Post-op Pain Management: Cardiac Arrest

Post-op Pain Management: Cardiac Arrest Post-op Pain Management: Cardiac Arrest (2/2) Sheila Dalton, 52 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Gas Exchange 2. Acid-Base Balance 3. Fluid and Electrolyte Balance 4. Clinical Judgment 5. Patient Education 6. Communication 7. Collaboration © 2016 Keith Rischer/www.KeithRN.com UNFOLDING Reasoning Case Study: STUDENT Post-op Pain Management 2/2: Cardiac Arrest History of Present Problem: Sheila Dalton is a 52-year-old woman who has a history of chronic low back pain and COPD. She had a posterior spinal fusion of L4-S1 earlier today. Her pain is currently controlled at 2/10 and increases with movement. She was started on a hydromorphone patient-controlled analgesia (PCA) with IV bolus dose that is 0.2 mg and continuous rate of 0.2 mg/hour. The nurse reported that her nausea has improved after receiving ondansetron IV four hours ago. She was having increased pain despite using the PCA every 10 minutes. Her pain has decreased from 6/10 to 2/10 since the PCA bolus was increased from 0.1 mg to 0.2 mg of hydromorphone IV one hour ago. Patient Care Begins: Current VS: T: 99.8 F/37.7 C (oral) P: 78 RELEVANT Data from History: Clinical Significance: R: 12 COPD BCPh: ro9n2/ i 4c 8low back pain Recent spinal fusion surgery History of respiratory issues, likely retains CO2, potential alveoli dysfunction Use of pain medication with chronic back pain? Post-op day 0, need to assess for surgical complications/expected findings, risk for infection/bleeding Narcotic use (decr. RR) Low oxygenation status on 4L NC Is BP complication of meds, sign of bleeding? OH2ydsarto:m89o%rphrooonme uaisre4wliittehrs n/c worsened pain Nausea, relieved with Zofran Low SpO2 89% Low BP 92/48 Your shift continues... Thirty minutes later she is feeling more nauseated, and you administer ondansetron 4 mg IV push prn. Five minutes later she puts the call light on again. You are not able to respond immediately because you are helping your other patient get on the commode. Little do you know that Sheila is going to depend on your ability to THINK LIKE A NURSE and clinically reason to save her life. When you arrive in her room you observe the following... © 2016 Keith Rischer/www.KeithRN.com What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Unresponsive Ashen pale Minimal resp. effort Liquid emesis in mouth Weak carotid pulse 24 bpm Does not awake or arouse to painful stimuli signs of cardiac arrest, heart is not pumping blood and shunting to core is likely occurring Loss of consciousness from sudden lack of blood flow Aspiration of gastric contents during arrest could have occurred Needs immediate intervention!!! Current VS: T: not assessed P: 24 R: 4 BP: 72/40 O2 sat: 76% 4 liters n/c What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: HR 24 RR 4 BP 72/40 O2 76% This is still consistent with cardiac arrest, the heart has suddenly stopped pumping blood resulting in bradycardia, hypotension, and loss of perfusion to brain, minimal to no respiratory effort is occurring Clinical Reasoning Begins... 1. What is the primary problem that your patient is most likely presenting with? Cardiac Arrest 2. What is the underlying cause/pathophysiology of the primary problem? The heart suddenly stops pumping blood due to an electrical malfunction. 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) CABC… Compressions, airway, breathing, then circulation. Call for help and immediately perform compressions to start perfusing the tissues. Maintain patent airway, potential for intubation. Manually breath patient with ambu bag. Perform defibrillation to allow the SA node to take control of the electrical impulses of the heart for return to functioning. Airway, Breathing, Circulation! © 2016 Keith Rischer/www.KeithRN.com 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: Compressions Ambu bag breathing Defibrillation Manual pumping of the heart to perfuse the tissues Oxygenate the pt during CPR between compressions Allow the SA node to take over control of the heart improved circulation Improved oxygenation Return of heart functioning 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Respiratory and Cardiovascular 6. What is the worst possible/most likely complication to anticipate? Sudden Cardiac Death or organ failure from lack of blood flow 7. What nursing assessments will identify this complication EARLY if it develops? Attaching pt to monitor to assess heart rate/rhythm to