Reporting during a rapid response or Code Blue

[bakpacker13]

i have been a nurse for less than a year on surgical floor that more often than not gets medical clients. i have already had to call a few code blues and rapid responses. however, when i call the code or rapid response, i am never quiet sure what to tell the doctors when they finally get there.

example :

doing primary care on 3 clients from 1930 to 2359 all stable and doing well. however, at midnight got report on 2 additional clients that i had never seen before. one client was there for pre-op for a lap chole (this guy was basically a walkie talkie), the second client however was my main event of the night.

when i first got report i was told that he came in 5 days ago from the er with a strangulated hernia, he was pod #5 and had previously been in 5 point restraints and had a sitter with him, he was currently allowed to ambulate ad lib. the client also had a history of etoh, his last drink was 5-6 days ago. currently the client had already took out his iv x2 during days and evening. the previous nurse got another iv started and had just started to give him the start of his 2200 medications. when i first assessed him, about 0015, he was a little hostile however i had expected it given his history. all of his vitals were within normal limits bp116/74, hr 115 (normal for him x5days), rr 16, p02 93% on room air, and a/o x 2 (person and place). by the time i got his 3rd ivpb he was stating that he was going home in the morning and he was not going to be taking anymore medication, i had his last ivpb to give but he refused to let me start the new bag (i educated the reason for the ivpb and what it was for, but he still refused), i consulted my charge and she stated to chart it as refused and just keep watching him. he later took out his iv again and refused to let me start another, i documented and kept going in offering to start another iv. around 0500 he agreed to let me start an iv, he was (i don't know how to say this) he was acting weird!!!. at first i thought he was just playing around but when i said he was acting like a silly monkey. he started chanting "i'm a monkey, i'm a monkey." and other off the wall comments. something was not right. i called my charge and another nurse (who had him the night before) in to talk to him immediately. he was no longer able to say his name, only my name and he had urinated all over the bed, pupils were sluggish to respond, his vitals were all within 1-2 points of the previous vital check, his blood sugar was 105, physically he was fine, however mentally he was not there. i tried calling his doctor twice but she didn't call me back so my charge said to call the rapid response team. when they showed up i told them his vitals, the surgery he had, what had happened during my shift, but they kept looking at me like they wanted more information. i had this guy for 5hrs between dealing with him and my other 4 clients, all primary care, i didn't have time to sit down and go through past charting, i didn't know what else to tell them other than what i had seen during the last 5 hours. when it was all done and over with the abg c/ lytes were normal except his k+ was 2.7, the cbc was all normal, and here's the real kicker he was back to his cantankerous self saying his name and where he was, like nothing ever happened.

now to end this long winded scenerio, what else could i have told the doctors, is there a checklist that i can go through to give the doctors all the information that they need? i just want to be able to give the information in short effective manner.

[UM Review RN, ASN, RN]

You did just fine, don't worry about that. Just give them all the vitals that you know and tell them that the patient's behavior and LOC has changed dramatically from AOx3 to blahblahblah. If it's long-winded, it's long-winded because of all the changes you noted.

Hopefully they decided to get a neuro consult with a carotid US, a head CT, and a brain MRI. And also, because of his ETOH hx, I'd be completing a CIWA scale at least once a shift for the next couple of days, just to r/o that, even if it is a pretty remote possibility. Definitely do neuro checks over the next couple of days. Did anyone check his belongings to make sure he wasn't holding any contraband?

[Mr Ian]

Now all that real nursing stuff scares me... talk about HRs and BPs and PO2s and stuff just goes over my head.

But give me weird anyday and I'm happy as a pig in muck.

I'll assume you know the general stuff to call a physical code and what S/S to go by. But I think you didn't do wrong in this scenario tho a more experienced nurse may have delayed a little longer. No biggie - that will come in time and experience.

His physicals were not abnormal but his behaviour was indicative of some other sort of stuff going on for which there was no ready explanation.

It might have helped if you'd had some indication of what might have been wrong - or causing the behaviour - like a working diagnosis that we usually have for ?MI; ?CVA; etc before calling a code.

Even tho info is limited, with his history I'd be immediately looking at a working diagnosis of ?Delirium.

It's a frequent ICU event so your code team should have made necessary review to identify a potential cause - current medications; alcohol withdrawals; head injury. Delerium is a serious event with significant mortality rate if untreated.

For this reason alone you were right to call them, even just to exclude.

For odd behaviour like this - complete a mental state assessment and apply a GCS at intervals of 2-5 mins while awaiting the medical assistance to arrive. As a nurse there's not a lot else you can do.

The Intensive Care Delirium Screening Checklist is more relevant but you're not on ICU

Here's some stuff from NIH: (Admin staff: Am I allowed to reference websites of relevance?)

