ORIENTATION

1
PREFERRED NURSE STAFFING

• ORIENTATION

WELCOME
2
NATIONAL PATIENT SAFETY GOAL

• Improve the accuracy of patient identification
• Improve the effectiveness of communication
  among caregivers
• Improve the safety of using medications
• Reduce the Risk of Health care-associated
  infections
• Accurately and completely reconcile medications
  across the continuum of care
• Patient Safety Goals
• Improve the accuracy of Patient Identification
• Use at least two patient identifiers (neither to
  be the patients room number) whenever
  administering medications or blood products
  taking blood samples and other specimens for
  clinical testing, or providing any other
  treatments or procedures.
• Examples include patient name and account number
  or record number

3
Patient Safety Goals

• Improve the effectiveness of communication among
  caregivers
• For verbal or telephone orders or for
  telephonic reporting of critical tests results,
  verify the complete order or test results by
  having the person receiving the order or test
  result read-back the complete order or test
  result.
• Standardize a list of abbreviations, acronyms,
  and symbols that are not to be used throughout
  organization.

4
Patient Safety Goals

• Effective Communication
• Measure, assess and, if appropriate, take
  action to improve the timeliness of reporting,
  and the timeliness of receipt by the responsible
  licensed caregiver, of critical test results and
  values.
• Implement a standardized approach to hand
  off communication, including an
  opportunity to ask and respond to questions

5
Patient Safety Goals

• Effective Communication
• List of abbreviations that are not to be used
• Abbreviation Correction
• MgSO4 Write out name of drug
• MSO4 Write out name of drug
• MS Morphine Sulfate
• U or u Write out unit
• IU Write out International Unit
• Q.D., Q.O.D. Write daily and every other day
• Leading zeros ARE to be used. Trailing zeros are
  NOT to be used

6
Patient Safety Goals

• Effective Communication
• How Do We comply?
• No more Taped Reports
• Hand-off communication should take place whenever
  there is a change in the patients caregiver
• Includes all clinical staff
• Report patients condition, tx, services,
  relevant historical data and anticipated changes
  

7
Patient Safety Goals

• Improve the safety of using medications
• Limited Drug concentrations
• Many commonly used infusions are provided in
  pre-mixed, standardized concentrations (dopamine,
  dobutamine, milrinone, heparin, levofloxacin)
• Many compounded infusions are mixed in standard
  concentrations (felnoldopam, diltiazem,
  nitroprusside)
• Concentrated Electrolytes
• Concentrated electrolyte injections (potassium
  chloride, potassium phosphate, and sodium
  chloride) are not stored in o made available to
  patient care areas. Concentrated electrolytes
  are only available in the pharmacy for use in IV
  fluid preparation.

8
Patient Safety Goals

• Improve the safety of using medications
• Look-alike/Sound-alike drugs have been physically
  separated in the
• Acudose Rx cabinets and on shelves in the
  pharmacy.
• Drug master files are being modified to note on
  the MAR which items are look-alike/sound-alike
  (Tall Lettering).

9
Patient Safety Goals

• Medications must be delivered to the procedure
  field in an aseptic manner
• All medications, med containers and other
  solutions on or off the field should be labeled.
• Medications which are drawn up and given
  immediately does not leave your hand or sight) do
  not have to be labeled.
• Label includes name, strength, dosage and
  initials of person drawing up meds.

10
Patient Safety Goals

• Reduce the Risk of Health care-associated
  Infections
• Comply with current CDC hand hygiene
  guidelines.
• Wash hands with soap and water when hands are
  visibly soiled
• Decontaminate hands with alcohol-based foam when
  hands are not visibly soiled
• Banning of artificial nails in the
  hospital-setting
• Manage as sentinel events all identified cases
  of unanticipated death or major permanent loss of
  function associated with a health care-associated
  infection.

11
Patient Safety Goals

• Accurately and completely reconcile medications
  across the continuum of care
• Implement a process for obtaining and
  documenting a complete list of the patients
  current medications upon the patients admission
  to the organization and with the involvement of
  the patient. This process includes a comparison
  of the medications the organization provides to
  those on the list.
• A complete list of the patients medication is
  communicated to the next provider of service when
  it refers or transfers a patient to another
  setting, service practitioner, or level of care
  within or outside the organization.

