PREFERRED NURSE STAFFING
ORIENTATION
NATIONAL PATIENT SAFETY
GOAL





Improve the accuracy of patient identification
Improve the effectiveness of communication among
caregivers
Improve the safety of using medications
Reduce the Risk of Health care-associated infections
Accurately and completely reconcile medications across the
continuum of care
Patient Safety Goals

Improve the accuracy of Patient Identification

Use at least two patient identifiers (neither to be the patient’s room
Patient Safety Goals

Improve the effectiveness of communication
among caregivers


For verbal or telephone orders or for telephonic
reporting of critical tests results, verify the complete
order or test results by having the person receiving the
order or test result “read-back” the complete order or
test result.
Standardize a list of abbreviations, acronyms, and
symbols that are not to be used throughout
organization.
Patient Safety Goals

Effective Communication


Measure, assess and, if appropriate, take action to
improve the timeliness of reporting, and the timeliness
of receipt by the responsible licensed caregiver, of
critical test results and values.
Implement a standardized approach to “hand off”
communication, including an opportunity to ask and
respond to questions
Patient Safety Goals

Effective Communication

List of abbreviations that are not to be used
Abbreviation
MgSO4
MSO4
MS
U or u
IU
Q.D., Q.O.D.
Correction
Write out name of drug
Write out name of drug
Morphine Sulfate
Write out “unit”
Write out “International Unit”
Write “daily” and “every other day”
Leading zeros ARE to be used. Trailing zeros are NOT to be used
Patient Safety Goals

Effective Communication
How Do We comply?

No more Taped Reports
Hand-off communication should take place whenever there
is a change in the patient’s caregiver
Includes all clinical staff
Report patient’s condition, tx, services, relevant historical



data and anticipated changes
Patient Safety Goals




Improve the safety of using medications
Limited Drug concentrations
Many commonly used infusions are provided in pre-mixed,
standardized concentrations (dopamine, dobutamine, milrinone,
heparin, levofloxacin)
Many compounded infusions are mixed in standard concentrations
(felnoldopam, diltiazem, nitroprusside)

Concentrated Electrolytes

Concentrated electrolyte injections (potassium chloride, potassium
phosphate, and sodium chloride) are not stored in o made available to
patient care areas. Concentrated electrolytes are only available in the
pharmacy for use in IV fluid preparation.

Patient Safety Goals




Improve the safety of using medications
Look-alike/Sound-alike drugs have been
physically separated in the
Acudose Rx cabinets and on shelves in the
pharmacy.
Drug master files are being modified to note on
the MAR which items are “look-alike/sound-alike
(Tall Lettering).
Patient Safety Goals




Medications must be delivered to the procedure
field in an aseptic manner
All medications, med containers and other
solutions on or off the field should be labeled.
Medications which are drawn up and given
immediately does not leave your hand or sight) do
not have to be labeled.
Label includes: name, strength, dosage and initials
of person drawing up meds.
Patient Safety Goals

Reduce the Risk of Health care-associated
Infections

Comply with current CDC hand hygiene guidelines.
Wash hands with soap and water when hands are visibly
soiled
Decontaminate hands with alcohol-based foam when
hands are not visibly soiled
Banning of artificial nails in the hospital-setting

Manage as sentinel events all identified cases of
unanticipated death or major permanent loss of function
associated with a health care-associated infection.
Patient Safety Goals
Accurately and completely reconcile medications across the
continuum of care
Implement a process for obtaining and documenting a
complete list of the patient’s current medications upon the
patient’s admission to the organization and with the
involvement of the patient. This process includes a
comparison of the medications the organization provides to
those on the list.
A complete list of the patient’s medication is
communicated to the next provider of service when it
refers or transfers a patient to another setting, service
practitioner, or level of care within or outside the
organization.
Patient Safety Goals
Reduce the risk of patient harm resulting from
falls
Implement a fall reduction program and evaluate
the effectiveness of the program.
Assess daily and periodically reassess each
patient’s risk for falling, including the potential
risk associated with the patient’s medication
regimen, and take action to address any identified
risks
Stickers are placed on chart, patient’s armband,
call light and the Kardex is flagged.
NO
SMOKING
Lift
Devices
Write legibly!
PATIENT SAFETY
Suicide
precautions
Never use equipment you are
not familiar with…
ask for assistance!
Safety Rails
FALL PREVENTION

