Crash course in quick responses

widi96 · Nov 5, 2007

Your first set of vitals - I'd want to know O2 sat if they are breathing that fast. If the sat was stable I would probably call the doc immediately - if the sat is unstable, go ahead and call the rapid response team.

As for if the patient is not breathing but still have a pulse, if they aren't breathing, they won't have a pulse for very long. Go ahead and call the code.

bigsyis · Nov 5, 2007

Are you a student? A nurse? A member of the public?

poppy07 · Nov 5, 2007

new RN. what actions would you take besides sequestering the help of others? what should be anticipated?

This pt has sats in mid 90's... guidelines for increasing the O2 therapy?

bigsyis · Nov 5, 2007

When anybody has a RR of 40-50 they should be put on a NRB and you should page RT to stand by for possible intubation/and or code. With that HR it won't be long.

As far as rhythms and what to do when your patient is not breathing, but has a pulse, you should follow CPR/ACLS protocols. No resps and a pulse means A=airway. They need ventilation, or that pulse won't be felt much longer.

If the pulse is 15-30, they are in an idioventricular rhythm and you need to call a code.

Can't answer the PEEP question-never did vents.

Christie RN2006 · Nov 5, 2007

Usually if their HR is that unstable, their BP won't stay stable for long. 150s doesn't put me into "oh crap" mode... at least not in the ICU. I had a patient go into the 220s one time, their BP started bottoming out, and they looked like they were about to code...that was an "oh crap" call the doctor, get the crash cart, etc moment. (they suddenly went from NS to ST in the 160s and kept climbing from there... I started trying to call the doc shortly after they started going tachy and we ended up paging the doc 3 times by pager and twice as an overhead stat page before they finally came... I was ticked)

But for this particular scenario I would definitely want to know what their pulse ox was. If it was below 90% I would call for a resp therapist to immediately place them on a venti mask (possibly a nonrebreather depending on how low their sat was) and draw ABGs. If you work in an area that can call a rapid response team, I would do it. I work in the ICU, so we are the rapid response team, but I would definitely page for my charge nurse to come see what was going on and to help.

With that HR it could be A. Fib with RVR, ST, or SVT. SVT is usually over 150. Sometimes its hard to tell between the different rhythms, so I would most likely call for a stat EKG. Here is a good website on SVT that includes the different types and ways to treat it... http://en.wikipedia.org/wiki/Supraventricular_tachycardia

If the patient is not breathing, you need to call a code blue and start bagging the patient and have people gather supplies because most likely the doc is going to be intubating.

If the HR is 15-30 and you can't feel a pulse, call a code blue and immediately start CPR. ACLS says that if you are unsure if there is a pulse, you need to start compressions because you will do more damage not doing them than doing them. Once CPR is initiated and help is on the way, someone else can go get a doppler.

Since I work in the ICU, we have a lot of standing orders (ABGs, O2, fluid bolus, EKG, etc) I hope this helps!!

Medic/Nurse, BSN, RN · Nov 5, 2007

I'd be glad to answer any questions, I love a good clinical discussion.

What would you do if...?
Pt HR in 150s, RR 40-50?
Pt on NC 4L
B/P stable 115/89
* Hmmm, how old is this patient and are they having "symptoms" of anything?? Then physically assess the patient. Before a plan can be implemented, you gotta know what you are "treating".
How do you know when to change source of Oxygen? Any guidelines?
* Any patient in distress is getting all the oxygen I got!
How can you tell the difference btwn ST and SVT?
What do you do?
* Not sure of the question. I'm guess a SINUS Tach vs. a true SVT (above ventricular origin) Tach. Rate?, P waves present?, Regular? Then I go from there.
What do you do if pt is not breathing, has a pulse?
* This one is pretty straightforward. Ventilation per BVM with 100% oxygen. Then, I'll secure a definitive airway via ETT.
What if pt's HR is 15-30, but you can't feel a pulse...do you grab a doppler?
* Maybe after I start Chest Compressions/implement ACLS. I'm guessing that you are "seeing" this HR on a cardiac monitor - lets say you doppler a "pulse" of 15 - how long do you think that will last without IMMEDIATE intervention? I'm pretty good with a doppler, but it takes more time to "doppler" a pulse than this patient will have one.
What precautions do you take when pt is on a really high amount of PEEP on vent? Do you avoid moving them to prevent pneumos?
* PEEP can be a double edged sword in terms of compliance and hemodynamics. Further increasing thoracic pressures (or more likely inhibiting compliance with ventilatory support) could increase a chance for a pneumo, but PEEP can be turned down (or off). But, I'd think the reasonable and prudent course of action is to take the patient off the mechanical vent and manually ventilate the patient while moving them.

