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Lev <3, BSN, RN 45,741 Views

Joined Jun 3, '11 - from 'Another planet'. Lev <3 is a ED Registered Nurse. She has '4' year(s) of experience and specializes in 'Emergency - CEN, upstairs, troll bashing'. Posts: 2,772 (53% Liked) Likes: 5,134

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  • Apr 23

    Metabolic has to do with the kidneys and digestive system and respiratory has to do with the lungs and respiratory center in the brain.

    Think about buffers for each of these systems. That is the difference between the two types of imbalances.

  • Apr 22

    I have never worked on a step down unit but I have worked (inpatient) med-surg and I have transferred many patient from the ED to stepdown units so I am familiar with the acuity level (which varies from hospital to hospital)..

    General advice for an internship: Treat it like a job

    Be on time (early)

    Be prepared (stethoscope, pen, penlight, scissors, badge, any necessary paperwork etc)

    Be ready (to act quickly in an emergency situation)

    Introduce yourself.

    Have good communication. Inform your preceptor ahead of time if you will be absent. Make eye contact. Speak clearly and carefully and respectfully. Communicate messages as soon as possible.

    Know your limits. You are a nursing student, not a nurse. And not a doctor.

  • Apr 22

    University of Maryland School of Nursing B (public)

    Notre Dame of Maryland University School of Nursing B private)

    School of Nursing at Johns Hopkins University B (private)

    Salisbury University B (public)

    Towson University B (public)

    Stevenson University B (private)

    Anne Arundel Community College A (public)

    Cecil Community College A (public)

    Carroll Community College A (public)

    Howard Community College A (public)

    Hagerstown Community College A (public)

    Harford Community College A (public)

    College of Southern Maryland A (public)

    Wor-Wic Community College A (public)

    Maryland RN programs (the ones with consistently good NCLEX pass rates).

  • Apr 21

    Sir! I said I needed to listen to your heart and lungs, not put in a foley!

  • Apr 21

    Sir! I said I needed to listen to your heart and lungs, not put in a foley!

  • Apr 20

    Sir! I said I needed to listen to your heart and lungs, not put in a foley!

  • Apr 19

    Sir! I said I needed to listen to your heart and lungs, not put in a foley!

  • Apr 16

    University of Maryland School of Nursing B (public)

    Notre Dame of Maryland University School of Nursing B private)

    School of Nursing at Johns Hopkins University B (private)

    Salisbury University B (public)

    Towson University B (public)

    Stevenson University B (private)

    Anne Arundel Community College A (public)

    Cecil Community College A (public)

    Carroll Community College A (public)

    Howard Community College A (public)

    Hagerstown Community College A (public)

    Harford Community College A (public)

    College of Southern Maryland A (public)

    Wor-Wic Community College A (public)

    Maryland RN programs (the ones with consistently good NCLEX pass rates).

  • Apr 16

    University of Maryland School of Nursing B (public)

    Notre Dame of Maryland University School of Nursing B private)

    School of Nursing at Johns Hopkins University B (private)

    Salisbury University B (public)

    Towson University B (public)

    Stevenson University B (private)

    Anne Arundel Community College A (public)

    Cecil Community College A (public)

    Carroll Community College A (public)

    Howard Community College A (public)

    Hagerstown Community College A (public)

    Harford Community College A (public)

    College of Southern Maryland A (public)

    Wor-Wic Community College A (public)

    Maryland RN programs (the ones with consistently good NCLEX pass rates).

  • Apr 15

    Initial Response:

    Oh no! Your patient has gone unresponsive on you. First thing to do is a quick pulse check of their carotid artery.

    If you do not detect a pulse within five to ten seconds and your patient wishes to be resuscitated, call for help. Send one person to call the code blue and another to grab the crash cart and defibrillator. Then flatten the bed (max inflate the mattress if you know how) and "jump on their chest" and start compressions. The current Advanced Cardiovascular Life Support (ACLS) guidelines from the American Heart Association call for a compression rate of 100 to 120 compressions per minute.

    (If your patient has a pulse, but is not breathing or is breathing very slowly or ineffectively, call for help (code blue) and start providing rescue breaths with a bag valve mask device or “ambu bag" at a rate of one breath every five to six seconds. Give each breath over one second.)

