Dear code blue/ rapid response team nurse's ?????

[p123]

I have an assignment were I am the code blue nurse. I have been called to a med-surg floor to assess a client who has had abd. surgery, a jp drain placed and is holding their stomach complaining of pain. We have to give a 15 to 25 min presentation on just the information given in bold. We can go any route from "Whats the first thing to do, what to expect, any complications, anything is a go. I need at least three scenerios to go with and just need some general information to get started.

Please help me.

Rn student

[ghillbert, MSN, NP]

First thing I'd worry about is internal bleeding, wouldn't you?

[hawksit]

When I show up at rapid responses on med-surg floors I am always amazed that they seem to do so little.

The absolute first thing you need to do is A-B-C's. People who aren't around that situation often seem to freeze and forget their basic training sometimes. Get some vitals, hook them up to a monitor, give them some oxygen. It doesn't matter what kind of rapid response you go to you need these things on a patient.

I went to a rapid response the other day and the lady was complaining of severe back pain...upon entering the floor no one had take vitals or done basically anything for her except given more pain meds. After looking at her 50/30 BP is was pretty quickly decided that some serious action needed to be taken.

[Daytonite, BSN, RN]

yes, assess abcs first. then, considering that the patient has had surgery, consider the signs and symptoms of the complications of surgery and anesthesia:

• breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  
• hypotension (shock, hemorrhage)
  
• thrombophlebitis in the lower extremity
  
• elevated or depressed temperature
  
• any number of problems with the incision/wound (dehiscence, evisceration, infection)
  
• fluid and electrolyte imbalances
  
• urinary retention
  
• constipation
  
• surgical pain
  
• nausea/vomiting (paralytic ileus)
  

once abcs are ruled out, and signs and symptoms of shock and hemorrhage also ruled out, i'd be looking at the signs and symptoms for ileus, wound evisceration, wound dehiscence and wound infection (in that order). this is just overview. you really need to delve into the specifics of each.