12
Patient Safety Goals

• Reduce the risk of patient harm resulting from
  falls
• Implement a fall reduction program and evaluate
  the effectiveness of the program.
• Assess daily and periodically reassess each
  patients risk for falling, including the
  potential risk associated with the patients
  medication regimen, and take action to address
  any identified risks
• Stickers are placed on chart, patients armband,
  call light and the Kardex is flagged.

13
Lift Devices
NO SMOKING
Write legibly!

• PATIENT SAFETY

Suicide precautions
Never use equipment you are not familiar with
ask for assistance!
Safety Rails
14
FALL PREVENTION

• EVALUATE RISK Q 8 HRS
• INITIATE ORDERS
• PROVIDE INFORMATION
• PLACE LABELS ACCORDING POLICY

15
SAFETY WITH APPLICATIONOF RESTRAINTS

• Limb restraints
• Vest restraints
• Do not attach to side rails

16
WHY USE FOOT PUMPS OR A SEQUENTIAL COMPRESSION
DEVICE?

• PREVENTION OF DVT
• CONTRAINDICATED WITH EXISTING DVT

17
FOOT PUMP SAFETY

• SIZE
• SOCK/STOCKING
• INSPECT q SHIFT
• REPORT ANY S/S SKIN IRRITATION
• KEEP HEELS OFF BED
• REMOVE AND INSPECT WITH ANY C/O PAIN

18
MALFUNCTIONING EQUIPMENT
WHAT TO DO WHO TO NOTIFY
19
EQUIPMENT MALFUNCTION

• REMOVE FROM SERVICE
• TAG EQUIPMENT
• FOR CLINICAL CALL BIOMED
• ALL OTHER CALL MAINTAINENCE

20
WHEN TRANSPORTING A PATIENT BY WHEELCHAIR

• FACE PATIENTS TOWARD THE ELEVATOR DOOR
• MAKE SURE THE WAY IS CLEAR BEFORE PUSHING THE
  PATIENT INTO THE HALLWAY TO EXIT THE ELEVATOR

21
CORE MEASURES

• ANTERIOR MYOCARDIAL INFARACTION
• PNEUMONIA
• HEART FAILURE
• SURGICAL CARE INFECTION PROJECT

22
WHEN TRANSPORTING A PATIENT BY STRETCHER OR BED

• KEEP HANDS INSIDE RAILS
• USE SAFETY STRAPS ON STRETCHERS
• KEEP OUT OF LOW POSITION

23
LEAVING AGAINST MEDICAL ADVICE

• WHAT TO DO?
• WHO TO NOTIFY?
• AMA FORM
• EVENT REPORT
• DOCUMENTATION

24
ETHICS COMMITTE

• MEMBERS
• MEETINGS
• RECOMMENDATIONS
• EDUCATION

25
MEDICATION ADMINISTRATION
26
Home meds

• Send any meds brought to the hospital by the
  patient to the pharmacy for identification and/or
  safekeeping
• Continue home med orders
• Medication Reconciliation Form

27
ALLERGIES

• FACILITIES HAVE DIFFERENT
• POLICIES RELATED TO
• ALLERGY ARMBANDS
• KNOW WHERE ALLERGIES
• MUST BE DOCUMENTED!
• PHYSICIAN ORDER SHEET FRONT OF CHART
• MAR
• KARDEX

28
FOOD DRUG INTERACTIONS
29
PHARMACY WILL IDENTIFY MEDICATIONS THAT REQUIRE
FOOD DRUG EDUCATION ON THE MAR
THE NURSE WILL
EDUCATE THE PATIENT

