ORIENTATION

PREFERRED NURSE STAFFING

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 patient’s 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

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.

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

Patient Safety Goals

Effective Communication List of abbreviations that are not to be used

Abbreviation CorrectionMgSO4 Write out name of drugMSO4 Write out name of drugMS Morphine SulfateU 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

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 patient’s caregiver Includes all clinical staff Report patient’s condition, tx, services, relevant historical

data and anticipated changes

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.

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).

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.

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 soiledDecontaminate hands with alcohol-based foam when hands are not visibly soiledBanning 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.

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 patient’s current medications upon the patient’s 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 patient’s 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.

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 patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risksStickers are placed on chart, patient’s armband, call light and the Kardex is flagged.

PATIENT SAFETY

Write legibly!

Never use equipment you are not familiar with… ask for assistance!

NO

SMOKING

Suicideprecautions

LiftDevices

Safety Rails

FALL PREVENTION

EVALUATE RISK Q 8 HRS

INITIATE ORDERS

PROVIDE INFORMATION

PLACE LABELS ACCORDING POLICY

SAFETY WITH APPLICATIONOF RESTRAINTS

Limb restraints

Vest restraints

Do not attach to side rails

WHY USE FOOT PUMPS OR A SEQUENTIAL COMPRESSION DEVICE?

PREVENTION OF DVT

CONTRAINDICATED WITH EXISTING DVT

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

MALFUNCTIONING EQUIPMENT

WHAT TO DOWHO TO NOTIFY

EQUIPMENT MALFUNCTION

REMOVE FROM SERVICE

TAG EQUIPMENT FOR CLINICAL:

CALL BIOMED ALL OTHER: CALL

MAINTAINENCE

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

CORE MEASURES

ANTERIOR MYOCARDIAL INFARACTION

PNEUMONIA HEART FAILURE SURGICAL CARE INFECTION

PROJECT

WHEN TRANSPORTING A PATIENT BY STRETCHER OR BED…

KEEP HANDS INSIDE RAILS

USE SAFETY STRAPS ON STRETCHERS

KEEP OUT OF LOW POSITION

LEAVING AGAINST MEDICAL ADVICE

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

ETHICS COMMITTE

MEMBERS

MEETINGS

RECOMMENDATIONS

EDUCATION

MEMBERS

MEETINGS

RECOMMENDATIONS

EDUCATION

MEDICATION ADMINISTRATION

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

ALLERGIES•FACILITIES HAVE DIFFERENT POLICIES RELATED TO ALLERGY ARMBANDS

•KNOW WHERE ALLERGIES MUST BE DOCUMENTED!

PHYSICIAN ORDER SHEET FRONT OF CHARTMARKARDEX

PHARMACY WILL IDENTIFY MEDICATIONS THAT REQUIRE FOOD

DRUG EDUCATION ON THE MAR

THE NURSE WILL

EDUCATETHE PATIENT

USE THE HAND-OUTS PROVIDED

DOCUMENT ON PATIENT RECORD

AUTOMATIC STOP ORDERS

PHARMACY WILL SEND A NOTIFICATION

PHYSICIAN MUST SIGN FOR MEDICATION TO BE CONTINUED

MEDICATION ADMINISTRATION

STAT MEDS NOW MEDS GIVE ROUTINE MEDS

FROM 30 MINUTES BEFORE TO 30 MINUTES AFTER THE SCHEDULED TIME

KNOW POLICY !

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!

ADMINISTERING MEDICATIONS

ADVERSE DRUG REACTIONS

REPORT ADVERSE DRUG REACTIONS TO THE PHYSICIAN

REPORT ADVERSE DRUG REACTIONS TO PHARMACY

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

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.”

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 REPORTEDUSING AN EVENT REPORT FORM

THE FIVE RIGHTS

RIGHT DRUG RIGHT DOSE RIGHT ROUTE RIGHT PATIENT RIGHT TIME

MEDICATION ERRORS

DISPENSING ERRORS—EXAMPLES: WRONG DRUG, WRONG DOSE, IMPROPER PREPARATION

ADMINISTRATION ERRORS—EXAMPLES: WRONG PATIENT, WRONG MEDICATION, WRONG TIME, OMISSION OF ORDERED MED, ADMINISTRATION OF AN UNORDERED MEDICATION

