Celebrating Certification

Every year at the American Association of Critical-Care Nurses annual National Teaching Institute (NTI), I look forward to connecting with nurses from around the country. Often nurses add ribbons to their name tags to share a bit about themselves. Some designate "first time NTI," while others are fun or silly. My favorites are those that highlight certifications and the number of years the nurse has held a certification. At the last NTI, I saw a "CCRN 30 years" ribbon worn proudly by a nurse (their other ribbon read "Powered by coffee!"). Certification is a status worth celebrating because it highlights nurses' commitment, mastery, and accountability to our profession and to improved patient outcomes.1 When I attended my first NTI in 2007, I had just passed the CCRN examination the previous week. I was so excited to be in a room full of other nurses who valued the professional mark of excellence that a certification offers. There was special recognition for nurses who held a certification for 10, 15, 20, 25, and even 30 or more years. I truly felt I was among giants in critical care nursing. Then the emcee turned the tables and asked everyone to stand and be recognized, then sit down in order from most to fewest years of certification to honor the most recently certified nurses. I was the last one standing! The ovation and support I felt among those who had held the certification for decades bolstered my enthusiasm for certification and for the nursing profession. In this scenario, the patient experiences uncompensated respiratory acidemia (pH 45 mm Hg, and bicarbonate in the reference range 22-26 mEq/L). Increasing the respiratory rate will improve minute ventilation and lower the Paco2 to normalize the pH. The patient is receiving an appropriate tidal volume of 6 mL/kg of ideal body weight (target range is 6-8 mL/kg). Decreasing the tidal volume (B) will decrease minute ventilation, increasing Paco2 and worsening acidemia. Because the patient is receiving an Fio2 of less than 0.50 and has a Pao2 of greater than 60 mm Hg, increasing the Fio2 (C) is not indicated and may harm the patient by inducing oxygen toxicity (hyperoxia). A PEEP of 10 cm H2O (D) in a patient without any signs of impending barotrauma, such as a plateau pressure of greater than 30 cm H2O or a driving pressure (plateau pressure minus PEEP) of greater than 15 cm H2O, is appropriate. Driving pressure represents the ratio of tidal volume and respiratory system compliance. Research indicates that maintaining driving pressures below 13 cm H2O on the first day of mechanical ventilation is associated with reduced mortality.Tricyclic antidepressant overdose leads to sodium channel blockade, which causes symptoms such as altered mental status, cardiac arrhythmias, and seizures. The priority intervention is to administer an intravenous bolus of 1 to 2 g/kg of the antidote, sodium bicarbonate. Although levetiracetam (A) is used to treat generalized tonic-clonic seizures, it will not reverse the tricyclic antidepressant toxicity. Hemodialysis (C) is used to treat several drug toxicities, but it is not indicated for tricyclic antidepressant toxicity. Glucagon (D) can be given intravenously to treat β-blocker overdose.Posing an open-ended question helps the nurse understand the family's knowledge, enabling personalized education based on their specific needs. Although other responses could be appropriate according to the family's understanding, the nurse first needs to understand the family's distress to avoid responses that do not address the family's needs or concerns (A, B, C).The patient in this scenario has findings consistent with syndrome of inappropriate antidiuretic hormone secretion (SIADH). This syndrome results from excessive release of antidiuretic hormone, also known as vasopressin. The causes of SIADH include cancer, brain trauma or stroke, respiratory disorders (chronic obstructive pulmonary disease, asthma), and certain medications. High antidiuretic hormone levels act on kidney V2 receptors and reduce urine production, cause water retention, and increase intravascular volume. Symptom severity depends on onset speed and hyponatremia degree. Elevated intra-vascular volume leads to lower serum sodium level and serum osmolality, resulting in altered mental status and, in severe cases, cerebral edema and coma. Symptoms of fluid volume overload in patients with SIADH include dyspnea, weight gain, increased central venous pressure, and lung crackles. Laboratory findings include serum sodium level of less than 130 mEq/L, urine sodium level of greater than 20 mEq/L, urine specific gravity of greater than 1.020, and urine osmolality of greater than 500 mOsm/L. Severe, symptomatic hyponatremia is treated with 100 to 150 mL of 3% hypertonic saline over 10 to 20 minutes, repeated up to 3 times, for a goal serum sodium increase of 4 to 6 mEq/L over 1 to 2 hours. Caution should be taken to avoid rapidly increasing sodium levels, particularly in patients with chronic hyponatremia, to prevent osmotic demyelination syndrome. Although furosemide administration (A) will decrease intravascular volume, it also causes renal sodium loss and may worsen