• USE THE HAND-OUTS PROVIDED

DOCUMENT ON PATIENT RECORD
30
AUTOMATIC STOP ORDERS

• PHARMACY WILL SEND A NOTIFICATION
• PHYSICIAN MUST SIGN FOR MEDICATION TO BE CONTINUED

31
MEDICATION ADMINISTRATION

• STAT MEDS
• NOW MEDS
• GIVE ROUTINE MEDS FROM 30 MINUTES BEFORE TO 30
  MINUTES AFTER THE SCHEDULED TIME

KNOW POLICY !
32

ADMINISTERING MEDICATIONS

• OPEN THE INDIVIDUAL MED PACKAGES AT THE BEDSIDE
• TELL THE PATIENT WHAT EACH MEDICATION IS
• EXPLAIN THE ACTION OF EACH MEDICATION
• IF THE PATIENT QUESTIONS THE MEDICATION LISTEN
  TO THEM!

33
ADVERSE DRUG REACTIONS

• REPORT ADVERSE DRUG REACTIONS TO THE PHYSICIAN
• REPORT ADVERSE DRUG REACTIONS TO PHARMACY

34
NARCOTIC WASTING

• REQUIRES A WITNESS
• MISSISSIPPI LAW ALLOWS FOR WASTING OF A PARTIAL,
  UNUSED DOSE.
• WHOLE DOSES THAT HAVE BEEN OPENED BUT ARE NOT TO
  BE GIVEN MUST BE RETURNED TO THE PHARMACY

35
WHAT IS A MEDICATION ERROR

• Any preventable event that may cause or lead to
  inappropriate medication use or patient harm
  while the medication is under the control of
  the health care professional, patient or
  consumer.

36
MEDICATION ERRORS CAN BE CLASSIFIED AS A

• POTENTIAL EVENT (ERROR IS DETECTED AND CORRECTED
  BEFORE IT REACHES THE PATIENT
• ACTUAL OCCURRENCE (ACTUALLY REACHES THE PATIENT)
• BOTH SHOULD BE REPORTED
• USING AN EVENT REPORT FORM

37
THE FIVE RIGHTS

• RIGHT DRUG
• RIGHT DOSE
• RIGHT ROUTE
• RIGHT PATIENT
• RIGHT TIME

38
MEDICATION ERRORS

• DISPENSING ERRORSEXAMPLES WRONG DRUG, WRONG
  DOSE, IMPROPER PREPARATION
• ADMINISTRATION ERRORSEXAMPLES WRONG PATIENT,
  WRONG MEDICATION, WRONG TIME, OMISSION OF ORDERED
  MED, ADMINISTRATION OF AN UNORDERED MEDICATION
• OTHER ERRORSTRANSCRIBING ERROR, DOCUMENTATION
  ERROR, ILLEGIBLE ORDERS

39
PREVENTING MEDICATION ERRORS

• FIVE RIGHTS
• SPELL THE DRUG
• USE OF 0 IN ORDERS
• LOOK ALIKE/SOUND ALIKE DRUGS/TALL
• LETTERING
• ASSESS PATIENT CONDITION AND DRUG
• INDICATIONS

40
MEDICATIONS AT THE BEDSIDE

• If the physician writes an order to leave
  medication at the bedside, only a 24 hour supply
  may be left with the patient.
• No schedule drugs may be kept at bedside.
• The nurse should check to ensure that the 24 hour
  supply is not depleted prematurely.
• Document instructions to patient
• Document medication administration on MAR

41
PATIENT EDUCATION

• ADMISSION ASSESSMENT
• BARRIERS TO LEARNING
• SPECIFIC NEEDS
• TEACH TO IDENTIFIED NEEDS
• INCLUDE PATIENT, FAMILY, SIGNIFICANT OTHER

42
PATIENT EDUCATION

• EDUCATE PATIENTS ABOUT
• PAIN
• MEDICATIONS
• EQUIPMENT SAFETY
• DISCHARGE PLANNING
• SAFETY MEASURES
• FALL PREVENTION
• DOCUMENT EDUCATION ON THE PATIENT EDUCATION RECORD

