The Power of Mentoring.

Abstract

Carol Ann Rauen, RN-BC, MS, CCRN, PCCN, CEN, and Sara Knippa, RN, MS, CNS, CCRN, PCCN, ACCNS-AG, are the column coeditors. Carol is an independent clinical nurse specialist and education consultant in St. Augustine, Florida, and Sara is a clinical nurse specialist/educator in the cardiac intensive care unit at University of Colorado Hospital, Aurora, Colorado. They welcome feedback and practice questions from potential contributors at rauen.carol104@gmail.com. Carol wrote the CSC questions, and Sara wrote the introduction.RAUENKNIPPACritical Care Education Council, UnityPoint Health-Methodist Hospital: Hayley Brewer, RN, BSN, CCRN-CSC, Brittany Carothers, RN, BSN, CCRN, Heather Franklin, RN, BSN, CCRN, Jennifer Harvey, RN, BSN, CCRN-CSC-CMC, Penny Maher, RN, BSN, CCRN, Mellisa Mangers, RN, BSN, CCRN-CSC-CMC, Nicole Mathewson, RN, BSN, CCRN, and Kelly Strunk, RN, BSN, CCRN-CSC-CMC. Cheryl Herrmann, RN, APN, MS, CCRN, CCNS-CSC-CMC, Critical Care Clinical Nurse Specialist, is the facilitator. The group wrote CCRN review questions 1 through 4.Back row, left to right: Kelly Strunk, Penny Maher, Heather Franklin, Cheryl Herrmann Front row, left to right: Mellisa Mangers, Hayley Brewer, Nicole Mathewson, Brittany CarothersKelly Thompson-Brazill, RN, DNP, ACNP-BC, CCRN-CSC, is an assistant professor, Georgetown University School of Nursing and Health Studies, Washington, DC. Kelly wrote question 5 in the adult CCRN review.THOMPSON-BRAZILThis column is an excellent example of the power of mentoring. A mentor can be someone you approach because they have the knowledge or experience to help you meet a goal. Alternatively, a mentor might be someone who sees potential in you that you may not see in yourself and then provides opportunity and coaching to enable you to accomplish something that you never thought you could do. As I join Carol as coeditor of this column, I am thankful to be a recipient of her mentorship. Mentoring is also alive and well at Unity Point-Methodist Hospital in Peoria, Illinois: 4 of the questions in this column were written by members of the critical care education council under the mentorship of the hospital’s clinical nurse specialist. Let’s engage the power of mentoring to increase certification success. Who will you mentor or be mentored by today?The findings are consistent with increased intra-abdominal pressures. A distended abdomen can cause hypotension, decreased SpO2, and decreased urine output related to the increased abdominal pressure on the vena cava, diaphragm, and kidneys. A fluid bolus (A) may make the patient’s status more unstable because a positive fluid balance can increase abdominal pressures. A renal consultation (C) may be indicated, but only after assessment reveals no increase in intra-abdominal pressure. Antibiotics (D) may be indicated if a source of infection is present or suspected. The abdominal distension needs urgent assessment and treatment to prevent further complications.Early mobility (A), delirium assessment (B), and early extubation (C) are part of the ABCDEF bundle to reduce delirium and long-term complications in ICU patients. The ICU diary is specifically designed to help patients fill in memory gaps about their ICU experience and diminish post-ICU syndrome and posttraumatic stress syndrome.The toxic effects of cocaine cause hypertension and supraventricular arrhythmias by stimulating the central nervous system and peripheral α-agonists. A benzodiazepine should be the initial agent for all cocaine-induced hypertension and supraventricular arrhythmias to decrease the sympathetic output and thus help stabilize vital signs and rhythm. Fluid administration (A) is not indicated unless the patient has signs of hypovolemia. Use of β-blockers (B) is contraindicated because they block only β-receptors, leaving α-receptors unopposed, leading to more vasoconstriction. Emergent cardioversion (D) is used for rate-related cardiovascular compromise with signs and symptoms such as hypotension, acutely altered mental status, indications of shock, angina, or acute heart failure.Ventilator settings for obese patients should be set on the basis of the patient’s ideal body weight or predicted body weight to prevent pressure damage to the alveolar sacs and barotrauma. In most patients, initial tidal volume should be set to approximately 8 mL/kg of ideal or predicted body weight. A tidal volume of 6 mL/kg of predicted body weight (C) is used in morbidly obese patients with acute respiratory distress syndrome or acute lung injury. (A) and (B) are based on the patient’s actual weight.Patients with end-stage renal disease are at risk for hyperkalemia as a result of diminished renal function and the presence of metabolic acidosis. Hyponatremia (A) is associated with seizure, respiratory distress, and muscle weakness. Hypomagnesemia (B) is associated with hyperreflexia, tetany, seizures, and ventricular arrhythmias. Hypercalcemia (C) is associated with somnolence, nausea, vomiting, flat inverted T waves, and ST-segment prolongation.Argatroban is a synthetic arginine derivative and is used as a parenteral anticoagulant for patients who cannot receive heparin. Argatroban is cleared by the liver, and the dose is reduced 25% to 50% if the patient has hepatic insufficiency. Compatibility should be reviewed before argatroban is infused with other medications, but the infusion does not require a dedicated central catheter (B). Argatroban is not renally metabolized or cleared (C). An activated partial thromboplastin time of 50 to 90 seconds and an activated clotting time of 300 to 450 seconds are the therapeutic targets; PT is not an appropriate test to monitor argatroban (D).Pain is a normal response to chest and leg surgery. A patient in pain is less likely to take deep breaths and ambulate as much as desired. Determining why a patient does not want to take pain medication would be the first action. Allowing the patient to refuse (A) pain medication is appropriate, but the reason for refusal should be addressed first. Encouraging the patient to take the medication (B) without inquiring the reason for the refusal is paternalistic. A more detailed pain assessment would need to be done before a decision that administering an anti-inflammatory agent (D) would be the best medication in this situation.The decision between hemodialysis and CRRT is based primarily on the stability of the patient’s hemodynamic status. The hemodynamic status of a patient with MAP less than 60 mm Hg receiving a norepinephrine infusion is probably not stable enough for hemodialysis because of the rapid fluid shifts and removal. A patient who is successfully being weaned from mechanical ventilation (A) and requires pacing (D) or both should be able to tolerate either hemodialysis or CRRT. Renal failure (C) is the indication for dialysis.Something as simple as dehydration or as complicated as cardiac tamponade could cause a pulsus paradoxus waveform on the arterial catheter. Whatever is increasing the circulating volume will help offset the pressure outside the heart that is causing the pressure to decrease between inspiration and expiration. Increasing the dose of milrinone (A) should increase the cardiac contractility but not change the pulsus paradoxus. Increased thoracic pressure can cause pulsus paradoxus (C), but the goal is always to keep thoracic pressure as low as possible while achieving the optimal oxygenation. Decreasing the dose of norepinephrine most likely would increase the variance in pressure (D).As the patient warms up after cardiac surgery, vasodilatation will occur and bleeding may increase. The decrease in afterload caused the blood pressure to decrease, and the heart rate increased to compensate. An increase in glomerular filtration rate has increased the urinary output. A chest tube drainage of 185 mL in the first hour is not high on a warming patient, so a surgical hemorrhage is not likely (A); if it were, the urinary output would be low. Waking up (B) typically produces increases in both heart rate and blood pressure. Low levels of magnesium are characterized by low blood pressure and low levels of calcium (C) by dysrhythmias.AACN Certcorp publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN Certification exam handbook. The contributor of each question written for this column has listed the source used in developing each item.