EVALUATE RISK Q 8 HRS

INITIATE ORDERS

PROVIDE INFORMATION

PLACE LABELS
ACCORDING POLICY
SAFETY WITH APPLICATION
OF RESTRAINTS
 Limb
restraints
 Vest
restraints
Do not attach
to side rails
WHY USE FOOT PUMPS OR A
SEQUENTIAL COMPRESSION DEVICE?

PREVENTION OF DVT

CONTRAINDICATED
WITH EXISTING DVT
FOOT PUMP SAFETY…






SIZE
SOCK/STOCKING
INSPECT q SHIFT
REPORT ANY S/S SKIN
IRRITATION
KEEP HEELS OFF BED
REMOVE AND INSPECT
WITH ANY C/O PAIN
MALFUNCTIONING
EQUIPMENT
WHAT TO DO
WHO TO NOTIFY
EQUIPMENT MALFUNCTION




REMOVE FROM
SERVICE
TAG EQUIPMENT
FOR CLINICAL:
CALL BIOMED
ALL OTHER: CALL
MAINTAINENCE
WHEN TRANSPORTING A
PATIENT BY WHEELCHAIR…


FACE PATIENTS
TOWARD THE
ELEVATOR DOOR
MAKE SURE THE
WAY IS CLEAR
BEFORE PUSHING
THE PATIENT INTO
THE HALLWAY TO
EXIT THE ELEVATOR
CORE MEASURES
ANTERIOR MYOCARDIAL
INFARACTION
 PNEUMONIA
 HEART FAILURE
 SURGICAL CARE INFECTION
PROJECT

WHEN TRANSPORTING A
PATIENT BY STRETCHER OR BED…
KEEP HANDS INSIDE
RAILS
 USE SAFETY STRAPS
ON STRETCHERS
 KEEP OUT OF LOW
POSITION

LEAVING AGAINST MEDICAL ADVICE
•WHAT TO DO?
•WHO TO NOTIFY?
•AMA FORM
•EVENT REPORT
•DOCUMENTATION
ETHICS COMMITTE

MEMBERS

MEETINGS

RECOMMENDATIONS

EDUCATION
MEDICATION
ADMINISTRATION
Home meds



Send any meds brought to the
hospital by the patient to the
pharmacy for identification
and/or safekeeping
“Continue home med orders”
Medication Reconciliation
Form
ALLERGIES
•FACILITIES HAVE DIFFERENT
POLICIES RELATED TO
ALLERGY ARMBANDS
•KNOW WHERE ALLERGIES
MUST BE DOCUMENTED!
PHYSICIAN ORDER SHEET
FRONT OF CHART
MAR
KARDEX
PHARMACY WILL IDENTIFY
MEDICATIONS THAT REQUIRE FOOD
DRUG EDUCATION ON THE MAR
THE NURSE WILL
EDUCATE
THE PATIENT
USE THE HAND-OUTS
PROVIDED
DOCUMENT ON
PATIENT RECORD
AUTOMATIC STOP
ORDERS


PHARMACY WILL
SEND A NOTIFICATION
PHYSICIAN MUST SIGN
FOR MEDICATION TO
BE CONTINUED
MEDICATION ADMINISTRATION



STAT MEDS
NOW MEDS
GIVE ROUTINE MEDS
FROM 30 MINUTES
BEFORE TO 30
MINUTES AFTER THE
SCHEDULED TIME
KNOW POLICY !
ADMINISTERING
MEDICATIONS
OPEN THE INDIVIDUAL MED
PACKAGES AT THE BEDSIDE
 TELL THE PATIENT WHAT EACH
MEDICATION IS
 EXPLAIN THE ACTION OF EACH
MEDICATION
 IF THE PATIENT QUESTIONS THE
MEDICATION… LISTEN TO THEM!