Practice SAFE!

angelique777 · Nov 5, 2007

What would you do if...?

Pt HR in 150s, RR 40-50?

Pt on NC 4L

B/P stable 115/89

ANSWER: Assessment first: Ask patient if they have any symptoms, do EKG to see if patient is in afib, get pulse oxy but most important ask patient what they feel are they feeling Ex if they feel SOB. Check level of orientation (Is there any change in mental Status) Call coverage person ask what meds to give based on information I have obtained Ex: If Afib they may order Cardizem po or gtts. Cant leave them for long time at this rate cause they will eventually crash.

How do you know when to change source of Oxygen? Any guidelines?

First assessment. Do pulse oxy but do not depend on that solely for your intervention must ask patient how they feel. Most know patient medical history as well. Ex COPD or if they are CO2 retainers.

If patient saturation still in 80-70 with 4lnc to 5lnc then try venti mask, if patient saturation still does not improve try 100% rebreather. Should be taking vitals and assessing lungs .

Ex: I Had a patient with sputum plug some Chest physiotherapy, nebulizer treatments and triflow helped cough it up and saturation improved. If CHF patient check lungs to see if in fluid overload may need to give lasix. Therefore assessment comes first to find source of problem so you know what treatment will be given. The masks are temporary remedies to give oxygen while you treat the problem

How can you tell the difference btwn ST and SVT?

When in doubt do EKG then call coverage patient let them know EKG done vitals done your assessment done and ask what intervention to give. They can decide from that point based on EKG. Once had a patient that look like he was in SVT based on telemetry strip but once I did the EKG you can see it actually was AFIB. Even the coverage person thought it was SVT on telemonitor. That taught me when in doubt do EKG and for those fast rates I also do EKG.

What do you do?You assess assess assess and ask coverage person what they want to do first. If patient is in VT and VF you know what to do shock for the other stuff assess patient mental status, VS, Saturation, and what symptoms patient has along with the rhythm you see. Some people live in the 120 and the doctor wont treat cause patient does not sustain the rate and is asymptomatic What is done is based on your assessment and on patient symptoms.

What do you do if pt is not breathing, has a pulse?

Try to arouse patient check airway. pt does not arouse call code Ambu patient call for help have some one do vitals, EKG etc

At our hospital code team includes respiratory therapist who will intubate if needed

What if pt's HR is 15-30, but you can't feel a pulse...do you grab a doppler?If patient on monitor and pulse is 15-30 you know you have a pulse. Do EKG to see if patient has a heart block. Patient AXOX3 asymptomatic Put patient on pacer pads with pacer at bedside, keep atropine at bedside, get vital signs, call doc. PT symptomatic maybe starting loose conciousness call code becoming disoriented may want to call code.

Is this patient a post op CABG patient for example and has external pacer wires you may have to connect external pacer and start pacing the patient.

What you do is based on patient hx, what you assess and what doc decide from there.

I Had patient SB in low 20's 23-25 26 asymptomatic no intervention given except for the pacer pads on and pacer at bedside atropine available in case needed and monitored her through out night closely plan was eventually pacemaker but in the meantime she gave me a night of anxiety:uhoh21:.......CCU would not take her cause she was asymptomatic Then you pray all night till your shift ends lol;)

What precautions do you take when pt is on a really high amount of PEEP on vent? Do you avoid moving them to prevent pneumos?

Can answer you hardly get vents do not know the answer to that.

poppy07 · Nov 5, 2007

new in ICU... I haven't gotten the EKG basic class yet, let alone ACLS. How would you know about the pacer pads? Is that learned in ACLS?

Also, what about PEA... good rule of thumb is to just go ahead with compressions if you can't get a pulse immediately?

If you're the only one in your pod in the ICU and you have a bad situation, how do you call for help?

When mentioning "moving a patient" with a high PEEP--20-25, I'm referring to repositioning, pulling up in bed, turning, etc. How do you handle?

THANKS A LOT!!! : ):balloons:

Altra, BSN, RN · Nov 5, 2007

Poppy, as a new ICU nurse these are excellent questions to start a discussion with your preceptor.

poppy07 · Nov 5, 2007

Also...a HR in the 150s and increasing for a 21 y.o. F. no PMH, 1 wk s/p c-section.... the HR is a concern...

Altra, BSN, RN · Nov 5, 2007

Poppy, I assume you're still on orientation. Are these questions a part of a critical thinking assessment?