Nursing Concepts for Adult Health Adult 3-Unit 1 Emergency medicine,100% CORRECT

Adult 3-Unit 1 Emergency medicine Nursing Concepts for Adult Health (Arizona State University) RapidResponseVs.CodeBlue Unit1—EmergencyMedicine RapidResponse(theyhaveapulseandarebreathing,beforetheyaredead) -Calledintimeifthereisachangeincondition(V/S) -ICUhasnorapidresponse -Potassiumcamebackat7?RAPIDresponse -Sepsis(confusion,inc. -Urineoutputloweredfor2hoursanddoctorisnotdoinganythingRRT(Sole) 1. Identifyclinicaldeteriorationthattriggersearlynotificationofaspecificteamofresponders 2. RapidInterventionbytheresponseteamthatincludesbothpersonnelandequipmentthatisbroughttothepatient 3. Ongoingevaluationthroughdataandanalysistoimproveprevention CriteriaforRRTactivation 1. DeteriorationinHR,BP,RR,pulseoximetry,mentalstatus,urinaryoutput,andlabvalues 2. Staffmaydoitifworriedaboutchangeinconditionorfamilymembers Effectiveness: Decreasecost,decreasepalliativecareandcoding Reduces:cardiacarrest,ICUlengthstaycauseweareactingquick,Respiratoryfailure,CVA,severesepsis,AKI(Preventpotentialproblems/Codes) Palliativecare:comfortablebutwithmedicalinterventions - rapidresponseincreasespalliativecare-wearetothepointifwecatchthingsearlyandeducatethefamily,comingtoendoflife,canavoidtheunnecessarycodes - palliativecareistreatingsymptoms,butnotlifesavinginterventions,goalistomakethemcomfortable Team: RespiratoryTherapist,Doctor/APN/Physician,CriticalCareNurse(ACLS) -Minimal:3members Cardiac/RespiratoryArrest -Resuscitationneeded(Nobreathingorheartbeat) -DEAD(nobreathingortheyhavenoheartbeat,orboth) -BLS/AEDandACLS -CPRifnopulse -HighqualityofCPR CodeTeam(muchmoreInvolved) 1. Leader(Notificationsystemactivated)CodeLeader(Directs/MakesDx) 2. Teammembersvary(ACLStrainedatleastonenurse,Physician,HouseSupervisor,Recorder,Compressions,RespiratoryTherapy(airway),Pharmacist/Tech,ECGtech(EKGaftercode/ordemise),ChaplainorNursingTech,Runner,Takecareoffamily -RolesNeedtobeassigned(Drisleader,ifnottherethenACLSleader) -Nurseneedstotelleveryonewhathappened -RT,pulmonologyorDr,anesthesiologistdoesINTUBATION 1. Teamapproach 2. FollowACLSprotocolswhenpossible Roomdoesnotneedtobeflooded Intheroom:5people(twocompressors,primarynurse,crashcartnurse…) Page222-11.1-shepointedthisout…SOLE–Codeteammembers 1. CodeLeader(Dr),DirectsCode/MakesDiagnosesandtreatmentdecisions 2. PrimaryNurse(Providesinformation,measuresvitals,assist,administersmed) 3. SecondNurse(Coordinatecodechart,preparesmeds,assemblesequipment) 4. NursingSupervisor(Controlsthecrowd,contactattendingDr,assists,ensurebedreadyincriticalcareunit,assistwithtransfer) 5. Nurseorassistant(Recordseventsondesignatedform) 0. Recorderdocumentstheevents 6. AnesthesiologistorNurseAnes.