ADVERSE DRUG REACTIONS
REPORT ADVERSE
DRUG REACTIONS TO
THE PHYSICIAN
 REPORT ADVERSE
DRUG REACTIONS TO
PHARMACY

NARCOTIC WASTING



REQUIRES A WITNESS
MISSISSIPPI LAW ALLOWS
FOR WASTING OF A
“PARTIAL, UNUSED DOSE.”
WHOLE DOSES THAT HAVE
BEEN OPENED BUT ARE
NOT TO BE GIVEN MUST BE
RETURNED TO THE
PHARMACY
WHAT IS A MEDICATION
ERROR

“Any preventable event that
may cause or lead to
inappropriate medication
use or patient harm while
the medication is under the
control of the health care
professional, patient or
consumer.”
MEDICATION ERRORS CAN
BE CLASSIFIED AS A


POTENTIAL EVENT (ERROR IS
DETECTED AND CORRECTED
BEFORE IT REACHES THE
PATIENT
ACTUAL OCCURRENCE
(ACTUALLY REACHES THE
PATIENT)
BOTH SHOULD BE REPORTED
USING AN EVENT REPORT FORM
THE FIVE RIGHTS
 RIGHT
DRUG
 RIGHT DOSE
 RIGHT ROUTE
 RIGHT PATIENT
 RIGHT TIME
MEDICATION ERRORS



DISPENSING ERRORS—EXAMPLES: WRONG
DRUG, WRONG DOSE, IMPROPER PREPARATION
ADMINISTRATION ERRORS—EXAMPLES:
WRONG PATIENT, WRONG MEDICATION,
WRONG TIME, OMISSION OF ORDERED MED,
ADMINISTRATION OF AN UNORDERED
MEDICATION
OTHER ERRORS—TRANSCRIBING ERROR,
DOCUMENTATION ERROR, ILLEGIBLE ORDERS
PREVENTING MEDICATION ERRORS
• FIVE RIGHTS
• SPELL THE DRUG
• USE OF “0” IN ORDERS
• LOOK ALIKE/SOUND ALIKE DRUGS/TALL
LETTERING
• ASSESS PATIENT CONDITION AND DRUG
INDICATIONS
MEDICATIONS
AT THE BEDSIDE





If the physician writes an order to leave
medication at the bedside, only a 24 hour supply
may be left with the patient.
No schedule drugs may be kept at bedside.
The nurse should check to ensure that the 24
hour supply is not depleted prematurely.
Document instructions to patient
Document medication administration on MAR
PATIENT EDUCATION

ADMISSION ASSESSMENT




BARRIERS TO LEARNING
SPECIFIC NEEDS
TEACH TO IDENTIFIED NEEDS
INCLUDE PATIENT, FAMILY,
SIGNIFICANT OTHER
PATIENT EDUCATION
EDUCATE PATIENTS ABOUT:
 PAIN
 MEDICATIONS
 EQUIPMENT SAFETY
 DISCHARGE PLANNING
 SAFETY MEASURES
 FALL PREVENTION
 DOCUMENT EDUCATION ON THE
PATIENT EDUCATION RECORD
HEARING AND SPEAKING
IMPAIRED PATIENTS




TELEPHONES FOR THE HEARING IMPAIRED
CLOSED CAPTION DEVICE FOR TV
SIGN LANGUAGE INTERPRETER
COMMUNICATION BOARDS
LANGUAGE PROBLEMS

