“To Know”: A Great Reason for Certification

Carol Rauen,rn, ms, ccns, ccrn, pccn, cen, the department editor, is an independent clinical nurse specialist in The Outer Banks of North Carolina. Carol welcomes feedback from readers and practice questions from potential contributors at rauen.carol104@gmail.com.Pam Shumate,rn, dnp, ccrn-cmc, is a clinical instructor at the University of Maryland School of Nursing, Shady Grove Campus. She contributed the Introduction and the CCRN/CCRN-E questions 1 through 4.Carol Jacobson,rn, mn, is the owner of Quality Education Services in Seattle, Washington, and a partner in Cardiovascular Nursing Education Associates. She contributed Cardiac Medicine Certification question 1.Karen Marzlin,rn, dnp, ccns, ccrn-cmc, chfn, is an acute care clinical nurse specialist at Aultman Hospital in Canton, Ohio, and a partner in Cardiovascular Nursing Education Associates. She contributed Cardiac Medicine Certification questions 2 and 4.Cynthia Webner,rn, dnp, ccns, ccrn-cmc, chfn, is an acute care clinical nurse specialist at Aultman Hospital in Canton, Ohio, and a partner in Cardiovascular Nursing Education Associates. She contributed CCRN/CCRN-E question 5 and Cardiac Medicine Certification question 3.Ancient Greeks knew that storms and natural disasters occurred because the gods of Olympus were angry. Before Christopher Columbus, European sailors were sure that the world was flat. During the Middle Ages, healers believed that drilling a hole into a person’s skull would cure headaches, epilepsy, and mental illness. Although each example was later proven to be false, people at the time knew these facts were true. True knowledge is a complicated mixture of experience acquired through scientific observation, the meaning or context assigned to what has been observed, and the ability to apply the intelligence gathered through observation to unobserved or unobservable phenomena.1Certification is a great way for nurses to demonstrate that they “know” to themselves, to their patients, and to their employers. Through certification, nurses validate that they possess specialty knowledge and clinical decision making beyond what is necessary for basic licensure.2 Improvements in 30-day inpatient mortality rates and failure-to-rescue rates have been found in hospitals with higher proportions of baccalaureate nurses and baccalaureate nurses with specialty certification.3 Higher perceptions of overall workplace empower-ment have been positively associated with certification.4 Moreover, because certification must be renewed periodically, it helps to address the Institute of Medicine’s recommendation that ongoing education and periodic reexamination be required of health care providers.5Test plan topic: Cardiovascular, 20% of the CCRN questionsTest plan topic: Renal, 6% of the CCRN questionsTest plan topic: Cardiovascular, 20% of the CCRN questionsTest plan topic: Cardiovascular, 20% of the CCRN questionsTest plan topic: Professional, ethical and caring practices, 20% of the CCRN questionsSv̄o2 measures the amount of hemoglobin saturated with oxygen in the venous blood returning to the pulmonary artery. It is useful as a global indicator of the balance between tissue oxygen supply and tissue oxygen demands or consumption. A normal Sv̄o2 is 60% to 80%. Hypothermia (A), anesthesia, chemical paralysis, and sedation lower the body’s oxygen demands and may result in an elevated Sv̄o2. Fever, pain, seizures, and shivering (B) increase metabolic demands and may lower Sv̄o2. Cardiogenic shock (C) and anemia decrease oxygen delivery to tissues and may lower Sv̄o2. Weaning the patient off of mechanical ventilation (D) would affect the patient’s carbon dioxide level, which is not a direct contributor to Sv̄o2.Hypokalemia may be refractory to potassium replacement when magnesium levels are low. Magnesium is necessary for potassium to move into the cell. Magnesium plays a role in more than 300 enzymatic reactions in the body, especially those involved in adenosine triphosphate (ATP) production and utilization such as sodium-potassium ATPase. Magnesium helps to regulate the activity of the renal outer medullary potassium (ROMK) channels in the distal convoluted tubules and collecting ducts of the glomerulus. When magnesium levels are low, potassium secretion in urine may remain elevated.The normal etco2 is 35 to 40 mm Hg. etco2 values less than 10 mm Hg in intubated patients indicate a cardiac output that is too low to achieve ROSC. A common cause of this is poor quality chest compressions (compressor fatigue, hand placement, or compression depth). Abrupt increases in etco2 during CPR may indicate ROSC.The American Heart Association (AHA) recommends systematic postresuscitation care to gain optimal survival-to-discharge results. Care priorities include determining the most likely reason for the cardiac arrest, correcting treatable causes, optimizing cardiopulmonary function, and maintaining tissue perfusion. (A) The AHA recommends therapeutic hypothermia on any patient who is not following commands after ROSC. A patient who is already following commands immediately after ROSC is presumed to have relatively intact