OTHER ERRORS—TRANSCRIBING ERROR, DOCUMENTATION ERROR, ILLEGIBLE ORDERS

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

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

PATIENT EDUCATION

ADMISSION ASSESSMENT BARRIERS TO LEARNING SPECIFIC NEEDS

TEACH TO IDENTIFIED NEEDS INCLUDE PATIENT, FAMILY,

SIGNIFICANT OTHER

PATIENT EDUCATION

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

PATIENT EDUCATION RECORD

HEARING AND SPEAKINGIMPAIRED PATIENTS

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

LANGUAGE PROBLEMS

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

SURGICAL ASSESSMENT

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

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

CCONSENT FORM

Know Policy for each facility

TIMECONSENT

INFORMEDCONSENT

X SIGNATURE

WHEN TOSIGN

Comfort Measures

Undergarments Prosthetics Jewelry Cosmetics Family

PRE-OP CARE…

PRE-OP MEDICATIONS

PRE-OP CHECKLIST

ARM BAND

STANDING ANESTHESIA ORDERS

PRE-OP

Pre-op Physical Assessment

Cardiovascular Peripheral pulses Heart sounds & ECG Venous Access

Respiratory Rate, Depth, Rhythm Breath Sounds

GU Lab Values—BUN, Creatinine Historical Data Have patient empty bladder or Foley Catheter

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

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

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

Systematic Post-Op Assessment

Respirations Depth, Rate and Pattern Auscultate lung fields q 4 hours Report rates <10 or >30

Cardiovascular Rate, Rhythm and Quality of pulses Compare distal pulses bilaterally along with color, sensation and temperature of

extremities Capillary Refill Time Homan’s 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

Systematic Assessment, Cont.

Genitourinary Assess lower abdomen for urinary retention Assure Foley Catheter is draining Measure Input & Output correlating measurements Report output <30ml 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

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

Systematic Assessment, Cont.

Neurological Assess LOC and cerebral function with V/S at minimum the first 8

hours Same as pre-op? Assess gag reflex—prevent 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

Post-Op ALARMS

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

Systematic Assessment, Cont.

Pain Assess Patient’s 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

IV Therapy

After 2 attempts—get another nurse—after second nurse makes 2 attempts—

contact the supervisor

2 strikes and you’re

out!

No lower extremity IV sites without a physician’s order

Pharmacy should label solutions requiring filters

KNOW POLICY ABOUT SECONDARY SETS

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.

IV solution containers should not hang more than 24 hours

IV start Site prep---Chlorhexidine gluconate

now in IV start kit per CDC recommendation

IV Start Kit not utilized at all facilities!

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

RNs and LPNs can do IV site care –central lines included

Central line care is

a sterile

procedure--

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

IV certified LPNs may NOT:

Record FLUSHES on the MAR

Know policy foreach

facility

Restrictions on IV medications---

Cholinergic drugsCurare-Type drugsDiagnostic agents

ChemotherapyDiagnostic dyes

May not be given by theMed-surg nurse

Emergency Code drugsMay be given by

ACLS certified RNsKNOW POLICY

Pediatric IVs

Know policy of facility

NURSING & PHARMACY

• ADVERSE DRUG REACTIONS

• MISSING DOSE FORM

• CORPORATE COMPLIANCE ISSUES…MEDICATION CHARGES

“PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE”

TYPES:

ACUTE

CHRONIC THE PATIENT’S PERCEPTION IS THE ONLY

WAY TO MEASURE PAIN

PATIENTS HAVE THE RIGHT TO

APPROPRIATE ASSESSMENT AND

MANAGEMENT OF PAIN…..JCAHO

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

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 PATIENT’S PERCEPTION OF PAIN INTENSITY IS THE ONLY WAY TO MEASURE THE PAIN.

CANCER PAIN MAY BE ACUTE,

CHRONIC OR BOTH RESULTS FROM

TISSUE OR NERVE DAMAGE RELATED TO DISEASE PROCESS OR CANCER TREATMENTS

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

NOCICEPTIVE PAIN—THE BODY’S 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

SOMATIC—FROM

MUSCLES AND BONES

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

PHANTOM PAIN

PAIN SENSED IN A BODY PART THAT HAS BEEN AMPUTATED.

