Codes/End of life

Question 1

Cardiac arrest survivability

Answer 1

Only 15% of cardiac arrest patients survive til discharge
After 85 yo, only 6% of patients survive til discharge
Of those that survive, 25% of them will need to go to a ltc facility, and 50% will be discharged home

Question 2

How long can it take for the code team to arrive at the bedside?

Answer 2

3-5 minutes

Question 3

When should you call a code blue?

Answer 3

Immediately if any patient becomes unresponsive, apneic, or pulseless (check carotid pulse)

Question 4

What should you do after initiating code blue?

Answer 4

Yell out for help and begin initiating CPR. Responding code team members will announce their roles upon entering the room. A staff member that is not participating in the code should call the patient’s PCP.

Question 5

Effective chest compressions during CPR

Answer 5

Chest compressions should be performed at a rate of 100-120/min (“Staying Alive”)
Push hard, at least 2 inches in depth
Allow for full chest recoil
If the client is not on a hard surface utilize a backboard for CPR
When alone do not wait for a backboard to be placed. It can be placed when further help is available
Switch compressors approximately every 2 minutes, sooner if fatigued
Chest compressions cause air to be expelled from the chest and oxygen to be drawn into the chest due to elastic recoil
Ventilation requirements are lower during cardiac arrest that normal
Oxygen supplied by passive delivery should be sufficient for several minutes after the onset of cardiac arrest in a client with a patent upper airway
Research supports the delay of ventilation until additional help arrives

Question 6

Effective airway management during CPR

Answer 6

2 ventilations for every 30 compressions
Use a bag-mask device (ambu bag) with the flow at 15 L/min
Each ventilation should cause the chest to visibly rise
On oropharyngeal can be placed to ensure airway patency
Bag-mask ventilation is most effective when performed by two trained providers
Prepare to assist with intubation

Question 7

How strong is monophasic defibrillation?

Answer 7

Monophasic begins at 360 J

Question 8

How strong is biphasic defibrillation?

Answer 8

Biphasic begins at 120-200 J depending on the manufacture.

Question 9

Proper use of hard paddles during defibrillation

Answer 9

When using hard paddles you must apply a conducting medium to prevent burns

Question 10

Proper use of soft patches during defibrillation

Answer 10

Patches must have full contact with the client’s bare skin

Avoid pacemaker sites or transdermal patches

Question 11

During and after defibrillator administers a shock

Answer 11

Announce the shock and make sure everyone is clear
Immediately after the shock resume chest compressions
-Don’t delay to recheck the rhythm or pulse
-Resumption of a normal rhythm won’t initially produce enough cardiac output for adequate perfusion
Continue CPR for five cycles or about 2 minutes
Recheck should occur with change of compressors
Check for return of spontaneous circulation (ROSC) by checking the carotid pulse

Question 12

What are shockable rhythms?

Answer 12

Ventricular tachycardia and Ventricular fibrillation

Question 13

What are nonshockable rhythms?

Answer 13

Pulseless electrical activity and asystole

Question 14

Ventricular tachycardia (V-tach)

Answer 14

Life threatening rhythm arising from an excitable ventricular focus in the tissue distal to the bifurcation of the bundle of His
It is initiated by a premature ventricular contraction (PVC)
Heart rate is greater than 100 beats per minute
P waves usually not recognizable, PR interval not discernable, QT interval not measurable

Question 15

Ventricular fibrillation (V-fib)

Answer 15

Rapid, disorganized depolarization of the ventricles
No organized electrical impulses, no coordinated atrial or ventricular contraction or palpable pulse
Multiple ventricular sites initiate electrical impulses
P wave, PR intervals, QRS complexes, and QT intervals are all absent

Question 16

Pulseless electrical activity

Answer 16

Heart muscle loses its ability to contract even though cardiac electrical activity is present
Represents an organized rhythm outside of V-tach or V-fib. Usually bradycardia or heart block
Client has no detectable pulse or blood pressure
Initiate CPR per ACLS guidelines
Clinical outcome is usually poor unless a reversible cause is identified and treated

Question 17

Asystole

Answer 17

Complete termination of all cardiac electrical activity
Client has no detectable pulse or blood pressure
Initiate CPR per ACLS guidelines

Question 18

Reversible causes of code blue

Answer 18

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary

Question 19

Medications during CPR

Answer 19

Medications are secondary to high-quality CPR and rapid defibrillation
Epinephrine IV/IO dose
-1 mg every 3 - 5 minutes
-First dose after second shock
Amiodarone IV/IO dose
-First dose 300 mg bolus
-Second dose 150 mg bolus
-First dose after third shock

Question 20

What does the primary nurse do during a code?