monitor for improvement, monitor pt response to interventions, does pt become responsive or breath independently?, assessing perfusion and vital signs to see if there is adequate cerebral blood flow 8. What nursing interventions will you initiate if this complication develops? Continue resuscitation and assess extent of organ damage if possible… Comfort care and family support is SCD occurs. A crash cart is brought into the room, and the patient is placed on the cardiac monitor/defibrillator. The following rhythm is displayed: Cardiac Telemetry Strip: Interpretation: Ventricular Fibrillation Clinical Significance: Disorganized electrical activity. This shows that the ventricles are not effectively pumping blood, this is not a sustainable rhythm. © 2016 Keith Rischer/www.KeithRN.com Medical Management: Rationale for Treatment & Expected Outcomes I recognize that most students/new nurses have not had ACLS training or exposure to this certification in nursing school. It is important for the new nurse to understand the most common ACLS algorithms as it is relevant to clinical practice. If and when ACLS certification as a registered nurse is taken, this case study will have provided practice of this essential skill! Please recognize that doing this case study does not qualify for ACLS interventions in practice! You must be officially certified to actually intervene with these measures in a code. Nurses who are BLS certified can have an active part in the code such as chest compressions; pulse check; bag ventilation; and vital sign checks. Nurses should feel that they can work within their scope and certification. So many times, nurses who are not ACLS certified will not even do those things that are taught in the BLS certification course. But there is a place for a nurse who is not ACLS certified during a code that is an important role...the RECORDER. Every crash cart has a simple 1-2 page form that documents the code and is selfexplanatory. Though this role should ultimately be done by a certified ACLS nurse when one arrives, until then begin documentation and remain present in the room so that you as the primary nurse can communicate to the code team and physician the patient’s story and what led up to the code. Once the code team arrives, the role of the primary nurse is to contact physician, family, and pastoral care to update on patient status and assist with care. Care Provider Orders: Rationale: Expected Outcome: ACLS Priorities: Resuscitation provided to facilitate blood flow and oxygenation Heart will return to functioning rhythm Oxygenation to tissues Pt arousal Return of spontaneous circulation Start CPR Monitor heart rhythm to determine if rhythm is shockable Attach monitor/defibrillator Depolarizes to allow SA node to return as pacer of heart Provide shock if rhythm is shockable CPR 2 min + create/maintain IV access Shock again CPR 2 min Admin Epinephrine every 2-3min Vasoconstriction/bronchodilator to improve blood flow/oxygenation Advanced airway Shock again Antiarrhythmic helps to prevent SCD and return heart to regular rhythm CPR 2 min Admin amiodarone Depends on heart rhythm and return of spontaneous circulation to continue care per ACLS standards Go to Post-arrest care or Shock Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Epinephrine 1:10,000 1 mg/10 mL IV/IO every 3-5” push Bronchodilator, vasoconstrictor. causes accumulation of cyclic adenosine monophosphate (cAMP) at beta-adrenergic receptors, and alphaadrenergic agonist properties that cause vasoconstriction. Improves cardiac output, contractility, and cerebral/coronary blood flow. 10 mL syringe IV Push: Volume every 15 sec? 2.5 mL every 15 sec, given over 1 min -Assess lung sounds, respiratory pattern, pulse, and BP before administration and during peak of medication SE: nervousness, tremors, palpitations -Monitor ECG, respiratory rate frequently, hemodynamic parameters, and urine output -risk for pulmonary edema, MI, v-fib Mechanism of Action: f Volume/time rame to Safely Nursing Medication/Dose: Administer: Assessment/Considerations: Amiodarone 300 mg IV push 150 mg/3 mL vial Antiarrhythmic. Prolongs action potential and refractory period. Inhibits adrenergic stimulation. Slows the sinus rate, increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation). Reduces risk of SCD in pts with arrhythmias IV Push: Volume every 15 sec? 0.15 ml/15 sec, 6 ml given over 10 min -Monitor ECG, HR -watch for bradycardia or increased arrhythmias SE: