Nursing Interventions for Abnormal Situations

NurseOnAMotorcycle, ASN, RN · Feb 14, 2014

Hiya RescueNinja (I love that name, btw!) The best information you can get is to take an ACLS class. It pretty much covers most shock situations.

Waiting for a code team, I would 1.Do what I could to help the pt (CPR ABCs), then grab the pt's chart and have it open to answer questions with "Current condition, comorbidities, medications...". You can never go wrong with remembering your CPR basics!

Also, I love the book: Quick Reference for Critical Care.

Basically, there are 2 questions.

1. Why is the patient having those problems?

2. How do we fix it?

Finally, JUST REMEMBER THIS: You are not alone!! Other nurses, etc are there to help you. If you are out of ideas, I can guarantee that they are not.

Biffbradford · Feb 14, 2014

Not what you want to hear, but experience will teach you signs of impending doom, and not everyone my pick up on the same clues. WHile being text smart is great, there are things that are just not written in books that you just have to learn from the school of hard knocks. :nailbiting: :woot:

SubSippi · Feb 14, 2014

Also, in a situation like with the pt with high blood pressure, make sure you know which BP meds they are on, how much, and when the last time they got them was. Know if you have any PRN medications ordered. Know what they've been trending at, and their history. If the pt was in respiratory distress, you should check O2 sats, and if they're low, first sit the bed all the way up, then bump their O2 up to 6 (if they have a nasal cannula), and if that doesn't work fast, have someone get you a non-rebreather and turn the O2 up more. With a BP that high I would assess for s/s of a CVA.

On a med/surg floor the most important thing is that you can communicate the info to the code or RR team that they need to know to help the pt. If the pt is really bad off, they will probably be transferred to the ICU or IMU, so you don't have to worry about how to handle it after that.

brownbook · Feb 14, 2014

I am the queen of dear in the headlights. When my patient goes sour I can't remember ANYTHING. This is after almost 30 years of nursing. I must have the strongest flight response ever measured!

First thing I do is a phony chuckle or laugh....under my breath.......think ha ha ha...my patient is trying to die, isn't that funny. It really helps decrease my tension so I can think!

Try to relax, breath deeply, think ABC, Airway berating circulation. So if those are kind of okay the patient is still A & O, then what?

Their heart rate is 38 or their BP is 240/108. (Ha, ha ha. Isn't that a funny HR.). When I am panicky I can't remember drugs vs other interventions, I keep a tiny cheat sheet taped to my badge for low and high heart rates.

There are easily ten to forty "things" you can, should, try to do all at the same time. You will get lots of great advice here. Calmly call for help. (When help arrives it is your chance to sneak out of the room, ha ha ha just joking.)

RescueNinja2013 · Feb 17, 2014

Thank you all for your responses! I appreciate them, please keep them coming! Brownbook, you had me chuckling. What's on your cheat sheet for low and high BPs? C'mon, share the love lol.

brownbook · Feb 21, 2014

My cheat sheet is at work. I will give you my answers on Monday. It is for low and hi HR's not BP's.

RescueNinja2013 · Feb 21, 2014

Great! I appreciate it Brownbook!

brownbook · Feb 21, 2014

There is a really good nursing thread titled Black Friday Code Blue. But the original post is what NOT to do. Go to the last page of replies and read CodeTeamB's response. That is what to do.

The whole seizure scenario doesn't make a lot of sense. A seizure is a seizure, I am NOT a seizure expert but generally seizures don't cause, or end in, a patient needing ACLS or even BLS interventions? So don't let the post scare you about seizures.

For about 10 years I was actively involved in responding to or working where ACLS was used with some frequency. So I knew the drugs and interventions. The deer in the headlights didn't show up very often.

For the last 15 years I have worked out patient surgery. Luckily, thankfully, for me I haven't been in a code. I still have to renew ACLS. But ACLS is like learning a foreign language, or any knowledge. If you only retest it every two years and never use it....well you (I) forget most of it.

What I'm trying to say is it isn't hard if you do this stuff frequently. But if you only exposure is every few years.....then forgedaboudit ....just know how to call the code team or rapid response team. Good BLS is the most critical intervention.

kaylee. · Feb 22, 2014

I would just add something, as a very new grad, it is imperative to not try to remember everything for an emergent situation. The first things to remember are the very basic ABCs, and STAY with the patient. The first safe moment you get, grab ur phone from ur pocket and call a seasoned nurse. Usually the charge. They will b there in a split second and with their years of wisdom will guide what to do. After a few times you will start to catch things, but a text book cannot teach you what to do with a new experience. Use the text to tie up your knowledge after u have a clinical situation (next day i mean).

I am 8 months in and i always call the charge or break nurse to keep them informed, even if i feel i have a handle on things. If its respiratory, u will want to call the RT on the floor too...

I learned this as i went along...but one thing i make sure i do before things get crazy on a shift, is spend 20 minutes at the start to read and understand the patient's history and current reports and labs. Then when the RRT does get there you can answer their questions and be the source of knowledge for the patient.

brownbook · Feb 22, 2014

I got my cheat notes. I typed them in a small font and printed them on pink paper, cut the paper down to 2 1/2 by 1 1/2 inch size, scotch taped it, punched a hole in the top, and put it through a loop on my name badge.

However this is the perfect example of A LITTLE KNOWLEDGE IS A DANGEROUS THING. I have taken ACLS at least 15 times, I have used some of these drugs and interventions. So I know how to use them under a Dr's supervision.

These interventions are for "STABLE" patients, still A & O, breathing on their own, talking, etc.,

You will not, should not, cannot, be doing any of this without the direct supervision of a Dr. or code team.

BRADY

O2, monitor,

atropine .5

TCP

TACHY

O2, monitor

VAGAL

Adenosine if regular

Sync Cardio Vert

BB's (lol)

Ca+ (nifidipine

diitiazem,

verpamil)

Monitor is the bed side monitor, 3 lead EKG, O2 sat, and auto BP cuff. If no bedside monitor, get a portable one (or the crash cart monitor.) O2 can be, simply putting a nasal cannula on 2 - 4 liters, doesn't need to be any fancy face mask. TCP is trans-cutaneous pacing.

Vagal is vagal maneuvers, you can Google that, sync cardio vert is synchronized cardio vert. BB's is beta blockers..... lol is my cheat way to remember beta blockers end in lol, propanalol, metropolol, etc. Ca+ is calcium channel blockers and I listed some common ones.