(Intubates,Airway/Oxygen) 7. RespiratoryTherapist(AssistswithVentilation/Intubation,airway,ABG,respiratoryequip) 8. PharmacistorTech(Preparesandassistswithmedication,prepareIVinfusion) 9. ECGTech(12-LeadECG) 10. Chaplain(SupportsFamily) 0. familyisallowedtoobservethecodeifdesired,aslongastheydon’tinterfere 1. familyMUSTbewithasupportpersonatalltimes Equipment: 1. Crashcart(CardiacBoard,portablesuctionmachine,bag-valvemask,oxygentubing,monitordefibrillatorwithrecorder,clipboardwithcoderecordandmedicationcalculation,airwayequipment,IV,medication,MISC,procedurekits) 2. Backboard-firmforCPR 3. Defibrillator/AED 4. Bag-valve-maskdevice(AMBU100%) 5. Airwaysupplies/suction 6. Medications 7. IVsupplies-20gauge(Rapidinfusion),2IV’s 8. Nasogastrictube/OGtube-preventaspiration/aspirationpneumonia 9. Bloodpressurecuff(Manual)Documentation CrashCart Checkedevery12-24hours(Whichitemwillexpirefirst,letsomeoneknowandreplace) -IsitpluggedinandchargedLocations-clearlymarkedareaforeasyaccess Locks-lockafterusageandbringittopharmacyafterusage FlowofEventsDuringaCode-Sole 1. Recognitionofarrest,arrivalofcodeteam(AED),identifycodeleader,Rhythmdiagnosis(ECG12lead/AED),promptdefibrillation,intubation(ifventilationisinadequateandtrainedpeoplearethere),venousaccess,medication,ongoingassessment,drawingblood,cdocument,controlcrowdfamilynotified,transfertocriticalcare BLS-restoreeffectivecirculationandoxygenation–involvesCPR,ambubag,andAED 1. Defibrillation- V-fibrillationandpulselessV-tach 1. Compressionrate(100-120) -Depth:1-2inches–completechestrecoil -Stayin’alive -Chestrising?Effectivebreaths 2breathsafterevery30compressions(head/tiltchinunlessheadtrauma)ContinuouscompressionswithETT EverytwominuteswegowithoutoxygenthebrainhastissuedeathTwoapprovedplacestofeelforpulse: -CarotidArtery -FemoralArtery ACLS:heartandrespiratoryemergenciesAirwayManagement(ABC) Jawthrust-ifthereisheadtrauma/neurotrauma–don’tmoveheadatall,movingjawalittleHeadtiltandchinLiftifnotrauma ListenonbothsidesforlungsoundsManualVentilation AirwayOpeningManeuversIntubation ProtectAirway 100%Oxygen-15lpm IdealTidalVolume(bodywtandht)Suction Medications(ViaRespiratory)-AdvancedAirwayContinuousCPRonceintubated ACLS:Access 1. IV-2largebore-atleast18orlarger(smaller#=bigger;) 2. IO(Intraosseousline-intothebone(humeralhead,tibialplateau,orsternum) 0.Physiciandoesthis 0.Highriskforinfectionandonlyfor24HOURS 2. CVC-CentralLine 0. FemoralincodeduetoETT,notbestsiteb/cofwherethelocatedb/ccangetsoiled,highriskforinfection 1. Subclavian-CPRruinsthis 2. Intrajugular 2. ETT:canputmedicationthroughthis,HIGHERdosagebutnormaldosageforTESTING 0.Pneumonic–VeryLEAN 0. Vasopressin 1. Lidocaine-forventriculararrhythmiasonly 2. Epinephrine 3. Atropine 4. Narcan CodeEvents: 1. Assess(Ongoing):PulseOx,ETCO2(showsifit'sintherightspot),PulseChecks,Labwork *Earlydefibrillateifshockablerhythm *BLS,ACLS,ROSC?ROSC–returnofspontaneouscirculationCheckpulse,--checkforchestrise→nopulseorbreath→CPRkeepdoingCPR/BLS/ALSuntilROSC checkACLSalgorithms Defibrillator/AED(automatedexternaldefibrillation) - turnedonpriortouse - Whenanalyzingrhythm,don’ttouchpt - ShockableisV-FIBandpulselessV-tach