ARRANGEMENTS CAN BE MADE
FOR AN INTERPETER:
 SOCIAL SERVICE
 LANGUAGE LINE
SURGICAL ASSESSMENT
PRE-OPERATIVE ASSESSMENT
History
 Personal and family history of surgery/anesthesia
experiences
 Pre-existing medical conditions & Risk factors
 Allergies
 Medications (include OTC)
 Alterations in physical & communication status
 Religious considerations
 Cultural considerations
Required Documentation



Physician History AND Physical
Lab & Diagnostic Data
Consents





Surgical and Blood
Allergies: Drugs; Foods; Latex
Medications
Special Forms: Sterilization paper; DNR;
Advanced Directives
Miscellaneous: Old Chart; X-rays; Special
Equipment
CCONSENT FORM
TIME
CONSENT
X
SIGNATURE
Know Policy for
each facility
INFORMED
CONSENT
WHEN TO
SIGN
Comfort Measures
Undergarments
 Prosthetics
 Jewelry
 Cosmetics
 Family

PRE-OP
CARE…
PRE-OP
PRE-OP MEDICATIONS
PRE-OP CHECKLIST
ARM BAND
STANDING ANESTHESIA ORDERS
Pre-op Physical Assessment

Cardiovascular




Respiratory



Peripheral pulses
Heart sounds & ECG
Venous Access
Rate, Depth, Rhythm
Breath Sounds
GU



Lab Values—BUN, Creatinine
Historical Data
Have patient empty bladder or Foley Catheter
Pre-op Assessment, Cont.

GI




Neurological




Food allergies
NPO Status
Reflux History
LOC & Orientation
Pre-existing Deficits
Communication Barriers
Musculoskeletal



ROM limitations to affect positioning
Existing prosthesis
Height & Weight on ALL patients
Pre-Op Assessment, Cont.

Integumentary
Skin turgor & general conditioning
 Rashes, bumps and bruises
 Any Breaks in Skin


Psychosocial/Educational
Anxiety level
 Support System
 Knowledge Deficits
 Discharge planning

Post-Operative Assessment

Physical Assessment post- PACU

Immediately assess






Vital Signs


Temperature
Vital Signs
O2 Saturation
LOC
Surgical Site
As ordered by physician or facility policy
Assess Surgical Site
Systematic Post-Op Assessment

Respirations




Depth, Rate and Pattern
Auscultate lung fields q 4 hours
Report rates <10 or >30
Cardiovascular







Rate, Rhythm and Quality of pulses
Compare distal pulses bilaterally along with color, sensation and temperature of
extremities
Capillary Refill Time
Homan’s sign q 4 hours
Vascular Access Devices for patency, rate of fluids & Site Characteristics
Lab Values, especially H & H
Report HR &/or BP deviating 20 beats or 20% from pre-op baseline
Systematic Assessment, Cont.

Genitourinary





Assess lower abdomen for urinary retention
Assure Foley Catheter is draining
Measure Input & Output correlating measurements
Report output <30ml per hour
Gastrointestinal




Auscultate abdomen for bowel sounds until heard in
all four quadrants
N/G tubes should be checked for placement q 8 hours
and prior to giving any medication/solutions
Maintain suction per order
Measure output
Systematic Assessment, Cont.

Integumentary






Assess thoroughly for skin integrity post-op
Assess dressings & drain sites with Vital Signs
Document time, amount, color, consistency & odor
of drainage. Report measurable drainage with
Output.
Assess skin integrity around surgical site for any
redness, blistering or signs of inappropriate healing
Report Break-through bleeding after reinforcing
dressings
Report unusual pain
Systematic Assessment, Cont.

