Lab 5- code Flashcards
code
red
blue
white
yellow
green
orange
black
brown
grey
pink
amber
silver
fire
cardiac arrest
violence/aggression
missing person
evacuation
mass casualty
bomb threat
hazardous spill
system failure
pediatric emergency
missing or abducted infant/child
active attacker
code silver principles
run hide fight
- chest compression rate
- depth
- allow for
- ventilate
- 100-120/min
- at least 2 inches (5cm) for adults
1/3 AP diameter if the chest for children and infants - full recoil after each compression
- adequately (2 breathes after 30 compressions) over 1 sec each watching for chest to rise
if advanced airway in place give ___ breath
1 breath every 6 secs (10 breathes/min)
- Start CPR
- Give
- attach - rhythm shockable
- 8.
- oxygen
- monitor/defibrillator
rhythm shockable ?
- Yes: VF/pVT
- shock
- CPR (2 mins)
- IV/IO access - rhythym
When naloxone is indicated give it
as soon as possible
this is important
5 RIGHTS of CLINICAL REASONING
Right Cues
Right Action
Right Patient
Right Reason
Right Time
Right cues (3)
- Available patient information (Physiological or psychosocial changes)
- Current clinical assessment data
- Recall of knowledge
examples of Available patient information (Physiological or psychosocial changes)
(5)
Patient charts, handover, patient history, results of investigations, family members
Current clinical Assessment data
Vital signs, head to toe assessment, results of investigations, lab values
Recall knowledge examples
Physiology, pathophysiology, pharmacology, epidemiology, therapeutics, context of care, ethics, evidence-based practice - EVERYTHING YOU LEARN IN NURSING SCHOOL
Nurses need to learn how to identify an ______ and ______in a timely manner
ex:
at risk pt
intervene
- Getting help (like phoning the MRP or calling CCOT)
- Identifying early warning signs vs. late warning signs and understanding nursing interventions to be done at the right time and sequence
Right action and reason
- action is comprised of
- what is
the application of practical skills, critical thinking and crucial communication (ie….who are you going to call for help?)
your reasoning process, and include questions of is it ethical legal and professional
½ of avoidable arrests had
clinical signs of deterioration in the 24 hours preceding but were not acted upon
clinical reasoning includes
- Clinical judgement (deciding what’s wrong with the patient)
- Problem solving
- Decision making (deciding what to do)
- Critical thinking
- Processing by selecting from alternatives, weighing evidence, using intuition and pattern recognition
experienced nurses
- select
-
- select relevant and specific cues,
- select cues that are context dependent,
- collect information on a range of factors in addition to the patient’s presenting symptoms and have a way of “being with the patient” and instantly knowing the patient after scanning,
- they know what to pay attention to and what to ask.
Novice nurses
- Less focused selection
- over select cues,
- follow rules ignoring the context
- concentrate on only the presenting symptoms and focus on tasks and technology, rather than the patient, often missing important cues
Clinical reasoning cycle
8
Start with the patient- what is the issue? holistic approach
Collect cues/information- handover report, hx, meds, pt assessment
Process info: – Interpret- data, signs and symptoms, normal and abnormal.
Identify problems: analyze the facts and interferences to make a definitive diagnosis of the patients problem
establish goals- describe what you want to happen, desired outcomes and timeframe
Take action – Select a course of action between alternatives available.
Evaluate Outcomes – The effectiveness of the actions and outcomes. Has the situation changed or improved?
Reflect on process and new learning – What have you learnt and what would you do differently next time.