fatigue, dizziness, nausea/vomiting, constipation -risk for cardiogenic shock, sinus arrest, hepatotoxicity, and fatal gasping syndrome © 2016 Keith Rischer/www.KeithRN.com TEN minutes post-arrest: After two doses of epinephrine and amiodarone bolus and the third defibrillatory unsynchronized shock at 360 joules, the following rhythm is present on the monitor: Cardiac Telemetry Strip: Interpretation: Sinus Tachycardia Clinical Significance: Normal sinus rhythm with elevated rate Nursing Priority Intervention: RELEVANT Lab(s): Clinical Significance: Slow down heart rate, vagal maneuvers, relaxation, medication admin (beta blockers, calcium channel blockers) The in-house physician running the code orders a stat ABG right after she is successfully resuscitated and is now intubated. You obtain the following results: Arterial Blood Gases: Current: High/Low/WNL? pH (7.35–7.45) 7.15 Low pO2 (80–100) 64 Low pCO2 (35–45) 78 High HCO3 (18–26) 22 WNL O2 sats (92%) 90% Low Oxygen delivery 100% High What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Lab Planning: Creating a Plan of Care with a PRIORITY Lab: pH: 7.15 paO2: 64 paCO2: 78 O2: 90% The pt is in uncompensated respiratory acidosis Lab: Normal Value: 7.35-7.45 Why Relevant? Nursing Assessments/Interventions Required: pH Value: 7.15 Critical Value: 6.8 The pt is experiencing acidosis that if it becomes lower, it could be incompatible with sustaining life. ister oxygen © 2016 Keith Rischer/www.KeithRN.com Evaluation: ONE minute post-resuscitation: After determining that her current rhythm also has a pulse, you collect the following assessment data: Current VS: T: 99.1 F/37.3 C (oral) P: 128 (regular) R: ambu bag rate of 20/minute (physician ordered increased rate) BP: 128/88 O2 sat: 92% 100% O2 Current Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Color slightly improved. Is pale/pink, coarse crackles/rhonchi scattered in both lung fields even after suctioning. No spontaneous resp. effort. Requires ambu bagging CARDIAC: Pulses 2+ throughout. Strong femoral pulse. No edema in extremities. Heart rate regular–S1S2. NEURO: Remains unresponsive. Responds to pain stimuli by bringing both hands toward the source of pain GI: Abdomen soft, non-tender with active bowel sounds GU: Foley placed, 30 mL clear, yellow urine present in bag SKIN: Surgical incision intact, no redness, drainage, or dehiscence present 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Ambu bag rate 20/min O2 92% on 100% O2 While other VS are WNL this shows that the patient is still requiring airway intervention and is not breathing on their own. This supports the assessment findings of unresponsiveness and no spontaneous respiratory effort. RELEVANT Assessment Data: Clinical Significance: -coarse The pt has impaired respiratory status, fluid build-up in the lungs, and crackles/rhonchi -No spontaneous resp. effort -unresponsive, responds to pain decreased LOC 2. Has the status improved or not as expected to this point? The pts status has improved in regard to circulation/perfusion with the assessed regular HR, improving color, pulses present. The pt remains unresponsive which is non-reassuring as well as their respiratory status. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Yes, the plan of care should now focus on optimizing ventilation in the post-cardiac arrest care. Blood pressure is stable not requiring immediate intervention. 4. Based on your current evaluation, what are your nursing priorities and plan of care? Nursing priorities are now to optimize ventilation and oxygenation since spontaneous circulation is returned. This includes administering O2, monitoring capnography, monitoring with ECG, maintaining patent airway with ETT, frequent vital signs, suctioning secretions, and potentially performing target temperature management since the patient is unresponsive. Changes in heart rhythm/circulation may require hemodynamic optimization. © 2016 Keith Rischer/www.KeithRN.com Think ABC’s... A: AIRWAY–Maintain placement and integrity of endotracheal tube B: BREATHING–Impaired gas exchange C: CIRCULATION–Maintain adequate blood pressure and stable cardiac rhythm (impaired tissue perfusion) TEN minutes post-resuscitation: Medical Management: Rationale for Treatment & Expected Outcomes: Care Provider Orders: Rationale: Expected Outcome: ACLS Priorities: Adequate oxygenation, SpO2 94% Maintain SpO2 94%, 10 breaths/min, lowest effective setting, titrate ventilation, use waveform capnography to assess CO2 levels 12-lead ECG Transfer