Answer 20

Assesses client, calls code, provides chest compressions, provides leader with client information

Question 21

What does the secondary nurse do during a code?

Answer 21

Provides chest compressions, alternates with primary nurse

Question 22

What does the airway manager do during a code?

Answer 22

Provides basic airway management including bag-mask ventilation

Question 23

What does the medication nurse do during a code?

Answer 23

Prepares and administers IV medications

Question 24

What does the defibrillation nurse do during a code?

Answer 24

Retrieves crash cart, applies defibrillation patches, delivers shocks

Question 25

What does the recorder do during a code?

Answer 25

Documents medications and code activity on the code blue document

Question 26

What does the team leader do during a code?

Answer 26

Follows the ACLS algorithm, ensures scene control and appropriate care

Question 27

Communication during a code

Answer 27

Effective communication is critical for teams working in crisis situations
Communication ensures that everybody knows what is going on, what needs to be done, and what is already done
A message is only communicated if it is both sent and received
Utilize closed loop communication
-An order is given by the leader, leader confirms it was heard, and the receiver informs the leader when the task is complete
All communication should be clear and calm

Question 28

Post code care

Answer 28

Prepare to transfer the client for further treatment
-Client may go to cath lab, surgery, interventional radiology, ICU
-Needs: ambu bag, medication box, portable defibrillator, cardiac monitor, full oxygen tank
Client should be on continuous cardiac monitoring
Additional IV access may be needed
Client may require vasopressor support such as epinephrine, norepinephrine, dopamine
To preserve neurological function may begin therapeutic hypothermia
Contact with family

Question 29

Cardioversion

Answer 29

Indicated for the treatment of tachyarrhythmias
-atrial tachycardia, rapid atrial fibrillation, atrial flutter, junctional tachycardia
Performed at the bedside or in a procedure area
Set the defibrillator to synchronous mode
-This means the defibrillator will only discharge on the down slope of the R wave or with the S wave of the QRS
NPO for at least 6 hours because the client will be sedated but not usually intubated
Pad placement is usually anterior/posterior
Initial voltage depends of defibrillator type and client condition

Question 30

Pacing

Answer 30

Temporary transcutaneous pacing
-Delivers an electrical stimulus directly through the chest wall
-Large surface adhesive electrodes similar to defibrillator patches are placed on the anterior and posterior chest
Programmed rate is set
Output is increased until there is capture
Palpate a pulse in a major vessel to verify capture
Client may require sedation during sustained transcutaneous pacing

Question 31

What is palliative care?

Answer 31

Comprehensive care focused on alleviating suffering and promoting the quality of a patient’s remaining life when living with a chronic, life-threatening, or terminal illness, allows patients and families to guide treatment based on identified goals for care at the end of life

Question 32

Ethical dilemmas when switching from curative care to comfort care

Answer 32

Caregivers’ own values, culture, religion, education, and life experiences
Advanced treatment options
Family structure

Question 33

Communication during palliative care

Answer 33

Monitoring in the ICU provides families with a massive amount of information that can be confusing
-Some information could signal a positive outcome while other information does not
Family members may need information repeated several times in different formats
Families need constant reassurance through actions and words

Question 34

Who is on the palliative care team?

Answer 34

Physicians, nurse practitioners, nurses, social workers, and chaplains that specialize in palliative care

Question 35

What is an advanced directive?