Neurological




Assess LOC and cerebral function with V/S at minimum the first 8
hours
 Same as pre-op?
 Assess gag reflex—prevent aspiration pneumonia
Assess motor function, especially with regional anesthetics
If extremity involved, assess neuro-circulatory status
Fluid & Electrolyte Balance

Assess Hydration Status with V/S





Mucous Membranes: color & moisture
Skin Turgor and Texture
I&O
Signs of Edema/Fluid Retention
Lab Values
Post-Op ALARMS
Cool Extremities
 Low urinary output
 Slow capillary refill
 Low BP with increasing HR & RR
 Restlessness
 Anxiety
 Confusion

Systematic Assessment, Cont.

Pain
Assess Patient’s perception of pain as well as
pain relief on a 1 – 10 Scale
 Report Break-through pain or unrelieved
pain early for intervention orders
 CHECK PACU RECORD FOR PREVIOUS
PAIN INTERVENTIONS PRIOR TO
ADDITIONAL PAIN MEDICATIONS
 Remember localized pain/restlessness maybe
indicative of post-op bleeding, hematoma or
site abscess

IV Therapy
After 2 attempts—get another nurse—
after second nurse makes 2 attempts—
contact the supervisor
2 strikes and
you’re out!
No lower extremity IV sites
without a physician’s order
Pharmacy should label
solutions requiring filters
KNOW POLICY ABOUT
SECONDARY SETS
IV tubing changes every 96 to 72 hours
except for TPN –change TPN tubing every 24
hours



IV site changes routinely
every 96 to72 hours
IV site changes prn if s/s
infection or infiltration
Restart an IV that was
started in an emergency
situation where breaks in
aseptic technique may have
occurred within 24 hours.
IV solution containers should
not hang more than 24 hours
IV start Site prep--Chlorhexidine gluconate
now in IV start kit per CDC
recommendation
IV Start Kit not utilized at all facilities!
WHO CAN REMOVE CATHETERS?
RNs and LPNs may dc peripheral lines
Physicians must remove central catheters
designed for long term use (Groshong, Hickman etc)
RNs may dc PICC lines and
temporary central lines
RNs and LPNs can do IV site
care –central lines included
Central line
care is a
sterile
procedure--
IV certified LPNs may NOT:
•ADMINISTER REGLAN
•ADMINISTER PROTONIX
•ADMINISTER IV MEDICATIONS/FLUIDS
TO PEDIATRIC PATIENTS ON A MED/SURG UNIT
•ADMINISTER IV PUSHES OR BOLUSES
•ADMINISTER IV NARCOTICS
Record FLUSHES on the MAR
Know policy for
each
facility
Restrictions on IV medications--Cholinergic drugs
Curare-Type drugs
Diagnostic agents
Chemotherapy
Diagnostic dyes
May not be given by the
Med-surg nurse
KNOW POLICY
Emergency Code drugs
May be given by
ACLS certified RNs
Pediatric IVs
 Know
policy of facility
NURSING & PHARMACY
• ADVERSE DRUG REACTIONS
• MISSING DOSE FORM
• CORPORATE COMPLIANCE
ISSUES…MEDICATION
CHARGES
PATIENTS HAVE THE RIGHT TO
APPROPRIATE ASSESSMENT AND
MANAGEMENT OF PAIN
…..JCAHO


“PAIN IS AN UNPLEASANT SENSORY AND
EMOTIONAL EXPERIENCE”
TYPES:
ACUTE
CHRONIC

THE PATIENT’S PERCEPTION IS THE ONLY
WAY TO MEASURE PAIN


FOLLOWS INJURY AND
GENERALLY DISAPPEARS
WITH HEALING
IS OFTEN ASSOCIATED WITH
OBJECTIVE PHYSICAL SIGNS
OF AUTONOMIC NERVOUS
SYSTEM ACTIVITY SUCH AS:
TACHYCARDIA
 HYPERTENSION
 DIAPHORESIS
 MYDRIASIS
 PALLOR