43
HEARING AND SPEAKINGIMPAIRED PATIENTS

• TELEPHONES FOR THE HEARING IMPAIRED
• CLOSED CAPTION DEVICE FOR TV
• SIGN LANGUAGE INTERPRETER
• COMMUNICATION BOARDS

44
LANGUAGE PROBLEMS

• ARRANGEMENTS CAN BE MADE FOR AN INTERPETER
• SOCIAL SERVICE
• LANGUAGE LINE

45
SURGICAL ASSESSMENT
46
PRE-OPERATIVE ASSESSMENT

• History
• Personal and family history of surgery/anesthesia
  experiences
• Pre-existing medical conditions Risk factors
• Allergies
• Medications (include OTC)
• Alterations in physical communication status
• Religious considerations
• Cultural considerations

47
Required Documentation

• Physician History AND Physical
• Lab Diagnostic Data
• Consents
• Surgical and Blood
• Allergies Drugs Foods Latex
• Medications
• Special Forms Sterilization paper DNR Advanced
  Directives
• Miscellaneous Old Chart X-rays Special
  Equipment

48
CCONSENT FORM
X SIGNATURE
TIME CONSENT
Know Policy for each facility
WHEN TO SIGN
INFORMED CONSENT
49
Comfort Measures

• Undergarments
• Prosthetics
• Jewelry
• Cosmetics
• Family

50
PRE-OP CARE
PRE-OP
PRE-OP MEDICATIONS PRE-OP CHECKLIST ARM BAND
STANDING ANESTHESIA ORDERS
51
Pre-op Physical Assessment

• Cardiovascular
• Peripheral pulses
• Heart sounds ECG
• Venous Access
• Respiratory
• Rate, Depth, Rhythm
• Breath Sounds
• GU
• Lab ValuesBUN, Creatinine
• Historical Data
• Have patient empty bladder or Foley Catheter

52
Pre-op Assessment, Cont.

• GI
• Food allergies
• NPO Status
• Reflux History
• Neurological
• LOC Orientation
• Pre-existing Deficits
• Communication Barriers
• Musculoskeletal
• ROM limitations to affect positioning
• Existing prosthesis
• Height Weight on ALL patients

53
Pre-Op Assessment, Cont.

• Integumentary
• Skin turgor general conditioning
• Rashes, bumps and bruises
• Any Breaks in Skin
• Psychosocial/Educational
• Anxiety level
• Support System
• Knowledge Deficits
• Discharge planning

54
Post-Operative Assessment

• Physical Assessment post- PACU
• Immediately assess
• Temperature
• Vital Signs
• O2 Saturation
• LOC
• Surgical Site
• Vital Signs
• As ordered by physician or facility policy
• Assess Surgical Site

55
Systematic Post-Op Assessment

• Respirations
• Depth, Rate and Pattern
• Auscultate lung fields q 4 hours
• Report rates lt10 or gt30
• Cardiovascular
• Rate, Rhythm and Quality of pulses
• Compare distal pulses bilaterally along with
  color, sensation and temperature of extremities
• Capillary Refill Time
• Homans sign q 4 hours
• Vascular Access Devices for patency, rate of
  fluids Site Characteristics
• Lab Values, especially H H
• Report HR /or BP deviating 20 beats or 20 from
  pre-op baseline

56
Systematic Assessment, Cont.

• Genitourinary
• Assess lower abdomen for urinary retention
• Assure Foley Catheter is draining
• Measure Input Output correlating measurements
• Report output lt30ml per hour
• Gastrointestinal
• Auscultate abdomen for bowel sounds until heard
  in all four quadrants
• N/G tubes should be checked for placement q 8
  hours and prior to giving any medication/solutions
  
• Maintain suction per order
• Measure output

57
Systematic Assessment, Cont.

• Integumentary
• Assess thoroughly for skin integrity post-op
• Assess dressings drain sites with Vital Signs
• Document time, amount, color, consistency odor
  of drainage. Report measurable drainage with
  Output.
• Assess skin integrity around surgical site for
  any redness, blistering or signs of inappropriate
  healing
• Report Break-through bleeding after reinforcing
  dressings
• Report unusual pain