Answer 35

Instructions individuals can give, in advance of a health problem to guide caregivers in the event the individual is no longer able to speak for themselves
Can be written or oral
Health care providers are obligated to follow an advanced directive or the patient’s wishes regarding care and treatment
It can be a appointment of an agent or surrogate decision maker
Or it could be specific instructions about care and treatment
It Can be cancelled or changed at any time

Question 36

Nurses responsibilities related to advanced directives

Answer 36

• Query all clients regarding the existence of an advanced directive
• Document its existence in the medical record
• Provide information about advanced directives if the client does not have one
• Clients should be encouraged to have a copy readily available for emergency situations
• When family members disagree or the client is not able to advocate for themselves, an ethics committee should be consulted

Question 37

Managing pain at end of life

Answer 37

Management of pain at the end of life is the client’s right and the caregiver’s duty
Failing to administer a drug to relieve symptoms because it may hasten death is viewed as causing the client harm and increased suffering
Pain should be assessed in a holistic manner
-Look for nonverbals such as blood pressure, heart rate, breathing pattern, facial grimaces

Question 38

Simple interventions to promote comfort at end of life

Answer 38

Combine oral and parenteral medications
Environment plays a role in comfort (calm, quiet, playing soft music)
Avoid using restraints
Use alternative or complementary therapies (i.e. spirituality)

Question 39

Managing dyspnea at end of life

Answer 39

Dyspnea can be extremely frightening and distressing

• Elevate the head of the bed
• Use a fan to circulate air
• Use of supplemental oxygen through a nasal cannula
• Use of opioids

Question 40

Medications at end of life

Answer 40

Opioids include morphine, hydromorphone, and fentanyl
Meperidine is not recommended because it can cause tremors and seizures
There is no set dosage for opioids at the end of life. Clearly document need for increased dose
Benzodiazepines are given to reduce anxiety, sedative effect, and can prevent seizures
Xanax, valium, ativan, versed
Neuroleptics, such as Haldol, can be used for delirium but care must be taken to distinguish between anxiety and delirium

Question 41

Terminal weaning from mechanical ventilation

Answer 41

Terminal weaning is the gradual discontinuation of mechanical ventilation

• Advantages: no upper airway obstruction, no acute air hunger, promotes comfort and reduced family anxiety
• Disadvantages: may prolong death, family may perceive it as an attempt to successfully separate from the ventilator

Question 42

Terminal extubation from mechanical ventilation

Answer 42

Advantages: does not prolong the dying process, allows the client to be free from an artificial tube
Disadvantage: client distress

Question 43

Before terminal extubation/weaning

Answer 43

Clients that are weaned from mechanical ventilation and/or extubated should receive analgesics and sedatives prior to the process
Neuromuscular blocking agents should be stopped in order to restore neuromuscular function if possible
Calm, quiet environment with family present
Remove equipment and turn off alarms

Question 44

Communication during end of life

Answer 44

Support for cultural and spiritual beliefs
Support for family through the grief process
-Be present, active listening, emotional support, encouraging verbalization, identifying support systems, identifying the need for assistance or referrals

Question 45

What is hospice?

Answer 45

Provision of care at the end of life aimed at comfort instead of cure
Care is directed toward relieving physical, psychosocial, and spiritual suffering for the client and facilitating the grieving and coping strategies of family and caregivers
Generally utilized for clients who have a prognosis of 6 months or less

Question 46

Interdisciplinary hospice team

Answer 46

Physicians, nurses, social workers, dieticians, spiritual counselors, aides, volunteers
Regular team meetings

Question 47

Hospice care

Answer 47

Provided within the home, hospice facility, hospital
Along with client care it also provides respite care
Bereavement services for a minimum of 1-year after the client’s death
Care revolves around symptom relief to improve quality of life

Question 48

Post mortem care

Answer 48

Remove soiled linens, dressing, equipment, supplies, etc.
Wash the body
Pay special attention to head and hands
Handle with care as the skin will be fragile
Remove tubes and lines and cover site with dressing and paper tape
Ensure clean, comfortable environment for family viewing
After family viewing place body in body bag (shroud)
Chux under bottom and head
Toe tag with client information on toe
Leave ID band on
Leave dentures in place
Send body to morgue
May be put on a special morgue cart
Security may retrieve or you may have to escort

Question 49

What types of deaths are coroner case’s?

Answer 49

Any death within 24 hours of admission to a hospital
Deaths while under anesthesia or undergoing a procedure
Deaths while in the custody of a law enforcement officer
Deaths related to disease which might constitute a threat to the health of the general public
Any death occurring under suspicious or unknown circumstances

Question 50

Post mortem care for coroner cases

Answer 50

Post-mortem care is different because you do not remove tubes or lines. Cap them and leave in place (i.e. IVs, foley, endotracheal tube, chest tube, drains, etc.)
You can remove foley bags, IV bags and tubing, drain collection apparatus, etc.
When in doubt, treat it like a coroner’s case