SurvivalRatesdecreaseeveryonetotwominutesthereisnoshockAEDusedinfield/outsideoffield -TellsyouifitsashockablerhythmDefibrillatorsmighthavebuiltinAED -CancausedamagetocardiactissueandburnsresultincomplicationsfromAEDSafety-donottouchthepatientifthereareshockshappening Complications Defibrillation 1. Padplacement(Apex-front,mostcommon;toprightbelowclavicle,andleftside)Sidetoside(PEDS0,Apexback(Hearttransplant)Frontbackhasvagusnerve 2. Charge 3. Clear 4. Shock 5. ResumeCPR Iseveryoneclearandthatincludesoxygen–DON’Ttouchptwhenshocking–announceloudandclearShock-thebodywillbeliftedoffthebed 1.Shock,2.TwoMOREminutesofCPRaftershock,pulseafterCPR200-300joulesforAED AutomatedExternalDefibrillator -Defibrillator -Ifwehaveapulse(v-tach)itwillshockagain -RhythmAnalysis-don’ttouchptwhilethisishappening -Watchingforbreathing Ifnoshockadvised,startCPR–100-120 Nomouthtomouth,continuousCPR(outsideofthehospital)--keepbloodcirculatingbacktoheart Cardioversion:hastohavepulse (Neverpartofacode,onlyrapidresponse) -Physicianrequiredatbedside(Doctoratesdegree)3rhythmsforCardioversion: UNSTABLE:Afib/Aflutter,SVT(SupraventricularTachycardia),VentricularTachycardiawithapulseJoulestocardiovertwith:50-100joules -WewanttopreventRonTphenomenonsoweshockonRwave -SynchronizedonRwave -Pulsatilerhythmsonly -Lowelectricalcurrentused -Painmanagementb/cverypainfulprocedure,ptisawake–doconscioussedationifpossible,ifptcriticalsometimesthereisn’ttimetodoit VentricularFibrillation/PulselessVentricularTachycardia -KnowstripandrhythmVTACHlooksliketombstoneVFIBlookslikeachaoticmess treatmentissameforthesetworhythmswhenpulselessVentricularFibrillation(L)PulselessVentricularTachycardia® -Wecanshockifthosetwo 1. CPR/BLS 2. Defibrillation(120-200joules) 0.Shock,CPR,checkpulse 2. Epinephrine(pulseless)andAmiodarone(DrugsgivenforVfibandpVT) 0. Alldeadpeoplegetepinephrine1st–epiisFIRSTdrugofchoice 1. Amiodarone(300mg,then150mg)afterepinephrine,every3-5minutes,twice 2. Lidocaine/Procainamide 2. CheckElectrolytes 0.Ifacidotic,givesodiumbicarbonate,checkABG’s 2. Wewillhavetointubate TorsadesDePointes(MagnesiumissueorprolongedQT)--looksalotlikeVFIB,buttorsadesisupanddownMaincause:prolongedQTandlowmagnesium -OndansetroncausesprolongedQT,andLevofloxacin -PolymorphicVT -ProlongedQT 1. Magnesium-firstlinedefense,2grams-FIRSTPRIORITY 2. EPIiftheydon;thaveapulse 3. CPRifindicatedifnopulse TorsadeswithpulsecanturnintopulselessVTACHVerydifficultrhythmtoconvert PulselessElectricalActivity: Electricitywithoutapulse -SinusBradycardia(PulselessElectricalActivity) EX:showsbradycardiaonmonitor,butnopulsewhencheckingthept -Hardestrhythmtogetback,doNOTshockthisrhythm -ItcannotbeV-fiborVTachandTorsadesDePointes(Alwaystreatedaswhatitis) 1. CPR 2. ACLSprotocol 0. (Epinephrine)drugofchoice,onlymedicationunlesstheyoverdosed 1. *Iftheyoverdosed(Narcan)*narcanwon’thurtanybodyifyougiveit - ALLDEADPPLGETEPI