for coronary reperfusion This allows for reduced risk of O2 toxicity which could lead to poor cerebral perfusion, avoid excess ventilation To rule out STEMI or AMI For percutaneous coronary intervention at an appropriate facility Diagnosis of STEMI/AMI to adjust plan of care Rapid infusion of ice-cold (4° C), isotonic, non-glucose-containing fluid to a volume of 30 ml/kg to maintain target temp. 32-36 ° C (89.6 to 96.8 ° F) Initiate target temperature management If unable to follow commands, this will preserve tissue and increase survival rate Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Naloxone 0.02 mg IV push every 2 minutes 0.4 mg maximum dose Opioid antagonist, blocks the effect of opioids (CNS and respiratory depression) Half-life: 60-90 min IV Push: Volume every 15 sec? 0.01mg/15 sec, give bolus over 30 sec 0.02-0.2mg/2- 3min -monitor respiratory rate/rhythm, ECG, BP, LOC -monitor for return of opioid effects due to short half life -assess return of pain and signs of withdrawal © 2016 Keith Rischer/www.KeithRN.com The room is now ready, and it is now time to transfer to ICU. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient: Situation: Name/age: Sheila Dalton, 52 year old female BRIEF summary of primary problem: Pt went into sudden cardiac arrest and is ten minutes postresuscitation. Day of admission/post-op #: Today, post -op day 0 Background: RELEVANT past medical history: Pt has a history of COPD and chronic low back pain. Pt had posterior spinal fusion L4-S1 today and was receiving IV hydromorphone and ondansetron. During resuscitation, pt received two doses epinephrine and a bolus of amiodarone. Assessment: Most recent vital signs: T: 99.1 F/37.3 C, P: 128 regular, R: ambu bag rate 20/min, BP: 128/88, SpO2: 92% on 100% O2 RELEVANT body system nursing assessment data: Coarse crackles/rhonchi bilat lung fields, no spontaneous respiratory effort Pulses 2+, no edema, S1S2 present Remains unresponsive except to pain Foley in place RELEVANT lab values: Current uncompensated respiratory acidosis with a pH: 7.15 ECG: Ventricular Tachycardia INTERPRETATION of current clinical status (stable/unstable/worsening): Pt is stable post-resuscitation with interventions in place. Recommendation: Suggestions to advance plan of care: Pt may require Narcan to reverse any opioid induced CNS/respiratory depression. Following ACLS protocol, pt should be considered for PCI and TTM. Continue monitoring ECG, cardiac/respiratory status, LOC and interpret lab values. © 2016 Keith Rischer/www.KeithRN.com TWENTY minutes post-resuscitation: Radiology Reports: Portable Chest Xray What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Results: Clinical Significance: Tip of ET tube 1 cm above the carina. Heart size normal. The ET tube is too low, should be 5-7 cm from the carina. May cause sympathetic stimulation on the carina. Arterial Blood Gases: Current: High/Low/WNL? Prior: pH (7.35–7.45) 7.29 Low 7.15 pO2 (80–100) 102 High 64 pCO2 (35–45) 48 High 78 HCO3 (18–26) 23 WNL 22 O2 sats (92%) 100% WNL 90% Oxygen delivery 100% High? 100% What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: CO2: 48 O2: 102 pH: 7.29 CO2/O2 both elevated showing improvement in oxygenation status pH low but showing improvement from prior level, still in acidosis Trending towards improvement to be WNL Complete Blood Count (CBC): Current: High/Low/WNL? Prior: WBC (4.5–11.0 mm 3) 8.9 WNL 7.8 Hgb (12–16 g/dL) Low 10.2 11.8 Platelets (150-450 x103/μl) 148 Low 155 Neutrophil % (42–72) 85 High 81 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Hgb: 10.2 Platelets: 148 Neutrophil: high Low Hgb may be related to blood loss from surgery or complication Low platelet indicates increased risk of bleeding Elevated Neutrophils may be sign of infection Trend worsening for all Basic Metabolic Panel (BMP): Current: High/Low/WNL? Prior: Sodium (135–145 mEq/L) 138 WNL 140 Potassium (3.5–5.0 mEq/L) 4.1 WNL 3.8 CO2 (Bicarb) (21–31 mmol/L) 20 Low 22 Glucose (70–110 mg/dL) 152 High 122 Creatinine (0.6–1.2 mg/dL) 1.7 High 1.1 Misc: Lactate (2.6) 4.9 High N/a © 2016 Keith Rischer/www.KeithRN.com What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Bicarb: 20 Glucose: 152 Creatinine: 1.7 Lactate: 4.9 Low CO2/bicarb shows improvement in respiratory acidosis Elevated glucose may be from acute stress during SCA Creatinine may indicate damage to kidneys Lactate related to acidosis, impaired tissue perfusion and build up in body CO2 trend improving Glucose/Cr/Lactate trend worsenin