How to recognize the failing patient

Question 1

When you know something is just “not right” with a patient, but he/she does not meet code criteria (cessation of pule and/or breathing), What do you do?

A.) Use a wait or see approach?
B.) Call the attending physician?
C.) Perform a more through assessment and monitor closely?
D.) Call the rapid response team?

Answer 1

D

• Often deciding to call the physician first can be dangerously time consuming with interventions being delayed for hours while playing phone tag and wait for new orders.
• So a rapid response team should be called to intervene when a patient’s condition starts to deteriorate and before a cardiac arrest occurs.
• When RRT is called, ICU nurses and res. therapists arrive and provide emergency care if needed.
• Crisis is usually resolved within 30 mins and pt is transferred to ICU, or monitored bed.

Question 2

Name some subtle signs and symptoms made by the Institute for Healthcare Improvement (IHI) of instability that may occur hours before a cardiac arrest?

Answer 2

• Mean arterial pressure < 70 or > 130 mm Hg
• HR < 45 or > 125 beats/min. normal 60-100
• Res. rate < 10 or > 30 (accessory muscle use, adventitious breath sounds, weak cough, threatened airway). Normal 12-20
• Uncontrolled hypertension
• Complaints of chest pain not controlled by nitroglycerine/cardiac arrhythmia
• Change in mental status (confusion, drowsiness, prolonged unexplained agitation)

Question 3

In addition to basic criteria, guidelines list other changes that should raise a red flag and include what signs and symptoms?

Answer 3

• Hemorrhage
• New, frequent, intractable seizures
• Sudden loss of mvmt or weakness of face, arm of leg
• Diaphoresis (sweating)
• Dyspnea (SOB)
• Change in color of central or peripheral skin (pale, dusky, gray or blue)
• Acute onset of pain or sudden increase in quality of pain
• Oliguria (little or no urine output)

Question 4

At St. Joseph’s/ Candler, what codes is called for the Emergency Response team and full cardiopulmonary arrest?

Answer 4

• ERT——> Code CAT and dial 7777

* Full CP arrest ——> Code 99 and dial 7777

Question 5

At Memorial what number do you dial and what are the codes for Ped. ERT, Maternal ERT, Adult ERT, and full CP arrest?

Answer 5

Dial 8888

• Pediatric emergency response team (code PET)
• Maternal child emergency response team (code NOEL)
• Adult emergency response team (code MET)
• Full cardiopulmonary arrests (code BLUE)

Question 6

What are the RN’s responsibilities while waiting for code teams?

Answer 6

• Stay with patient
• Assess vital signs/ blood glucose
• Insure reliable IV access
• Enlist the aid of colleague
• Get the crash cart to the bedside
• Set up O2 and suction
• Position the pt on the back board in case cardiopulmonary resuscitation is needed

Question 7

The emergency responders consist of a multidisciplinary team who includes:

Answer 7

1. ) Airway mgmt (MD or CRNA- ventilation, O2 admin, intubation if needed)
2. ) Airway assistance (RN or RT-assists with ventilation and suction)
3. ) Bedside assessor (ICU or bedside RN)-assesses for IV access, admisters meds, applies defibrillator pads)
4. ) Crash cart manager (ICU RN- prepares meds and records code events)
5. ) Treatment leader (MD- directs medical treatment; makes triage decisions)
6. ) Circulation manager (RN, MD or RT- chest compression, pulse assessment)
7. ) Procedure clinician (MD, CRNA- performs procedures i.e chest tubes, IV lines)
8. ) Data manager (RN-reports from chart, pt condition, lab results, records interventions)