questionex:PthasbeenbroughtinbyEMStoED,ptwasonscene,didnothaveapulse,theyhadalreadydonetworoundsofCPR,givenonedoseofepi,whatisnextstep? Questionsofnextstep,priority,SATA(anyanswersyouwoulddo,true/falsequestions)IMPORTANTREMINDER: STABLE:SBPgreaterthan90andMAPgreaterthan65withnosymptomssuchasSOB,diaphoretic,pale - STABLE→yougiveMEDS UNSTABLE:SBPlessthan90andMAPlessthan65,symptomsofSOB,diaphoretic,pale - UNSTABLE→Youcardiovert–rhythmsyoucancardiovertisunstableAFIB/Aflutter,unstableV-Tachwithpulse,andunstableSVT - PulselessV-tachandVfib–CPR/DEFIB→EPI→AMIODARONE→LIDOCAINE Asystole:Dead,noelectricityAssesswithtwoleadsalways 1. Assessfirst 2. Code 0. CPRactivelyfirst 1. Epinephrine,q3-5minutes,pulsechecks 2. Narcan-Overdose(Onlycangetthisunlessoverdose) TreattheCause(228,box11.2)H’s 1. Hypoxic-Oxygen 2. HydrogenIon(acidotic)-SodiumBicarbonate 3. Hypovolemia-Fluidsorblood(bloodissueorfluidissue,treatproblem) 4. Hypo/hyperkalemia- 0. 3.4code,5.5code 1. givepotassiumiflow,sodiumbicarbisseverehyperkalemia 2. Hypothermia-slowlyrewarm TreattheCause:T’s 1. TensionPneumothorax-NeedleDecompression 2. Tamponade-Needtodrainthefluid 0.Hadheartsurgery 2. Toxins-Reverseitorpumpstomach(NG) 0.Heroin,meth 2. PulmonaryThrombosis-Highdosebloodthinner,TPE 0.Cannotbreathe 2. CoronaryThrombosis-Cathlab,stent,TPE,ballooning(Needtostabilize) 0.Heartattack SymptomaticBradycardia(Stable:greaterthan90,greaterthan:65) -AnythingbelowthoseareunsatbleBradycardia:60andbelow TwoIVS TreatmentforSymptomaticBradycardia 1. Atropine-bindtovagusnerveandincreaseheartrate(0.5-1mg)Ifthisdoesn'twork 2. Pace(Transcutaneous)-needanalgesics,it'spainful(Ifthisdoesntwork:)continuethisuntiltheygetpermanentortemporarypacemaker 3. Dopamine/EpinephrineDrip Allofthesecancausehypertension HoldtheirmedicationifitdecreaseBPandHR–suchasbetablockersMaintainairwayandO2 Donottreatthingsthatdonotneedtobetreated,ifBPisstableandHRlowdonotdoanythingBox11.3page229 TranscutaneousPacemaker-usedforSymptomaticBradycardia -ExternalPads(onlygoodfor12hours) -DemandMode(givenatarate:70-80,sometimes100)--byphysician -Joulesisprettylowforthis -AdjustmAstoinitiatepacedrhythm(forcapturetooccurthisiswhatwedid) -Adjustsensitivity -mAincreasedbytwoaftercaptured,mAisdifferentthanjoules -Pausepacemakerevery12hourstoassess,changeifnotstickyanymoreTemporarypacemakerorpermanentpacemakerassoonaspossible Donotunplugfromptasunderlyingrhythmcanbeasystole - checkonceashift Higherthejoules,highertheshockBOX11.7page234 StableBradycardia–justmonitor,thinkathlete -ptBPisgreaterthan90,MAPgreaterthan65=,nosymptoms Tachycardia(100+bpm) -WideisVTach–wideQRS -NarrowisSVTakasupraventriculartachycardia-narrowQRS -StableorUnstable-biggestindicatorisBP 1. Stable:above90,MAPabove65 2. Unstable:below90,MAPbelow65 0. Cardiovert:50-100joules(sedate),synchronizetoRwaveMakesurethereisairway,O2,andIVaccess UnstablePatient/Stable 1. Assesspatient Medications: 2. Unstable:Cardioversion,hastohaveapulseandneedtopreventphenomenon 0. Ycomplexventriculartachycardia(Top),SVT(bottomrhythm) 1. Adenosine(main)forSTABLESVT 