neurological function. Therapeutic hypothermia is the only intervention that has been shown by research to improve neurological recovery after CPR. (B) If an acute myocardial infarction (MI) is present or highly suspected, coronary revascularization procedures should be attempted. Therapeutic hypothermia can safely be performed in conjunction with PCI procedures. (C) Blood pressure should be maintained above 90 mm Hg by using fluids such as normal saline or lactated Ringer solution and, if necessary, vasopressor infusions. If therapeutic hypothermia will be instituted, cool fluid may be used. (D) Oxygenation and ventilation support, including mechanical ventilation, if indicated, should be initiated immediately. Avoid excessive ventilation. If waveform capnography is available, maintain an etco2 of 35 to 40 mm Hg. Maintain a minimum oxygenation level of 94%.Children who are properly prepared to visit relatives in the ICU show less negative behavior and fewer emotional changes than children who are not allowed to visit. Infrastructure including staff training should be in place to help nurses partner with patients and families for safe visiting experiences. Critical care nurses who are used to adult populations may benefit from the expertise of nurses and other providers familiar with the needs of children of all ages. By forming a committee to explore visitation that includes unit staff and pediatric experts, the nurse is acting as an advocate for patients and a consumer of evidence-based practice.Mitral insufficiency (or regurgitation) can occur acutely as a complication of MI when a papillary muscle is dysfunctional. A new-onset systolic murmur, especially one that is present with pain but not when pain free, can indicate ischemia affecting the papillary muscles responsible for holding the mitral valve closed during systole. Aortic stenosis (A) can cause a systolic murmur, but is heard best at the second right intercostal space. Both aortic regurgitation (C) and mitral stenosis (B) are diastolic murmurs. Stenosis does not occur acutely; it takes years for a stenotic valve to cause symptoms. Regurgitation can occur acutely, especially mitral regurgitation with papillary muscle ischemia or rupture, or aortic regurgitation due to an aortic arch aneurysm that dissects backward to affect the aortic valve.When assessing ST-segment alarms, it is important to have the patient supine because changes in body position can trigger alarms. The precordial leads evaluate the cardiac electrical vector from the center of the heart to the chest wall. When the patient is not supine, the change in heart position relative to the chest electrode could be depicted as an abnormality. Turn the patient on his back, then reassess the ST segments. ST-segment deviation can indicate silent ischemia, so alarms must be carefully addressed even if the patient is not experiencing symptoms. Although a 12-lead ECG should be used when ST segments are changing, it is more appropriate to first assess the ST segments with the patient on his back. Then, if changes persist, a 12-lead ECG is appropriate. Normal evolutionary changes would be normalization of the ST segment and the development of T-wave inversion. ST-segment reelevation is not normal after STEMI.Approximately one-third of inferior wall MIs are complicated by a coexisting right ventricular (RV) infarction. The most common signs of RV involvement are hypotension, clear lung fields, and jugular vein distension (JVD). Patients with RV infarction are often hypotensive because the RV cannot adequately fill the left ventricle (LV), resulting in a decreased LV stroke volume and cardiac output. Fluids are necessary in RV infarction to optimize RV filling in order to adequately fill the LV. Dobutamine (A) or dopamine (C) might also be appropriate to increase RV contractility if volume alone fails to improve hypotension. Norepinephrine (B) is a vasoconstrictor and should not be used until volume status is optimal.Leads II, III, and aVF face the inferior wall of the heart. ST-segment elevation is the ECG sign of acute myocardial injury. The right coronary artery supplies blood to the inferior wall and the sinoatrial (SA) and atrioventricular (AV) nodes in most people; therefore, bradycardia and AV block are common complications of inferior wall MI. Anterior wall (C) MI presents as ST-segment elevation in leads V1 through V4. Lateral wall (B) MI presents with ST-segment elevation in leads I, aVL, V5, and V6. Posterior wall MI presents as ST-segment depression (D) (reciprocal change) in leads V1 through V3 and usually accompanies inferior or lateral wall infarction.All 3 of these medication groups have proven benefits in the reduction of future cardiac events. Antiplatelet agents help prevent thrombus formation, statins reduce low-density lipoprotein (LDL) cholesterol, and β-blockers reduce the incidence of reinfarction and decrease mortality after acute MI. Nitrates and calcium channel blockers can be used for treatment of angina and hypertension but do not have proven benefits in the reduction of mortality and morbidity after an acute MI.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.