    Getting help - time for some delegation!

    Make sure your charge nurse and the patient’s doctor or provider is aware. Once help arrives, quickly place the patient on the backboard. One staff member should start manually bagging the patient with a bag valve mask device at a compression to ventilation ratio of 30 compressions to two breaths. The other person should hook the patient up to the defibrillator. While your coworker is getting the pads on, continue compressions or switch off with someone if you are tired. In general, someone should switch off doing compressions every two minutes.

    Defibrillation:

    There are two popular methods of placing defibrillator pads. The method seen most publicly is anterior-lateral placement. This is usually the method illustrated on the package of the defibrillator pads seen in AEDs. Anterior-lateral placement is great for defibrillation but not for pacing. Anterior-posterior placement is ideal for both pacing and defibrillation, but requires the patient to be turned to place the second pad under the left scapula. When placing the pads, try to avoid nipples. Quickly shave the chest if chest hair is preventing the pads from making contact with skin. Avoid placing the pads over a pacemaker site to avoid damaging the pacemaker.

    The defibrillator located on inpatient units generally has two modes. There is the automatic external defibrillator (AED) mode - which is similar in functionality to the AEDs used in the public setting. These defibrillators recognize a fatal arrhythmia and advise a shock if indicated. The other mode is manual where a person who is competent at cardiac arrhythmia recognition recognizes a shockable arrhythmia (either ventricular fibrillation (VF) or “V-fib” or ventricular tachycardia (VT) or “V-tach.”). Follow your unit and institutional policies and standards for energy selection if your unit uses defibrillators in manual mode. If using a defibrillator in AED mode, pause compressions while the defibrillator is analyzing the rhythm and then resume compressions until the “all clear” is given before a patient is shocked. As soon as the patient is shocked, compressions should be restarted for a full two minutes. When using a defibrillator in manual mode, compressions need only be paused for the shock and then resumed immediately after defibrillation.



    Lots of things to do:

    Before the resuscitation team arrives there are a couple things that can be taken care of.

    1) Make sure that there is suction set up in the room. It is good practice to have suction set up in your rooms at the beginning of the shift.

    2) Get a second and ideally third IV line and draw blood if possible. Have a liter of normal saline hanging and ready at the bedside. It is helpful to have running IV fluids to help flush medications and to make sure the IV is patent. It is also helpful to have some flushes ready.

    3) Check a finger-stick blood glucose level. Hypoglycemia is one of the causes of cardiac arrest.

    4) Have the patient’s labs, previous vital signs, medications, and past medical history at easy access.

    When the resuscitation team arrives:

    The “code” team is made up of critical care staff and may include nurses, a physician assistant or nurse practitioner, a respiratory therapist, an attending physician/hospitalist and/or a resident physician.

    The respiratory therapist should take over bagging the patient. In some hospitals respiratory therapists routinely intubate while in others they just assist with intubation.

    The PA or doctor may recommend a 1mg dose of epinephrine. Epinephrine or Adrenaline is a poten vasoconstrictor which is a naturally occurring catecholamine in the body, responsible for the “fight or flight” response of the sympathetic nervous system. Per ACLS protocols, a dose of epinephrine can be given every three to five minutes. The lower concentration of epinephrine (1:10,000) is used for cardiac arrest contrary to the epinephrine in epi pens used for anaphylaxis.

    The team will try to find and reverse the possible causes of the cardiac arrest. These are known as the "Hs and Ts."

    Other medications given during codes:

    Narcan - given to counteract opioid overdose.

    Sodium bicarbonate - given for hyperkalemia and acidosis.

    Calcium gluconate/calcium chloride - given for hyperkalemia or hypocalcemia or suspected calcium channel blocker/beta blocker overdose.

    Magnesium sulfate - given for hypomagnesemia, hypokalemia, V-tach, or Torsades de Pointes.

    Dextrose - given for hypoglycemia.

    Amiodarone - antiarrythmic sometimes given after the first shock for V-fib or V-tach arrest.

    TPA - may be given in the setting of known embolism, pulmonary or otherwise.