2. Cardiozone(dithizone) 3. Amiodarone(SVTwillnotgetthis)forSTABLEVTachwithpulse 4. Assessandanalyzerhythm Oxygen(ICUbelow92%) Treathypoxia Improvetissueoxygenation CPR=100%oxygenor15L/minO2helpsperfusetissue NasalCannulaNon-rebreather PartialnonrebreatherVenturi MouthBreathing Epinephrine- Vasoconstrictor(notintorsades),alldeadpplgetEPIAlphaandbeta-adrenergiceffects(HRANDBP) Usedinrhythms -V-fib -pVT -Asystole -PEA -SymptomaticBradycardia(Drip)2micsperminute -TreatsHypotension Code:1mg,q3-4(afterpulsecheck)CanbegivenviaETtube Needscentralline,VERYbadforveins CheckeveryhourinperipheralIVforflashback/bloodreturn Whatdoesthisdo? - Increasesheartrateandincreasescontractilityoftheheart(constrict),vasoconstriction→raisesBP Atropine-SymptomaticBradycardia0.5-1mg,6dosesfor0.5-every3-5min-0.04mg/kg -Usedfordecreasedvagaltone(vagaltone=lowHR) -Havetohavepulse -Neverworksinhearttransplant/coronaryarterybypassbecausevagusnervenotthereanymore 2. Pacingonstandbyincaseatropinedoesn’twork 3. Dopamine/EpinephrineDrip ET:2-3mg(ONEdose)in10mlofnormalsaline(knowthenormaldosefortest) Amiodarone(Slowitdown)“Slowdarone” Dosage:GivenTwice300mgIVPUSH(deadperson),(seconddoseis150IVPUSH)so450mgtotal -Reducesmembraneexcitability -Alphaandbeta-adrenergicblockingproperties -Dilatescoronaryarteries:increasebloodflowandimprovecardiacfunction -HypotensionandBradycardiasideeffects StopitfrombeinginVTorVF(secondlineoftreatmentforthese) AmiodaronecancauseQTprolongationandcanleadtoPolymorphicV-tach(Torsades) -Checkmagnesiumlevel Lidocaine(2-4mgaminute),drip/infusion,1-1.5mg/kg -Antidysrhythmic,usedforVENTRICULARARRHYTHMIASONLY -SuppressesventricularectopyLidocainetoxicitycanlooklikebraindeadFirstsign: #1SIGNAlteredlevelofconsciousness(knowthis) 1. Adenosine a. PrimarilythefirsttreatmentforstableSVT i. SlowsconductionthroughAVnode ii. Doesn’tworkforotherrhythmsbecausetheyaren’tconnectedtotheAVnode b. Pushasfastaspossiblebecausehalf-lifeis10seconds,veryrapidIVpush i. Completelyoutofsystemin2minutes ii. onsetis10-40secs c. Dosage i. 1stdose--6mg-giveagainafter1minifptdon’tconvert ii. 2nddose—12mg iii. 3rddose-12mg iv. alwaysgiveflushaftermed,andflushasfastaspush v. friendtoldmetorememberthisby:“aidanhad6cookies,then12cookies” d. Incasethisdoesn’tworkwemusthaveacrashcartreadytocode e. Whatweneedtoknowbeforegivingthismed i. Codestatus(DNR?) ii. Ifthepatienthasrespiratorydisease(COPD/Asthma)b/citcancausebronchospasmsandwheezing 1. canstillgiveit,butmakesuretomaintainairway 2. Magnesium a. 1.8-2.4isnormallevel b. Dosage:1-2mg,10mlD5Wover5min,pushVERYslowly c. Ivbolusfollowedbyinfusion d. TreatmentforTorsades e. Givenover5minutes f. Sideeffects(becauseitsuppressesthenervoussystem) i. Respiratorydepression ii. Hypotensionwhengivenrapidly iii. bradycardia iv. Patientsturnbrightred g. Checklabs 3. Sodiumbicarbonate a. 1ampivpush=50m/equivalents b. Treats i. metabolicacidosis ii. Canreverseseverehyperkalemia c. Canbegivenasadrip