Navigating the 7 Cs of Certified Practice

Carol Rauen, rn, ms, ccns, ccrn, pccn, cen, rn-bc, the department editor, is an independent clinical nurse specialist in The Outer Banks of North Carolina. Carol contributed CCRN practice questions 3, 4, and 5.RAUENRichard Arbour, rn, msn, ccrn, cnrn, ccns, is an in-patient liver transplant coordinator at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Richard contributed CCRN practice questions 1 and 2.ARBOURCarol Jacobson, rn, mn, is the owner of Quality Education Services in Seattle, Washington, and a partner in Cardiovascular Nursing Education Associates. Carol contributed CMC practice questions 1 and 2.JACOBSONKaren 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. Karen contributed CMC question 5.MARZLINCynthia 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. Cynthia contributed CMC questions 3 and 4.WEBNERThe acute care setting is a turbulent environment. Certified nursing practice is more than just “passing an exam.” Certified practice is the application of knowledge and skills that serve as aids to navigation in treacherous waters. This treasure chest of skills includes collaboration, consultation, communication, confirmation, and critical thinking. Add continuity and compassion to create the 7 Cs of certified practice. These navigational aids are the guiding beacons that enable nurses to assist patients and their families with smooth sailing through the turbulent acute care environment.Extension with internal rotation is decerebrate posturing and might be an indication of increasing intracranial pressure (ICP) and brainstem herniation. The priority action would be to decrease all demands on the brain and lower the ICP as quickly as possible. Medication administration (B) and an ICP-measuring device (D) might be done, but initiating measures to lower the ICP is the priority.The most important priority is maintenance of airway/lung ventilation in any clinical scenario. This is particularly true in this setting, where the potentially unstable patient may be transported off the unit for diagnostic study. All of the options are important during transport of a patient with a brain injury, but it is not always possible to travel with portable suction (A) or to maintain the HOB elevation (D); for example, patients being transported for computed tomography (CT) or magnetic resonance imaging (MRI) have to lie flat. Although having continuous cardiac monitoring is important, having a patent IV is essential.Evidence-based practice dictates that diabetic ketoacidosis (DKA) is treated with normal saline, insulin bolus and continuous infusion, and possibly sodium bicarbonate. A sliding-scale insulin order is not appropriate for the management of DKA (C), so the prescriber of the order should be consulted to determine the need for a continuous infusion. The high potassium level in patients with DKA is from the acidosis, which has caused potassium to leave the cell (D). Correcting the acidosis by stopping the ketone production and also possibly giving sodium bicarbonate will cause the potassium to go back into the cell. Removing the potassium with Kayexalate will cause hypokalemia once the acidosis has been corrected.The Institute of Medicine defines EBP as the integration of best research, clinical expertise, and patients’ values in making decisions about the care of individual patients. Levels of evidence are the ratings attached to a recommendation on the basis of the strength of the research used to make the recommendation.The postoperative gastric bypass patient has risk factors for all 4 of these complications. The symptoms of pain, fever, and firm tender abdomen are classic for peritonitis. Pulmonary emboli (A) typically have more pulmonary symptoms, postoperative pain (B) would not explain the fever and firm abdomen, and gallstones (D) typically cause nausea and do not develop immediately after surgery.Pacemaker spikes that are not followed by paced QRS complexes indicate loss of capture. Pacemaker stimulus strength (output) is measured in milliamps (mA), and increasing the output may solve the capture problem. Turning the pacemaker off (A) is likely to result in symptomatic bradycardia or asystole in a pacemaker-dependent patient. Increasing the sensitivity (B) would be appropriate for loss of sensing, not loss of capture. Increasing the pacing rate (D) will not solve a capture problem.This patient has pulmonary and systemic congestion (crackles, orthopnea, distended neck veins) but no signs of hypoperfusion (BP is good, skin warm). Preload reduction with diuretics (IV furosemide) and a venous dilator (nitroglycerine infusion) is the therapy of choice for acute decompensated heart failure with pulmonary and/or systemic congestion. Dobutamine and dopamine are not indicated because both are positive inotropic agents, which are not needed in this patient because the BP is good and there are no signs of hypoperfusion. Nitroprusside is both an arterial and a venous dilator and might be used in a hypertensive patient for preload and afterload reduction. Hydrochlorothiazide is an appropriate diuretic for treating hypertension and can be added to furosemide in treating heart failure, but furosemide is the preferred first-line diuretic for acute decompensated heart failure.A pseudoaneurysm is an unstable pulsatile pouch attached to the arterial wall and occurs when the arteriotomy site fails to seal. With this, there is a to-and-fro movement of blood in the pouch. Physical assessment findings include groin pain, a pulsatile mass at the site, and an audible bruit heard during systole. Retroperitoneal bleeding (A) is bleeding into the space deep within the abdominal cavity. Signs and symptoms include pain in the flank, leg, back, or lower abdomen with signs of hypovolemia. Arteriovenous fistula (B) occurs when there is communication between the femoral artery and femoral vein resulting in turbulent blood flow between the two. A key assessment finding is a to-and-fro bruit that is audible in both systole and diastole. Track oozing (C) occurs most often with closure devices and is capillary bleeding due to inadequate compression. Other than oozing at the arteriotomy site, no further signs or symptoms associated with track oozing are present.It is critical that patients remain on dual antiplatelet therapy as prescribed (ASA indefinitely; clopidogrel, prasugrel, or ticagrelor for up to a year) to prevent rethrombosis following stent insertion. There is no restriction on driving (A) following stent insertion. Redness and exudate from the insertion site (B) are signs of infection and should be reported to the health care provider. Anginal pain (D) is significant as it could indicate restenosis at the site of the stent or stenosis in a different artery. A return of angina should be reported to the physician.In right ventricular infarction, right ventricular contractility is reduced, which causes pressure in the right ventricle to increase (high CVP) and decreases forward flow through the lungs and into the left ventricle, reducing left ventricular filling pressure (low PAOP). SVR increases as peripheral vasoconstriction attempts to compensate for reduced left ventricular stroke volume in an effort to maintain BP.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.