ACUTE
PAIN
CHRONIC PAIN




CHRONIC NON MALIGNANT PAIN MAY
RESULT FROM CONDITIONS SUCH A
ARTHRITIS AND LOW BACK PAIN
MAY BE IDIOPATHIC (FROM UNKNOWN
CAUSE)
CHRONIC PAIN MAY NOT BE ACCOMPANIED
BY SIGNS OF SYMPATHETIC NERVOUS
SYSTEM AROUSAL. THE PATIENT MAY NOT
“LOOK LIKE THEY ARE HAVING PAIN”.
THE PATIENT’S PERCEPTION OF PAIN
INTENSITY IS THE ONLY WAY TO MEASURE
THE PAIN.
CANCER PAIN


MAY BE ACUTE,
CHRONIC OR BOTH
RESULTS FROM
TISSUE OR NERVE
DAMAGE RELATED
TO DISEASE PROCESS
OR CANCER
TREATMENTS
BREAKTHROUGH

PAIN THAT BECOMES
INTENSE ENOUGH TO
OVERRIDE MEDICATION
AND OTHER PAIN RELIEF
MEASURES

MAY SIGNAL THE NEED
FOR CHANGES IN PAIN
MANAGEMENT PLAN
PAIN
NOCICEPTIVE PAIN—
THE BODY’S TYPICAL RESPONSE TO
ORGAN OR TISSUE DAMANGE
OCCURS WHEN PAIN
RECEPTORS ARE STIMULATED
OFTEN DESCRIBED AS ACHING
OR THROBBING
2 TYPES:
VISCERAL –FROM
INTERNAL ORGANS
SOMATIC—FROM
MUSCLES AND BONES
NEUROPATHIC PAIN



PAIN SUSTAINED BY
ABNORMAL PROCESSING
OF SENSORY INPUT BY
THE PERIPHERAL OR
CENTRAL NERVOUS
SYSTEM
OFTEN DESCRIBED AS
BURNING, TINGLING, OR
SHOOTING
CAUSE MAY NOT ALWAYS
BE CLEAR
PHANTOM PAIN


PAIN SENSED IN A BODY
PART THAT HAS BEEN
AMPUTATED.
PAIN MECHANISM IS
GENERATED IN THE
CENTRAL NERVOUS
SYSTEM…EVEN THOUGH
ORIGINAL INJURY
OCCURRED IN THE
PERIPHERAL NERVES
PAIN ASSESSMENT
SHOULD INCLUDE








LOCATION
INTENSITY
DURATION
DESCRIPTION…BURNING,
ACHING, SHARP, DULL
TRIGGERS
CONSTANT OR
INTERMITTENT
DOES IT RADIATE
WHAT HAS HELPED IN THE
PAST
INTENSITY SHOULD BE
RATED ON A 0-10 SCALE
HOW DO WE
MEASURE
PAIN?
Document on:
Nursing Admission History & Assessment
 Plan of Care
 Patient Education Profile
 Nurses Notes Assessments and Reassessments

CHEST TUBE
DRAINAGE SYSTEM
DRY SUCTION
ONE, TWO OR
THREE
BOTTLE
THORASEAL
PLEUR-VAC
COMPLICATIONS…
requiring immediate notification of physician
•Increase in respiratory distress and/or chest
pain
•Decrease in breath sounds over the affected
and/or non-affected lungs
•Subcutaneous emphysema
•Asymmetric chest movements
•Hypotension
•Tachycardia
•Excessive blood loss
•Mediastinal shift
•Cyanosis
SHIFT ASSESSMENT INCLUDES
•Rate and quality of respirations
•Auscultation of lungs to assess air exchange
•Presence or absence of bubbling or tidaling in
the water-seal chamber
•Palpating the area surrounding the dressing for
subcutaneous emphysema
•Amount, color, and consistency of drainage
•Pain assessment and interventions
•Type of chest drainage system used
•Amount of suction (if in use)
•Frequency of system inspection
•Evaluation of chest tube connector
WHEN TO CLAMP CHEST TUBES
2 RUBBER SHOD OR PLASTIC CLAMPS AT BEDSIDE
Changing the
Drainage
system
CHEST TUBES
ARE ALWAYS
DOUBLE CLAMPED
Assessing for
an air leak
Preparing for
chest tube
removal
CHEST TUBE DRAINAGE TIPS