d. checkABGS 4. Dopamine a. Vasoconstrictor i. Increasescardiacretractability,BP,HR,CO b. Dose i. 2-20mcg/kgforcontinuousdrip ii. Cardiac—2-5mcg/kgperminute iii. Vasopressor—Morethan10mcg/kgperminute iv. Moderatedose-cardiacdose v. Higherdose-vasopressordose c. Sideeffects i. Putsatriskforvtachandvfib ii. Causesskinsloughing/necrosis(tissuedeath),giventhroughcentralline 5. Recorderdocument a. Start/stoptime b. Actionstakenandpatient’sresponse c. Defibrillation d. Medications e. Procedures f. Pacemakeruse g. Intubationandairwaymanagement h. Teammembers - allneedstobefilledoutaccuratelyandsigned 6. Post-resuscitation a. Optimizecardiopulmonaryfunction b. Airwayisinplace-check c. Stabilizevitalsigns d. Controldysrhythmias i. Onceinadysrhythmiaoneishighriskforgoingintoanotherone.Along-termmedmustbetaken. e. Advancedneurologicalmonitoring f. Capnography i. TellsCO2number(normal35-45)andhowthepatientisactuallyperfusinghisbody g. 24hourEEG,continuousECGmonitor i. Highriskforhavingaseizureafterhavingcodedduetobrainbeingwithoutoxygen 7. ROSC a. Mostcommoncauseofcardiacarrestisheartattack b. 12leadECGchecksforheartattackandrhythmanalysis c. Mustinsertlines i. centralline ii. intubate iii. pulmonaryarterycatheters iv. foley d. Serialneurologicalexams–hourlyneuroassessment e. Treatelectrolytes 8. Post-codecare a. PainmanagementbecauseCPRbreaksribs b. Sedation c. CTheadandEEG d. Strictglucosecontrol e. Hypothermiaprotocol 9. Therapeutichypothermia a. Optimaltemperature32-36Celsius b. 38Candaboveisfever c. Usedforpatientswhodidn’timmediatelyregainconsciousnessaftercoding i. AlertandconsciousnessafterROSC?nohypothermiaprotocol d. Reach34tempwithin3hours e. After24hoursslowlystartrewarmingperson f. MustbeinICU g. Checktemperatureviaspecificroutes-notemporal,oral,tympanicoraxillary i. Corebodytemp 1. Bladder 2. Esophagealprobe 3. Rectalprobe-common 4. Pulmonaryarterycatheter-common h. Mustkeeppatientfromshivering i. Why? 1. Increasesoxygenconsumption 2. Increasesbodytemperature ii.ContinuousEEGmonitor i. Complications i. Bleeding(acoldlivercausesclottingfactorsnottowork) ii. Infection iii. Metabolicandelectrolytedisturbances iv. Hyperglycemia j. Whenwarmingbackuppotassiumincreases k. Nursingcarewithhypothermia i. Infectionprevention ii. Glycemicmanagement 1. GiveIVinsulinifnecessary iii. Monitorelectrolytes 1. Potassium,mag,phosphatedropinhypothermia 2. Don’treplacepotassium8hrsbeforewarming iv. Rewarmafter24hrsveryslowly6-12hours v. Onventilator–riskforventilatorassociatedpneumonia(VAP) 1. 30-45degreeselevated 2. Oralcare–CHGrinse 3. DVTandGIprophylaxis 4. Dailysedationvacation 10. Supportingotherpatients a. Removefromthesituation b. Talkwiththem c. Assesstheirfeelings d. Continuetheircare e. Ensureadequatenumberofstaffareavailableduringcodefortheotherpatients-everyoneonunitgoestotheroomwherethereisacode 11. Recap a. HighqualityCPR(BLS)leadstogoodACLS b. Alldeadpeoplegetepinephrine-giveepiwithev c. GothroughH’sandT’s