Unresponsive Patients Flashcards
You walk into a patient’s room and they are unresponsive.
What do you do?
Yell for help.
What does a person’s level of consciousness consist of?
Alert
- Awake or easily roused
- Oriented
- Responds appropriately
- Interacts meaningfully
What are some abnormal findings for a person’s level of consciousness?
Lethargic (somnolent): Drowsy, appropriate but thinking is slow, inattentive, decrease in spontaneous movement
Obtunded: difficult to arouse, confused when aroused, speech mumbled, incoherent, monosyllabic, requires constant stimulation
Stupor or semi-coma: spontaneously unconscious, responds to pain, appropriate motor response, groans, reflexes intact
Coma: completely unconscious, no response to pain
Light coma: some reflex activity, no purposeful movement
Deep coma: no motor response
What are some potential causes of unresponsiveness? (13)
- Neurological
- Stroke
- Seizure
- Trauma
- Cardiovascular
- Myocardial infarction
- Cardiac arrythmia
- Cardiac arrest
- Respiratory
- Pulmonary Embolism
- Respiratory Arrest (e.g. choking, opioid overdose)
- Endocrine
- Hypoglycemia
What does CAB stand for?
Circulation
Airway
Breathing
What should you do to establish if a pt is truly unresponsive?
Establish unresponsiveness (using noise & somatosensory stimulation)
- Shout
- Trapezius squeeze or pinch
- Press on supraorbital nerve (medial aspect of supraorbital ridge)
- Angle of the jaw
Your pt is unresponsive, now what?
1) Call for HELP! (shout, pull call bell out of wall, code blue or call 4444 @KGH)
2) ‘Circulation’: Check for Pulse (& breathing)
Where do you check for pulse in an unresponsive pt?
Check carotid pulse or femoral pulse
What do you do if your pt doesn’t have a pulse? Why may this occur?
1) ’C’: Circulation
No pulse – IMMEDIATE CHEST COMPRESSIONS
- Push hard & fast (100-120 compressions per minute)
- Depth of at least 2 inches (5cm)
- Allow chest recoil
- Minimize interruptions in compressions
2) ‘A’ Airway: Open airway
3) ’B’ Breathing: Bag Valve Mask (BVM) -> 30:2
- Ex: cardiac arrest, shock
What do you do if there is a definite pulse but no breathing? Why may this occur?
1) ‘C’ Check for pulse; pulse is palpable but no breathing or breathing is not normal
2) ‘A’ (Airway): Open airway
3) ’B’ (Breathing): Bag Valve Mask
- 1 breath every 5-6 seconds
- Pulse check every 2 minutes
- Head-tilt chin-lift!
- Ex: obstruction (choking, foreign bodies), inadequate respiratory effort (opioid overdose).
What do you do if there is a definite pulse and normal breathing? Why may this occur?
- Vital Signs
- Assess Responsiveness
- Glasgow Coma Scale
- Bloodwork/Imaging Tests
- Ex: stroke/TIA, slow brain bleed, medication
What are the roles during a code blue when the pt does not have a pulse and isn’t breathing?
1) Request the crash cart & defibrillator
2) Give report to the code team (witnessed vs. unwitnessed; patient history)
3) Participate (CPR; recording; moving patients out of the room)
Why is CPR so important?
Excellent CPR & shocks (for appropriate arrhythmias) remain the cornerstones of basic & advanced cardiac life support
Anything short of “excellent CPR” does not achieve adequate cerebral and coronary perfusion, thereby compromising a patient’s chances for neurologically intact survival
Strongly recommend that every effort be made toNOTinterrupt CPR; other less vital interventions (eg, tracheal intubation or administration of medications to treat arrhythmias) should be carried out either while CPR is performed or, if a required intervention cannot be performed while CPR is in progress, during the briefest possible addition to the two-minute rhythm check (after the completion of a full cycle of CPR)
What is SBAR?
Situation: I walked into the patient’s room this morning and the patient’s LOC was declining – he has a pulse (130 bpm) and is breathing 30 breaths/min
Background: He had hip surgery yesterday; history of high BP and high cholesterol. No opioids today. Was up walking. Right leg is swollen and had some shortness of breath this morning.
Assessment: I wonder if he could have a pulmonary embolism
Recommendation: I suggest we do an ECG & some blood work, as well as monitor his VS continuously.
When is SBAR used?
Non-critical situations: communication of concerns related to identified problems (e.g. discharge planning)
- Nurse to nurse shift report/break coverage report
- Interprofessional patient conferences
Critical situations: communication of changes in patient’s condition (e.g. BP is 200/87)
- Nursing student reporting to co-assigned nurse/instructor
- Nurse reporting to charge nurse
- Nurse reporting to physician
- Nurse reporting to RACE/CODE team
