is low
• Magnesium doesn’t come on a BMP; you’ll have to add that on if the physician wants it or you’re concerned about ectopy.

Pay close attention to their hemodynamics

• In the neuro world, when things start to change, it’s evident in the neuro assessment. In the cardiac world, often you’ll see changes in vital signs first.
• Make sure your alarms are set appropriately for your unique patient and their needs
• Know your patient’s unique trends because even though they may be in technically “in range” it may be abnormally high or low for that unique person
• Some people will not be concerned by alarms that stop or don’t continue; it is essential to see what caused the alarm
  • Was it a run of PVC’s?  How many runs have they been having?
  • Was it a pause? How long was the pause?
• Imperative the arterial line is accurate, the blood pressure cuff is sized appropriately, and that other vital signs are accurately taken

EKG Dance Video

EKGs can be tough to understand. Below is the video mentioned in the episode that all of us remember fondly from our early nursing days that helped solidify key aspects of cardiac conductivity.

Know your orders   

If something changed, it’s not your job to interpret the EKG perfectly in an instant. Know when something changes and get a 12-lead if you’ve got an order to do so. Many times there’s a standing order to get a 12-lead with telemetry changes. It can be a helpful time savings if you get this EKG first and then notify the physician, rather than calling to notify about a change you’re uncertain about that they’ll just want to get an EKG to evaluate anyway.

When to intervene

Sudden changes are concerning, as well as when a patient has a change on telemetry and it also has symptoms associated. Even if vitals are okay, the symptoms are imperative to take seriously.

For example, if your patient is suddenly short of breath and using accessory muscles to breath, and working really hard – that matters, even if their Pa02 is 98%. (It won’t be for long!)

Pay attention to persistent issues, like runs of PVCs. These are often indicative of another issue (like an electrolyte imbalance, or needing a medication) and if it is left unnoticed/not dealt with, it will only get worse and become harder and harder to address.

If you’re not sure if it’s a pulmonary cause or a cardiac issue, obtaining an ABG will allow you to differentiate.

More resources for cardiac nurses

• Afib with RVR: Nursing Responsibilities – FREE email course
• Telemetry Basics Brush-Up – mini course
• ECG Rhythm Master – self-paced online course that dives deep into ECG (7.0 contact hours)
• Cardiac Confidence: A Crash Course for New Cardiac Nurses – a comprehensive course (11.0 contact hours)
• 5 Lead ECG Interpretation Tips for Nurses – blog post
• Cardiac Assessment: What Nurses Need to Know – blog post