PAIN MECHANISM IS GENERATED IN THE CENTRAL NERVOUS SYSTEM…EVEN THOUGH ORIGINAL INJURY OCCURRED IN THE PERIPHERAL NERVES

PAIN ASSESSMENT SHOULD INCLUDE

LOCATION INTENSITY DURATION DESCRIPTION…BURNING,

ACHING, SHARP, DULL TRIGGERS CONSTANT OR

INTERMITTENT DOES IT RADIATE WHAT HAS HELPED IN THE

PAST

INTENSITY SHOULD BE RATED ON A 0-10 SCALE

HOW DO WE MEASURE

PAIN?

Document on: Nursing Admission History &

Assessment Plan of Care Patient Education Profile Nurses Notes - Assessments and Reassessments

CHEST TUBE DRAINAGE SYSTEM

DRY SUCTION ONE, TWO ORTHREEBOTTLE

THORASEAL

PLEUR-VAC

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

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

WHEN TO CLAMP CHEST TUBES 2 RUBBER SHOD OR PLASTIC CLAMPS AT BEDSIDE

CHEST TUBES ARE ALWAYS

DOUBLE CLAMPED

Assessing foran air leak

Changing theDrainagesystem

Preparing forchest tube

removal

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

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”

CARDIOPULMONARY ARREST

CODE TEAM WILL RESPOND TO THE ROOM OR AREA

CPR, ACLS, PALS, NCR, AS NEEDED

Making Assignments

Who’s in charge? Who is going to get the code

cart? Who’s applying leads to check

the patient’s rhythm & recording a strip for the MD?

Where is the patient’s chart? Has the physician been called ? Is anyone writing? Does the IV work and who is

giving meds?

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

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 30:2 100/MINUTE CHILD RATIO 30:2 100+/MINUTE INFANT RATIO 30:2

RESCUER # 2

HELP IS ON THE WAY!

Anyone who records on the CODE record must sign itThe physician must also sign the CODE record

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 IV…RUN FLUID THROUGH IV TUBING

CONNECT MONITORING LEADSWHITE ON RIGHT CHESTBLACK ON LEFT CHESTRED ON LOWER LEFT CHEST

PATIENT RECORD TO ROOM PLACE CALL TO PRIMARY PHYSICIAN

ASSIST WITH CPR…2-MAN RATIOADULT 30 : 2CHILD OR INFANT 15 : 2

Intent of Drug Therapy

Restore Adequate Cardiac Function

Slow Rhythms vs.

Fast Rhythms

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

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).

Oxygen Cardiac arrest results in:

decreased cardiac outputdecreased oxygen to cellsanaerobic metabolismmetabolic acidosisblunting of beneficial drug and

electrical therapy Bag/Mask Ventilation – 1 breath

every 5 – 6 seconds

Quick Review Shock (if indicated) as soon as the

defibrillator is available: Monophasic defibrillator…360 joules Biphasic defibrillator…120 – 200 joules Unknown type defibrillator…200 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)

Quick Review

Slow Rhythms: Oxygen External Pacing; Epinephrine;

Atropine Fast Rhythms:

Oxygen…IV…Wide or Narrow complex Stable

Medications Unstable

Emergency synchronized cardioversion Pulseless

Defibrillation

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 don’t know something

ASK! Debrief after the Code

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?

Ethical Dilemmas

No one agrees on degree of care & the patient is ‘OUT’

Where is the patient’s official advanced directive?

Conflicts can be averted

NO CODES

LEVEL OF CARE

WITHHOLDING/WITHDRAWING TREATMENT

CHART BINDER

PATIENT DEATH

•FAMILY SUPPORT•ORGAN RECOVERY AGENCY…1-800-362-6169•POST MORTEM CARE•NOTIFICATION OF CORONER•FUNERAL HOME NOTIFICATION•DEATH OF A PERSON WITH AN INFECTIOUS

DISEASE (RED TOE TAG)

DEATH and DYING

DENIAL

NumbnessNo, can’t be meDisbelief

ANGER

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

BARGAINING

Often becomes guilt “If you let me live I will….” Consider consulting chaplain or social

worker

DEPRESSION

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

ACECPTANCE

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

PATIENT DISCHARGE

•AMA DISCHARGE

•INSTRUCTION SHEET SHOULD BE

COMPLETED IN LAYMAN’S TERMINOLOGY

•ESCORT FROM THE BUILDING

•DOCUMENTATION IN NURSES NOTES

•MEDICAL RECORDS FORMS