58
Systematic Assessment, Cont.

• Neurological
• Assess LOC and cerebral function with V/S at
  minimum the first 8 hours
• Same as pre-op?
• Assess gag reflexprevent aspiration pneumonia
• Assess motor function, especially with regional
  anesthetics
• If extremity involved, assess neuro-circulatory
  status
• Fluid Electrolyte Balance
• Assess Hydration Status with V/S
• Mucous Membranes color moisture
• Skin Turgor and Texture
• I O
• Signs of Edema/Fluid Retention
• Lab Values

59
Post-Op ALARMS

• Cool Extremities
• Low urinary output
• Slow capillary refill
• Low BP with increasing HR RR
• Restlessness
• Anxiety
• Confusion

60
Systematic Assessment, Cont.

• Pain
• Assess Patients perception of pain as well as
  pain relief on a 1 10 Scale
• Report Break-through pain or unrelieved pain
  early for intervention orders
• CHECK PACU RECORD FOR PREVIOUS PAIN INTERVENTIONS
  PRIOR TO ADDITIONAL PAIN MEDICATIONS
• Remember localized pain/restlessness maybe
  indicative of post-op bleeding, hematoma or site
  abscess

61
IV Therapy
62
After 2 attemptsget another nurseafter second
nurse makes 2 attemptscontact the supervisor
2 strikes and youre out!
63
No lower extremity IV sites without a physicians
order
64
Pharmacy should label solutions requiring filters
65
KNOW POLICY ABOUT SECONDARY SETS
66
IV tubing changes every 96 to 72 hours except
for TPN change TPN tubing every 24 hours

• IV site changes routinely every 96 to72 hours
• IV site changes prn if s/s infection or
  infiltration
• Restart an IV that was started in an emergency
  situation where breaks in aseptic technique may
  have occurred within 24 hours.

67
IV solution containers should not hang more than
24 hours
68
IV start Site prep---Chlorhexidine gluconate
now in IV start kit per CDC recommendation
IV Start Kit not utilized at all facilities!
69
WHO CAN REMOVE CATHETERS?
RNs and LPNs may dc peripheral lines
Physicians must remove central catheters
designed for long term use (Groshong, Hickman etc)
RNs may dc PICC lines and temporary central lines
70
RNs and LPNs can do IV site care central lines
included
Central line care is a sterile procedure--
71
IV certified LPNs may NOT

• ADMINISTER REGLAN
• ADMINISTER PROTONIX
• ADMINISTER IV MEDICATIONS/FLUIDS
• TO PEDIATRIC PATIENTS ON A MED/SURG UNIT
• ADMINISTER IV PUSHES OR BOLUSES
• ADMINISTER IV NARCOTICS

72
Record FLUSHES on the MAR
Know policy for each facility
73
Restrictions on IV medications---
Cholinergic drugs Curare-Type drugs Diagnostic
agents Chemotherapy Diagnostic dyes May not be
given by the Med-surg nurse
Emergency Code drugs May be given by ACLS
certified RNs
KNOW POLICY
74
Pediatric IVs

• Know policy of facility

75
NURSING PHARMACY

• ADVERSE DRUG REACTIONS
• MISSING DOSE FORM
• CORPORATE COMPLIANCE
• ISSUESMEDICATION
• CHARGES

76
PATIENTS HAVE THE RIGHT TO APPROPRIATE
ASSESSMENT AND MANAGEMENT OF
PAIN ..JCAHO

• PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL
  EXPERIENCE
• TYPES
• ACUTE
• CHRONIC
• THE PATIENTS PERCEPTION IS THE ONLY WAY TO
  MEASURE PAIN

77
ACUTE PAIN

• FOLLOWS INJURY AND GENERALLY DISAPPEARS WITH
  HEALING
• IS OFTEN ASSOCIATED WITH OBJECTIVE PHYSICAL SIGNS
  OF AUTONOMIC NERVOUS SYSTEM ACTIVITY SUCH AS
• TACHYCARDIA
• HYPERTENSION
• DIAPHORESIS
• MYDRIASIS
• PALLOR