Failure to rescue is
Is the “inability of clinicians to save a patient’s life by timely diagnosis and treatment when a complication develops”
Research has shown that patients display signs and symptoms of impending arrest as early as ______ prior to the arrest
72 hours
4 major impediments
RCPD
- Failure to recognize clinical deterioration
- Failure to communicate and escalate concerns
- Failure to physically assess the patient
- Failure to diagnose and treat the patient appropriately
How can nurses prevent FTR
4 STTA
- Surveillance/Assessment MOST IMPORTANT ACTIVITY
- Nurses must be able to identify the progression and trending of assessment changes as benign or pathological - Timely identification of complications
- Nurses must be vigilant to detect trends in assessment changes that can signify a critical event - Taking action
-Nurses must take action regarding assessment findings - Activating a team response
- Nurses need to notify the physician and team appropriately and in a timely manner
Neurological bell curve
8
Restless
anxious
irritable
agitated
confused
combative
lethargic
unresponsive
respiratory bell curve
6
20
24
30
increasing 40s
4-10
apnea
resp rate increase to __/min is one of the earliest signs of instability
20
early stage of hypoxia clinical Signs and symptoms
restlessness, change in mental status, anxiety, headache, fatigue, tachycardia, dysrhythmia
intermediate signs of hypoxia
5
increased confusion
agitation
increased oxygen requirements
decreased oxygen saturation
lethargy
late signs of hypoxia
4
C
D
U
R
cyanosis
diaphoresis
unresponsive
respiratory arrest
management of acute respiratory failure
3
Provide supplemental oxygen:
improve ventilation (promote adequate gas exchange)
give meds
Nasal prongs L/min and % oxygen
1-6 L/min
24-44%
simple mask L/min and %
6-10 L/min 35-55%
NRB L/min and %
10-15L
60-80%
how to improve ventilation
2
- Positive and expiratory pressure (BiPaP)
- endotracheal tube
medications for resp failure
Bronchodilators
steroids
analgesics
sedatives
antibiotics (to treat underlying cause of respiratory failure)
Cardiac bell curve
7
> 100 bpm
PVC
couplets, patterns, shapes
runs V tach
V tach
V fib
Asystole
__________are an exceptionally accurate and timely predictor of clinical instability or impending adverse outcome
ventricles
4 main elements that maintain stability and function efficiently:
***When one or more of these elements are not optimal,
a) oxygenation
b) perfusion
c) electrolytes
d) acid/base imbalance
ventricular instability occurs (PVCs, bigeminy, trigeminy, VT, VF)
determining cardiac instability
change in __________
+ one of the following signs
- change in heart rhythm - palpate the pulse +
Hypotension
Dizziness
Chest pain
Shortness of breath
New or worsening heart failure
Weak pulse
Diaphoresis
Nausea, lightneaded
Unresosponsive
CCOT comprised of
1 Critically Trained RN from ICU
1 RT
purpose of CCOT
- to provide support to ward staff
- help with timely recognition and interventions with the aim of preventing deterioration of patient.
Why call them?
CCOT
Early recognition of signs and symptoms of pre-arrest indicators can have a significant outcome reducing patient mortality
When to call a CCOT
RR
SBP
HR
LOC
_____ symptoms
O2 sats
UO
Skin
unexpected or significant __________
new, repeated or prolonged
_____ pain
Failure to
- > 25 or less than 8/min or increased WOB
- less than 90 or drop of more than 30
- > 120 or less than 50 BPM
- change in LOC or GCS of less than 10
- stroke symptoms
- less than 90% with supplemental oxygen
greater than 0.5 FiO2 (50%) - less than 80 ml in 4 hours
- is Pale or diaphoretic or mottling on the trunk of the body
- bleeding
- seizures
- chest pain unrelieved with nitro spray as ordered
- for an acute problem/symptom
(ex: BP not responding to fluid bolus or prolonged fever not responding to antipyretics)
stroke symptoms
F facial droop
Arm weakness
Speech difficulty
Time
Visual disturbances
Aphasia
Neglect
sepsis is suspected if
Patient has 2 of the following:
AND
HR, RR, temp, WBC, Change in
- HR > 90
- RR> 20
- temp > or = to 38 or less than 36
- wbc > 12 or less than 4x 10^9
- change in LOC
confirmed or suspected source of infection or any of the symptoms below:
- cough/sputum/CP/sob
- Dysuria/frequency/catheter
- Skin or joint pain/redness/swelling
- central line preset , mottled/cold
preferred method of communication
SBAR
Always call ______ when you call CCOT
MRP
- The CCOT is there for support but the MD still needs to be aware, present and is the one who can write orders.
when to call a code blue
3
1) When your patient has a respiratory or cardiac arrest
2) When your assessment deems necessary – warning signs!
3) When directed to do so
Ideally we want to call a CODE prior to our patients experiencing a full respiratory or cardiac arrest!
what can you do when you wait for the code team
Start CPR
Get the backboard under the patient
Get the chart
Check MOST status
Ensure IV access
Hang a primary bag of fluids
Take note of the time
Make sure the vitals machine is attached to your patient
Get someone to start documentation
Get someone to call the family if they aren’t there
code team comprised of
5
Critical Care trained RN’s from ER/ICU
At least 2 RTs
MD from ER or ICU
Lukas (if the hospital has one)
Lab techs (will not respond automatically to a Code Blue)
YOU!