ALLOW NO KINKS OR DEPENDENT LOOPS
TO CHANGE SYSTEM:






PREPARE NEW SYSTEM
TURN OFF SUCTION
DOUBLE CLAMP TUBE
QUICKLY DISCONNECT OLD AND CONNECT NEW
IF TUBE DISLODGES: COVER SITE WITH
VASOLINE GAUZE/ CALL PHYSICIAN
IF SYSTEM BROKEN: INSERT
UNCONTAMINATED TUBE END IN BOTTLE
STERILE WATER. SET UP NEW SYSTEM
TRANSFERRING THE PATIENT
From unit to unit:
•The transferring unit writes the transfer orders
•The receiving unit transcribes the orders
•If the patient is deteriorating, the patient is
transferred and then the paperwork is completed
•Be sure that all belongings go with the patient
•Notify the physician and family of room change
•Report shall be given following “Patient Handoff Goal”
CARDIOPULMONARY ARREST
CODE TEAM WILL
RESPOND TO THE
ROOM OR AREA
 CPR, ACLS, PALS,
NCR, AS NEEDED

Making Assignments







Who’s in charge?
Who is going to get the code
cart?
Who’s applying leads to check the
patient’s rhythm & recording a
strip for the MD?
Where is the patient’s chart?
Has the physician been called ?
Is anyone writing?
Does the IV work and who is
giving meds?
First Priority in a Code



Basic CPR, early defibrillation if indicated
and airway management.
1st Rescuer initiates CPR
Know the main code medications
-- location in the code cart
-- how to assemble the syringes
--appropriate dosage and mechanism of
action
-- route(s) of administration
RESCUER # 1
 ASSESS FOR UNRESPONSIVENESS;
NOTE THE TIME
 CALL FOR HELP…
 PUT THE PATIENT FLAT IN THE BED
 LOWER THE SIDE RAILS
 USE STANDARD PRECAUTIONS
 OPEN THE AIRWAY; HEAD-TILT/CHIN-LIFT
 LOOK, LISTEN AND FEEL
 USING BARRIER DEVICE, GIVE 2 BREATHS
OVER:
ADULTS 1 SECOND PER BREATH
CHILD/INFANT 1 SECOND/BREATH
 ESTABLISH PULSELESSNESS
CAROTID PULSE: ADULT & CHILD
BRACHIAL PULSE: INFANT
 PLACE BACKBOARD UNDER PATIENT
 BEGIN CHEST COMPRESSIONS:
100/MINUTE ADULT RATIO 30:2
100/MINUTE CHILD RATIO 30:2
100+/MINUTE INFANT RATIO 30:2
HELP IS ON
THE WAY!
Anyone who records on
the CODE record must
sign it
The physician must also
sign the CODE record
RESCUER # 2
RESCUERS # 2 & 3

CALL CODE IF NEEDED

CRASH CART TO ROOM

ASSIST WITH PLACING BACKBOARD

CLEAR FURNITURE

USE STANDARD PRECAUTIONS

HOOK UP OXYGEN AND AMBU

SET UP SUCTION; GET OUT TONSIL
SUCTION AND SUCTION KIT

PREPARE TO START IV…RUN FLUID
THROUGH IV TUBING

CONNECT MONITORING LEADS
WHITE ON RIGHT CHEST
BLACK ON LEFT CHEST
RED ON LOWER LEFT CHEST

PATIENT RECORD TO ROOM

PLACE CALL TO PRIMARY PHYSICIAN

ASSIST WITH CPR…2-MAN RATIO
ADULT 30 : 2
CHILD OR INFANT 15 : 2
Intent of Drug Therapy