hyponatremia. Pericardiocentesis (B) is not indicated in this case because the dyspnea and jugular venous distention are due to SIADH, not a pericardial effusion. Mild SIADH in a patient with a serum sodium level of greater than 125 mEq/L is treated with fluid restriction of 800 to 1000 mL per day, but given the severity of the hyponatremia, fluid restriction (C) is not the preferred intervention in this case.The patient in this scenario has effort rupture of the esophagus, also known as Boerhaave syndrome. Patients with esophageal rupture are at high risk for sepsis due to the gastrointestinal flora leaking into the mediastinum. They require isotonic crystalloid fluid resuscitation and broad-spectrum antibiotics to cover aerobic and anerobic gram-negative bacteria and yeast from the gastrointestinal tract. Administering antiemetics (B) is not necessary because the vomiting resulted from trapped food. A smooth-muscle relaxant (B) may help relieve an esophageal spasm but is not indicated for esophageal rupture. Bedside insertion of a nasoenteric feeding tube (C) is contraindicated because it may worsen the esophageal injury. Chest tube insertion (D) is not indicated for pneumomediastinum alone. A chest tube would be indicated to drain the pleural space if the esophageal rupture led to a pleural effusion.Evidence-based guidelines recommend sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with symptomatic heart failure and a reduced ejection fraction regardless of whether the patient has a diagnosis of type 2 diabetes mellitus. Empagliflozin, an SGLT2 inhibitor, helps reduce systolic blood pressure through osmotic diuresis and natriuresis. SGLT2 inhibitors do not increase heart rate or blood pressure (A). Osmotic diuresis with SGLT2 inhibitors may lead to dehydration (C). When administering an SGLT2 inhibitor with a diuretic, consider lowering the diuretic dose to minimize this risk. SGLT2 inhibitors do not affect glucose uptake by the heart muscle cells; they reduce the reabsorption of glucose and sodium in the kidneys (D).Patients with severe sleep apnea are at risk for postoperative respiratory depression because of the decrease in central ventilatory drive that occurs with sedation and narcotic administration. Continuous positive airway pressure devices maintain airway patency, reducing the risk of respiratory complications. End-tidal carbon dioxide monitoring provides early detection of changes in carbon dioxide levels, enabling quicker identification of respiratory depression compared with pulse oximetry. Although pain management is important (A), opioid medications can increase the risk for respiratory depression. Arterial blood gas analysis (B) is beneficial when a patient has a change in clinical condition, but it is not routinely needed. If respiratory depression and hypoventilation occurred, the arterial blood gas would likely show respiratory acidosis caused by hypercarbia. Assessing vital signs is important (C), but continuous end-tidal carbon dioxide measurement would alert the nurse to early respiratory depression that develops between intermittent vital sign assessments.The most common surgical complication in older adult patients is postoperative delirium. The first step to identify delirium is to perform an assessment with a valid and reliable instrument, such as the Confusion Assessment Method algorithm, which is the most commonly used postoperative delirium assessment tool. Opioids (B) treat pain but may worsen delirium. The National Institutes of Health Stroke Scale (C) specifically assesses stroke, but this patient does not have signs or symptoms of acute stroke. Benzodiazepines (D) may worsen delirium and should be avoided in older adults.Patients with a diagnosis of type 1 diabetes mellitus rely on exogenous insulin for daily blood glucose management. When a patient is eating poorly, the patient has an increased risk for hypoglycemia (blood glucose level 2 minutes) or a seizure that does not respond to treatment for a reversible cause such as hypoglycemia.It is important for multiple members of the nursing team to have a voice and partnership in the development of a mentor program and to ground the mentor program in evidence-based practice. True collaboration allows clinical nurses to be a part of the decision-making process and ensures that the team's perspective is valued, supporting a healthy work environment. In addition, involving nurses in an organized committee using an evidence-based practice model helps promote a culture of clinical inquiry, elevating the professional practice of bedside nurses. Asking a leader to take charge (A) does not promote true collaboration or an environment of clinical inquiry. Although reaching out to other hospitals (C) is helpful and appropriate, creating a committee to assess the evidence on mentoring is more effective in ensuring that best practices are implemented. Relying on a single person's work (D) does not promote true collaboration and may not be as effective as a committee or team approach.AACN Certification Corporation publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification examination handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.