78
CHRONIC PAIN

• CHRONIC NON MALIGNANT PAIN MAY RESULT FROM
  CONDITIONS SUCH A ARTHRITIS AND LOW BACK PAIN
• MAY BE IDIOPATHIC (FROM UNKNOWN CAUSE)
• CHRONIC PAIN MAY NOT BE ACCOMPANIED BY SIGNS OF
  SYMPATHETIC NERVOUS SYSTEM AROUSAL. THE PATIENT
  MAY NOT LOOK LIKE THEY ARE HAVING PAIN.
• THE PATIENTS PERCEPTION OF PAIN INTENSITY IS THE
  ONLY WAY TO MEASURE THE PAIN.

79
CANCER PAIN

• MAY BE ACUTE, CHRONIC OR BOTH
• RESULTS FROM TISSUE OR NERVE DAMAGE RELATED TO
  DISEASE PROCESS OR CANCER TREATMENTS

80
BREAKTHROUGH PAIN

• PAIN THAT BECOMES INTENSE ENOUGH TO OVERRIDE
  MEDICATION AND OTHER PAIN RELIEF MEASURES
• MAY SIGNAL THE NEED FOR CHANGES IN PAIN
  MANAGEMENT PLAN

81
NOCICEPTIVE PAINTHE BODYS TYPICAL RESPONSE TO
ORGAN OR TISSUE DAMANGE

• OCCURS WHEN PAIN RECEPTORS ARE STIMULATED
• OFTEN DESCRIBED AS ACHING OR THROBBING
• 2 TYPES
• VISCERAL FROM
• INTERNAL ORGANS
• SOMATICFROM
• MUSCLES AND BONES

82
NEUROPATHIC PAIN

• PAIN SUSTAINED BY ABNORMAL PROCESSING OF SENSORY
  INPUT BY THE PERIPHERAL OR CENTRAL NERVOUS SYSTEM
• OFTEN DESCRIBED AS BURNING, TINGLING, OR SHOOTING
• CAUSE MAY NOT ALWAYS BE CLEAR

83
PHANTOM PAIN

• PAIN SENSED IN A BODY PART THAT HAS BEEN
  AMPUTATED.
• PAIN MECHANISM IS GENERATED IN THE CENTRAL
  NERVOUS SYSTEMEVEN THOUGH ORIGINAL INJURY
  OCCURRED IN THE PERIPHERAL NERVES

84
PAIN ASSESSMENT SHOULD INCLUDE

• LOCATION
• INTENSITY
• DURATION
• DESCRIPTIONBURNING, ACHING, SHARP, DULL
• TRIGGERS
• CONSTANT OR INTERMITTENT
• DOES IT RADIATE
• WHAT HAS HELPED IN THE PAST

85
INTENSITY SHOULD BE RATED ON A 0-10 SCALE

• HOW DO WE MEASURE PAIN?

86
PAIN

• Document on
• Nursing Admission History Assessment
• Plan of Care
• Patient Education Profile
• Nurses Notes -
• Assessments and Reassessments

87
CHEST TUBE DRAINAGE SYSTEM
ONE, TWO OR THREE BOTTLE
DRY SUCTION
THORASEAL
PLEUR-VAC
88
COMPLICATIONS requiring immediate notification
of physician

• Increase in respiratory distress and/or chest
• pain
• Decrease in breath sounds over the affected
• and/or non-affected lungs
• Subcutaneous emphysema
• Asymmetric chest movements
• Hypotension
• Tachycardia
• Excessive blood loss
• Mediastinal shift
• Cyanosis

89
SHIFT ASSESSMENT INCLUDES

• Rate and quality of respirations
• Auscultation of lungs to assess air exchange
• Presence or absence of bubbling or tidaling in
• the water-seal chamber
• Palpating the area surrounding the dressing for
• subcutaneous emphysema
• Amount, color, and consistency of drainage
• Pain assessment and interventions
• Type of chest drainage system used
• Amount of suction (if in use)
• Frequency of system inspection
• Evaluation of chest tube connector