Restore Adequate
Cardiac Function
Slow Rhythms
vs.
Fast Rhythms
Administration of Code Medications



Intravenous
-- Peripheral vein 1st choice (antecubital or
external jugular) and follow with 20cc NS
-- Elevate the extremity
Endotracheal Tube
-- ALE = Atropine, Lidocaine, Epinephrine
-- Give 2 – 2.5 times IV dose in 10cc NS or
sterile water
-- Give through a catheter, stop compressions,
bag quickly x 2, and resume compressions.
Intraosseous… Preferred over ET route
-- Peds – Anterior Tibia Bone
-- Adults – Distal Radius
Administering Code
Medications (continued)



Two nurses are involved:
-- one at the code cart
-- one at the bedside
State the name of drug and dosage aloud
and clearly for accurate documentation as
well as clarity for the code team.
Shock or continue compressions after each
medications (per ACLS protocol).
Oxygen


Cardiac arrest results in:
decreased cardiac output
decreased oxygen to cells
anaerobic metabolism
metabolic acidosis
blunting of beneficial drug and
electrical therapy
Bag/Mask Ventilation – 1 breath every
5 – 6 seconds
Quick Review

Shock (if indicated) as soon as the defibrillator
is available:








Monophasic defibrillator…360 joules
Biphasic defibrillator…120 – 200 joules
Unknown type defibrillator…200 joules
Resume CPR immediately
After 5 cycles of CPR, check rhythm
If shockable rhythm, give one shock
When IV/IO is available, give 1 mg epinephrine
(before or after the shock) (May use 40 units
Vasopressin to replace first or second dose of
epinephrine.)
Give one antiarrhythmic (before or after the
next shock)
Quick Review

Slow Rhythms:



Oxygen
External Pacing; Epinephrine; Atropine
Fast Rhythms:


Oxygen…IV…Wide or Narrow complex
Stable


Unstable


Medications
Emergency synchronized cardioversion
Pulseless

Defibrillation
Summary







To avoid chaos, make assignments for code
tasks. The Recorder is very important.
Know hospital policy.
Know the code drugs and their locations in the
code cart.
Know how to use the unit defibrillator.
Resume CPR immediately after defibrillation!
Remember, if you don’t know something ASK!
Debrief after the Code
Do Not Resuscitate?

What does this really
mean?
To the patient?
 To the family members?
 To you the care taker?


Does the patient have an
Advanced Directive?
Ethical Dilemmas

No one agrees on degree
of care & the patient is
‘OUT’
Where is the patient’s
official advanced
directive?
 Conflicts can be averted

NO CODES
LEVEL OF CARE
WITHHOLDING/WITHDRAWING TREATMENT
CHART BINDER
PATIENT DEATH
•FAMILY SUPPORT
•ORGAN RECOVERY AGENCY…1-800-362-6169
•POST MORTEM CARE
•NOTIFICATION OF CORONER
•FUNERAL HOME NOTIFICATION
•DEATH OF A PERSON WITH AN INFECTIOUS
DISEASE (RED TOE TAG)
DEATH and DYING
DENIAL
 Numbness
 No,
can’t be me
 Disbelief
ANGER
Difficult for family and friends to cope with
 Displaces anger
 Complain about care
 Be supportive
 Do not be defensive

BARGAINING
Often becomes guilt
 “If you let me live I will….”
 Consider consulting chaplain or social
worker

DEPRESSION
Allow time to adjust
 Be open and ready to listen
 Might need pharmacological assistance

ACECPTANCE
Final stage
 Able to express feelings
 Sleep more soundly
 Have less pain

PATIENT DISCHARGE
•AMA DISCHARGE
•INSTRUCTION SHEET SHOULD BE
COMPLETED IN LAYMAN’S TERMINOLOGY
•ESCORT FROM THE BUILDING
•DOCUMENTATION IN NURSES NOTES
•MEDICAL RECORDS FORMS