Exams and Tests

http://www.nlm.nih.gov/medlineplus/ency/article/000740.htm

The following tests may have abnormal results:

• An exam of the nervous system (neurologic examination)
  
• Psychologic studies
  
• Tests of feeling (sensation), thinking (cognitive function), and motor function
  

The following tests may also be done:

• Ammonia levels
  
• B12 level
  
• Blood chemistry (chem-20)
  
• Blood gas analysis
  
• Chest x-ray
  
• Cerebrospinal fluid (CSF) analysis
  
• CPK
  
• Drug, alcohol levels (toxicology screen)
  
• Electroenceophalograph (EEG)
  
• Glucose test
  
• Head CT scan
  
• Head MRI scan
  
• Liver function tests
  
• Mental status test
  
• Serum calcium
  
• Serum electrolytes
  
• Serum magnesium
  
• Thyroid function tests
  
• Thyroid stimulating hormone level
  
• Urinalysis
  

[UM Review RN, ASN, RN]

Yes you are, Mr. Ian, reference away! :)

[HouTx, BSN, MSN, EdD]

I guess your facility has not implemented "SBAR" communications? We have found that it really facilitates communications with the physician... they love it because it 'cuts to the chase'. Here's an IHI website that provides a good overview of the technique.

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

[reisling]

any advice for a new rapid response nurse. I feel like I need to make a diagnosis the minute I walk in the room, The nurse training me is no help at all.

[patwil73]

any advice for a new rapid response nurse. I feel like I need to make a diagnosis the minute I walk in the room, The nurse training me is no help at all.

You will get much faster with your diagnosis after having seen a lot of problems. At the start, just play detective - gather all the information you can and start eliminating systems: ie, is this a respiratory problem (no), ok, is cardiac the issue (no), ok is it neurological (yep), ok what type of problem could it be?

What I like to get in report when I respond to a rapid response is: What the main problem that they called me for? How is that different than before?

So in the case of the OP - when i walk into the room and ask what is wrong, I would like "pt is having an acute change of LOC. I 've had him since midnight and he went from a&o*2 to completely unoriented. His pupils are now sluggish and he has lost bladder control."

This tells me why I am here, so i can start gathering information. Disclaimer here as everyone is different - I prefer now to ask questions rather than have someone just rush through everything they can think of to tell me because the asking questions allows me to order it better in my mind - however some people might want all the info you can give.

So I'll start by asking the simple questions that could lead to change in consciousness - 1) Did he have any narcotics or benzo's recently? (No) 2) Is his sats low? (No) 3) Is his blood sugar low (No) -- each time I am mentally crossing off what might have caused the behavior.

At the same time I am gathering information I am directing more gathering - such as an ABG by RT, a stroke exam by me, labs by our tech, ekg by another RT - basically anything that can help me pierce together what has happened.

Once I get through the obvious, we start over. 1) Any change in vitals (No) 2) Any other change in behavior prior to this? (possible - going home, no need for meds) 3) Any pertinent history as to why he would want to go home (yep - etoh). 4) Why did he come into the hospital (hernia repair).

So in the end I have crossed off respiratory (unless abg came back acidotic), cardiac (unless ekg shows change in rhythm), medication (unless recent narcotic/benzo), metabolic (glucose is normal), infection (no since cbc and temp normal) - and have settled on neuro (possible tia versus seizure).

So as best as i can say a checklist for me would be:

What is the reason you called and why do you think it was important.

What have you given recently or what vitals might account for it.

Why is he here, and what other history do you think is pertinent.

When you call - always have the chart in the room and if you do electronic charting have the computer up and running. Get a blood glucose immediately if at all appropriate.

Hope this helps

Pat

Remember also to take a deep breath. When people get nervous (as a stressful situation can do) they tend to talk really fast and jump from area to area. If your patient is breathing and has a strong pulse - you got a little bit of time for us to assess and you to go over the problem.

[NeosynephRN]

It sounds like you did fine...but please keep that up. As a member of the rapid response/code team there is nothing worse than coming to help out, or run a code and have the primary nurse disappear. You may have had this patient for 3 days, 10 hours or 15 minutes, but that is all longer than I have! I do not come down to RR a patient and want to do your job on top of mine. I am happy to help and I love it when you call, because that means we are all working together to help this patient. I do not like to try to give report to an MD on a patient that I just walked in the room, I do not want you to hand me the phone to talk to this patients brothers, best friend.

I cannot even count the times that I have gone to a RR or a code and arrived with no nurse in the room, and no one in sight....more common on RR than codes obviously. Trust us we understand that you cannot know every little thing about your patient, but help me find stuff out! You may not know the potassium on spot, but be able and willing to look it up that goes a long way!!

Keep up the great work!!! You did fantastic.

[bakpacker13]

Thank you everyone that has given tips and ideas of how to report off. I have been in a few more codes and have gotten better at providing information to the RR team and the MDs. Luckily all pt. info is on the computer so more often than not, now, I just drag the computer in the room and can now rattle of more info even if I have only had the pt. for 6mins (Yes it has happened).

So thank you again!