90
WHEN TO CLAMP CHEST TUBES 2 RUBBER SHOD OR
PLASTIC CLAMPS AT BEDSIDE
Changing the Drainage system
CHEST TUBES ARE ALWAYS DOUBLE CLAMPED
Preparing for chest tube removal
Assessing for an air leak
91
CHEST TUBE DRAINAGE TIPS

• ALLOW NO KINKS OR DEPENDENT LOOPS
• TO CHANGE SYSTEM
• PREPARE NEW SYSTEM
• TURN OFF SUCTION
• DOUBLE CLAMP TUBE
• QUICKLY DISCONNECT OLD AND CONNECT NEW
• IF TUBE DISLODGES COVER SITE WITH VASOLINE
  GAUZE/ CALL PHYSICIAN
• IF SYSTEM BROKEN INSERT UNCONTAMINATED TUBE END
  IN BOTTLE STERILE WATER. SET UP NEW SYSTEM

92
TRANSFERRING THE PATIENT

• From unit to unit
• The transferring unit writes the transfer orders
• The receiving unit transcribes the orders
• If the patient is deteriorating, the patient is
• transferred and then the paperwork is
  completed
• Be sure that all belongings go with the patient
• Notify the physician and family of room change
• Report shall be given following Patient Handoff
  Goal

93
CARDIOPULMONARY ARREST

• CODE TEAM WILL RESPOND TO THE ROOM OR AREA
• CPR, ACLS, PALS, NCR, AS NEEDED

94
Making Assignments

• Whos in charge?
• Who is going to get the code cart?
• Whos applying leads to check the patients
  rhythm recording a strip for the MD?
• Where is the patients chart?
• Has the physician been called ?
• Is anyone writing?
• Does the IV work and who is giving meds?

95
First Priority in a Code

• Basic CPR, early defibrillation if indicated and
  airway management.
• 1st Rescuer initiates CPR
• Know the main code medications
• -- location in the code cart
• -- how to assemble the syringes
• --appropriate dosage and mechanism of
• action
• -- route(s) of administration

96
RESCUER 1 ? ASSESS FOR UNRESPONSIVENESS
NOTE THE TIME ? CALL
FOR HELP ? PUT THE PATIENT FLAT IN
THE BED ? LOWER THE SIDE RAILS ? USE
STANDARD PRECAUTIONS ? OPEN THE AIRWAY
HEAD-TILT/CHIN-LIFT ? LOOK, LISTEN AND FEEL
? USING BARRIER DEVICE, GIVE 2 BREATHS
OVER ADULTS 1 SECOND PER BREATH
CHILD/INFANT 1 SECOND/BREATH ?
ESTABLISH PULSELESSNESS CAROTID
PULSE ADULT CHILD BRACHIAL PULSE
INFANT ? PLACE BACKBOARD UNDER PATIENT ?
BEGIN CHEST COMPRESSIONS
100/MINUTE ADULT RATIO 302
100/MINUTE CHILD RATIO 302
100/MINUTE INFANT RATIO 302
97
HELP IS ON THE WAY!
RESCUER 2
Anyone who records on the CODE record must sign
it The physician must also sign the CODE record
98

• RESCUERS 2 3
• ? CALL CODE IF NEEDED
• ? CRASH CART TO ROOM
• ? ASSIST WITH PLACING BACKBOARD
• ? CLEAR FURNITURE
• ? USE STANDARD PRECAUTIONS
• ? HOOK UP OXYGEN AND AMBU
• ? SET UP SUCTION GET OUT TONSIL
• SUCTION AND SUCTION KIT
• ? PREPARE TO START IVRUN FLUID
• THROUGH IV TUBING
• ? CONNECT MONITORING LEADS
• WHITE ON RIGHT CHEST
• BLACK ON LEFT CHEST
• RED ON LOWER LEFT CHEST
• ? PATIENT RECORD TO ROOM
• ? PLACE CALL TO PRIMARY PHYSICIAN
• ? ASSIST WITH CPR2-MAN RATIO
• ADULT 30 2