    Lidocaine - not part of ACLS algorithms, but still given at times for wide complex tachyarrythmias such as V-tach.

    IV fluids - given for hypovolemia/support hemodynamics.

    Note: When a patient does not have a pulse, there is no need to inquire about a patient’s blood pressure. Without a perfusing rhythm, there is no self regulated blood pressure. Effective compressions can create a good blood pressure but any blood pressure measured while the patient is pulseless is really a waste of time.

    Intubation:

    The patient may be intubated with an endotracheal (ET) tube during or after the resuscitation attempt. Once the patient is intubated, tube verification is done by listening for breath sounds in both lungs and by listening to the stomach to make sure no gurgling is heard (indicating esophageal intubation). Watch for abdominal distention which can indicate esophageal intubation.

    Tube placement should also be verified through some sort of carbon dioxide (CO2) detection - either through waveform capnography on the monitor which shows end tidal carbon dioxide (EtCO2) or through a clip attached to the tube and bag valve mask which changes color when it detects carbon dioxide after the patient is bagged a couple times. EtCO2 measures the amount of carbon dioxide present at the end of exhalation and is normally 35 to 45 mmHg. Sometimes it is monitored during resuscitation attempts to gauge the quality of compressions and to help determine if spontaneous circulation returned indicated by a sharp increase in EtCO2.

    Link to a video about end tidal CO2 for those interested


    Once intubation occurs, the patient should continue to be bagged at a rate of six breaths per minute until the ventilator is attached. If the patient survives the resuscitation attempt, final verification of ET tube placement will be done by chest x-ray.

    Rhythms:

    Note: Effective compressions can look a lot like the V-tach shown in the first rhythm video below. Make sure to pause compressions before analyzing the rhythm.

    Ventricular Tachycardia (VT) - Rate >100 usually >120, can have pulse, must shock immediately if no pulse or unresponsive.



    Torsades de Pointes “Torsades” - A type of VT, no pulse, give magnesium IV push



    Ventricular Fibrillation (VF) - No pulse, must shock immediately



    Asystole



    After the code:

    Most patients do not survive resuscitation attempts. Some survive but with very diminished brain function. Do not expect your patient to wake up after CPR. The ones more likely to wake up right away are those who were successfully shocked immediately after the occurrence of a fatal shockable rhythm like ventricular tachycardia.

    To give the patients the best chance of consciousness after cardiac arrest, patients are cooled temperature of 32 to 36 degrees Celsius. The cooling process, also known as targeted temperature management (TMM), is usually initiated in the ICU.

    A debriefing process, either directly after the code, a couple hours after the code, or scheduled for another day is a good way to help staff members deal with any feelings they have after the resuscitation and to allow staff members to ask questions.

    Sources for information and BLS and ACLS algorithms:

    Adult Basic Life Support and Cardiopulmonary Resuscitation Quality

    Adult Advanced Cardiovascular Life Support

    Here is the link to a good code blue simulation video. I watched several of these and found this one to be the most accurate and informative. Many videos had lapses or delays in compressions that made me cringe. LINK

  • Apr 13

    Sir! I said I needed to listen to your heart and lungs, not put in a foley!

  • Apr 12

    Sir! I said I needed to listen to your heart and lungs, not put in a foley!

  • Apr 12

    Another thing to look at is the quality of the hospitals. How are their HCAHPS scores? Hospitals with low HCAHPS scores are under STRESS. I know, because I just left one (for a much better hospital). You can look up HCAHPS scores here.

  • Apr 10

    Sir! I said I needed to listen to your heart and lungs, not put in a foley!

  • Apr 10

    Quote from NursingInChaos
    Thanks so much everyone, it has been rough but I am managing. I will talk to our Chaplin at work I think.

    Last update this afternoon was that he is on the ventilator still, face is now swollen and the family said blood came out of his nose and ears . There was no blood when I worked on him at all thank goodness.

    They are keeping him on the machine for three days total and if he makes no progress then they will take him off.

    Doesnt sound good to me. But having never worked with kids I don't know the patho behind bleeding after drowning so I don't know.

    Thanks again for for all the support, it is very helpful to have someone to talk to, you all understand more than family would right now - I would just upset them if I talked openly.
    Probably DIC


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