Roles in a Code
- Code team leader
- Airway management
- Chest compressors
- medication management
- code cart
-timekeeper/documentation
- support runner
- charge RN
- family support designate
Code Team Leader – typically MRP or physician from ICU/ER, can also be a trained RN!
Airway management – Usually RT but RNs may need to start airway management prior to RT arrival (Oral airway)
Chest Compressors – As many people as you can, form a line, take turns providing high quality CPR. (typically ward RNs – perfect role for new nurses)
Medication Management – Critical Care RN pushes the medications according to the ACLS algorithms and Code Lead’s orders, ensure IV access
Code Cart – defibrillation and gets supplies
Timekeeper/Documentation – writes on the code blue record and provides 2 minute prompt reminders for rhythm checks and medication administration
Support Runner – often ward RN who can run and get supplies as necessary
Charge RN – has chart and provides historical information in conjunction with the primary RN
Family Support Designate – staff member who can provide support to family who are present during the Code, explaining what the team is doing as the code progresses, can be an RN, Social Work, or Spiritual Care
code blue roles
Nurse 1
nurse 2
nurse 3
Patient (assessment, call for help, initiate CPR)
To Assist (call code/bring emergency equipment to scene, orange cone, suction, backboard; assist with CPR)
Environment (bring patient chart to bedside, start IV, remove headboard)
Primary survey during code
- Rapid assessment of the patient and environment
Make sure the scene /environment is safe - Airway: Is the airway open?
- Breathing: Is the patient breathing?
- Circulation: Is a pulse present?
- Disability: What is the level of responsiveness?
A = Alert
V = Respond to verbal stimuli
P = Responds to painful stimuli
U = Unresponsive
disability what is the level of consciousness
A = Alert
V = Respond to verbal stimuli
P = Responds to painful stimuli
U = Unresponsive
reversible causes of arrest
5 H’s 5T’s
hypovolemia
hypoxia
hydrogen ion (acidosis)
hypokalemia/hyperkalemia
hypothermia
tension pneumothorax
tamponade, cardiac
toxins
thrombosis, pulmonary
thrombosis, coronary
Remember: don’t rely on a___ Always check the
ECG
patients /pulse
code process at KGH
- Activate the Code Blue button, call for help
In the Centennial building of KGH the way- finding lights will also be activated - Call 22222 and identify Code
eg. “Code Blue 6 West centennial building”; “Code Blue 6 West centennial building” - Do not cancel the code button until all members of the code team arrive!
- Start CPR with an emphasis on chest compressions (100-120/min
what makes for good team dynamics
Clear Leadership
Clear Understanding of Roles
Clear Message: distinctive speech in a calm, direct manner
Mutual Respect
Clear Communication – closed loop communication
Adaptability!
Fears and biases of HCP of family
- The family will be too emotional and cause disruption
- The family will interfere with the code teams work
- They won’t be able to “handle” the chaos of the situation
- They may notice medical errors
- Perceive that wrong decisions were made and put the healthcare team at risk for litigation
- Fear of HCP losing objectivity
benefits of family presence
- Overwhelming evidence in support of best outcomes for family
- Families were able to grasp the seriousness of the patient’s condition
- Were able to see that everything is being done for their loved one
- Moved more positively through the grief process
- Less incidence of PTSD
- Patient’s basic right to family presence
- Family’s basic right to presence with loved one
post-resuscitation period is the time between
return of spontaneous circulation (ROSC) and the transfer to intensive care.
The emphasis of the post resuscitation critical period
2
- maintain optimal tissue oxygenation and perfusion
- to identify the cause of the arrest and to initiate treatment
tasks for post resscitation care
7
- Reassess secondary ABCDE
- Assess for complication that may have occurred during resuscitation (rib fractures, trauma, and displaced endotracheal tube).
- Most likely these will be done in ICU after transfer. Primary RN to go to ICU with patient
- Restart IVs that were inserted without aseptic technique.
- Insert foley, nasal/oral gastric tube and monitor intake and output.
- Temperature regulation
- Connect with the family to update them on the status of the patient (most likely the MRP of ICU/ER physician will call)
Depth and rate of CPR
5cm or 2 inch
100-120 bpm
When to administer epinephrine
for non-shockable rhythms as soon as possible
after shock has failed for shockable rhythms
C” of the CAB’s stands for
compressions
A rapid, chaotic heart rhythm that is completely disorganized is called
ventricular fibrillations