99
Intent of Drug Therapy

• Restore Adequate Cardiac Function
• Slow Rhythms
• vs.
• Fast Rhythms

100
Administration of Code Medications

• Intravenous
• -- Peripheral vein 1st choice (antecubital or
• external jugular) and follow with 20cc NS
• -- Elevate the extremity
• Endotracheal Tube
• -- ALE Atropine, Lidocaine, Epinephrine
• -- Give 2 2.5 times IV dose in 10cc NS or
  sterile water
• -- Give through a catheter, stop compressions,
  bag quickly x 2, and resume compressions.
• Intraosseous Preferred over ET route
• -- Peds Anterior Tibia Bone
• -- Adults Distal Radius

101
Administering Code Medications (continued)

• Two nurses are involved
• -- one at the code cart
• -- one at the bedside
• State the name of drug and dosage aloud and
  clearly for accurate documentation as well as
  clarity for the code team.
• Shock or continue compressions after each
  medications (per ACLS protocol).

102
Oxygen

• Cardiac arrest results in
• decreased cardiac output
• decreased oxygen to cells
• anaerobic metabolism
• metabolic acidosis
• blunting of beneficial drug and
• electrical therapy
• Bag/Mask Ventilation 1 breath every
• 5 6 seconds

103
Quick Review

• Shock (if indicated) as soon as the defibrillator
  is available
• Monophasic defibrillator360 joules
• Biphasic defibrillator120 200 joules
• Unknown type defibrillator200 joules
• Resume CPR immediately
• After 5 cycles of CPR, check rhythm
• If shockable rhythm, give one shock
• When IV/IO is available, give 1 mg epinephrine
• (before or after the shock) (May use 40 units
  Vasopressin to replace first or second dose of
  epinephrine.)
• Give one antiarrhythmic (before or after the next
  shock)

104
Quick Review

• Slow Rhythms
• Oxygen
• External Pacing Epinephrine Atropine
• Fast Rhythms
• OxygenIVWide or Narrow complex
• Stable
• Medications
• Unstable
• Emergency synchronized cardioversion
• Pulseless
• Defibrillation

105
Summary

• To avoid chaos, make assignments for code tasks.
  The Recorder is very important.
• Know hospital policy.
• Know the code drugs and their locations in the
  code cart.
• Know how to use the unit defibrillator.
• Resume CPR immediately after defibrillation!
• Remember, if you dont know something ASK!
• Debrief after the Code

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Do Not Resuscitate?

• What does this really mean?
• To the patient?
• To the family members?
• To you the care taker?
• Does the patient have an Advanced Directive?

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Ethical Dilemmas

• No one agrees on degree of care the patient is
  OUT
• Where is the patients official advanced
  directive?
• Conflicts can be averted

108
NO CODES

• LEVEL OF CARE
• WITHHOLDING/WITHDRAWING TREATMENT
• CHART BINDER

109
PATIENT DEATH

• FAMILY SUPPORT
• ORGAN RECOVERY AGENCY1-800-362-6169
• POST MORTEM CARE
• NOTIFICATION OF CORONER
• FUNERAL HOME NOTIFICATION
• DEATH OF A PERSON WITH AN INFECTIOUS
• DISEASE (RED TOE TAG)

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DEATH and DYING
111
DENIAL

• Numbness
• No, cant be me
• Disbelief

112
ANGER

• Difficult for family and friends to cope with
• Displaces anger
• Complain about care
• Be supportive
• Do not be defensive

113
BARGAINING

• Often becomes guilt
• If you let me live I will.
• Consider consulting chaplain or social worker

114
DEPRESSION

• Allow time to adjust
• Be open and ready to listen
• Might need pharmacological assistance

115
ACECPTANCE

• Final stage
• Able to express feelings
• Sleep more soundly
• Have less pain

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PATIENT DISCHARGE

• AMA DISCHARGE
• INSTRUCTION SHEET SHOULD BE
• COMPLETED IN LAYMANS TERMINOLOGY
• ESCORT FROM THE BUILDING
• DOCUMENTATION IN NURSES NOTES
• MEDICAL RECORDS FORMS

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THATS ALL FOLKS