Inpatient – NurseCheung.com https://nursecheung.com From "You're Not Good Enough" To "Look At Me Now!" Wed, 06 Dec 2023 15:11:19 +0000 en-US hourly 1 https://wordpress.org/?v=6.4.3 https://2hya11.p3cdn1.secureserver.net/wp-content/uploads/2023/01/nurse-cheung-logo-Logo-1000-×-1000-px-2-150x150.png Inpatient – NurseCheung.com https://nursecheung.com 32 32 Inpatient ACLS Airway Management Megacode: The Best Strategies for Saving Lives https://nursecheung.com/aclsmegacode-ip-airwaymanagement/ Sat, 07 Jan 2023 17:14:29 +0000 https://nursecheung.com/inpatient-acls-airway-management-megacode-the-best-strategies-for-saving-lives/

The Airway Management section of the AHA Inpatient ACLS algorithm is one of the most important, and it can be difficult to know what to do when someone is choking or has another airway emergency.

We will provide you with a step-by-step guide on how to manage an airway emergency, as well as some tips for avoiding common mistakes.

In this blog post, we will discuss the best strategies for saving lives in the inpatient setting.

Adult Inpatient Respiratory Arrest Megacode Scenario

The following is a scenario in which you would use the inpatient adult respiratory arrest Megacode:

You are the healthcare provider taking care of a female patient with a history of diabetes in the intermediate care unit. The patient is noncompliant with medications for her asthma and heart failure and is well known by the cardiologist and pulmonologist. She has been intubated and sedated prior to coming to you.

Demonstrate what you would do next

Initial Impression

The woman is currently on CPAP at 10 as part of her heart failure treatment. She is becoming restless, short of breath, and trying to take the mask off.

Primary Assessment Survey (A, B, C, D, E)

Airway: There is a CPAP mask present. It is hard to determine if the woman’s airway is patent due to her restlessness and combativeness.

Breathing: Oxygen saturation is showing 80% with CPAP 100% oxygen. Respiratory rate is 28/min. The patient states “I can’t keep this up much longer.” Breath sounds are diminished bilaterally. Wheezing and crackles are noted upon auscultation.

Circulation: Blood pressure is 128/90, heart rate is 82/min, and the pulse is present but weak. Capillary refill is 3 seconds.

Disability: The woman is alert, oriented, and restless. She is attempting to remove the CPAP mask and eventually takes it off.

Exposure: Skin is cool to the touch.

Change in Condition

After assessment of the initial impression and primary assessment, the woman becomes unresponsive while attempting to place the mask back on and waiting for respiratory therapy/rapid response.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The woman is unresponsive and doesn’t answer any stimuli.
  2. Activate the emergency response system. Shout for backup and announce what room you are in. It is perfectly acceptable to hit the code button for faster backup.
  3. Check for breathing: Look for visible chest rising and falling. No spontaneous breathing was present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

  1. Pulse is present so we will not begin CPR starting with compressions.
  2. Start providing oxygenation via bag valve mask with oxygen while waiting for help to arrive. Perform bag-mask ventilation for 1 minute effectively at the proper rate (1 breath every 6 seconds), speed (over 1 second), and volume (about half a bag) until the ventilator arrives.
  3. Consider endotracheal re-intubation due to condition deterioration. After endotracheal intubation, the oxygen saturation is 99% with positive color changes on the CO2 Detector. Waveform capnography is the gold standard.
 

The woman is stable, restless, and oxygen saturation is within normal but falling slowly due to her biting on the tube. What are your next steps?

Secondary Survey (SAMPLE)

Signs and Symptoms: Signs and symptoms are improving; however, no spontaneous breathing is noted.

Allergies: Allergic to morphine and acetaminophen

Medications: Albuterol, Metformin, and digoxin

Past Medical History: Diabetes, asthma, and congestive heart failure

Last Meal, Liquid Consumed: Unknown when the last meal and liquid were consumed as she was transferred to your unit without a full report.

Events: No events were noted outside of what was discussed.

What are your text interventions?

  • Albuterol
  • Sedation for restlessness
  • Arterial Blood Gases
  • Maybe Fluid – Depends on the Heart Failure
  • Waveform Capnography
  • Critical Care Consult
  • Transfer back to a higher level of care – Intensive Care Unit
 
 

You will begin the transfer to the unit. Your scenario has concluded.

]]> Inpatient ACLS Unstable Bradycardia Megacode: How to Respond in an Emergency Situation https://nursecheung.com/aclsmegacode-ip-unstablebradycardia/ Sat, 07 Jan 2023 17:14:24 +0000 https://nursecheung.com/inpatient-acls-unstable-bradycardia-megacode-how-to-respond-in-an-emergency-situation/

In this blog post, we will discuss how to respond to an inpatient ACLS unstable bradycardia megacode. This is a serious emergency situation that requires quick action.

If you are not familiar with the megacode, don’t worry! We will go over the steps that you need to take in order to provide lifesaving care for the patient.

Adult Inpatient Unstable Bradycardia Megacode Scenario

The following is a scenario in which you would use the inpatient adult unstable bradycardia Megacode:

You are a healthcare provider working in the cardiac telemetry observation unit. You are performing your morning patient assessment when you note that the monitor is showing bradycardia.

Demonstrate what you would do next

Initial Impression

The 45-year-old male is sitting upright on the hospital bed. He is feeling cold and clammy. There are no complaints of chest pain, dyspnea, or palpitations. Overall he has been healthy with no recent changes to his medications.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 98% on 2LNC.

Circulation: Blood pressure is 90/50, heart rate is 30/min, a rhythm check shows sinus bradycardia, and the pulse is present but weak.

Disability: The patient is alert and oriented.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient states he is having some chest discomfort and his extremities feel cool to the touch.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” This step is not necessary as the patient is awake, alert, and oriented.
  2. Activate the emergency response system. Call your charge nurse, call rapid response, and place a page out to the doctor.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is present but slightly weak.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but weak.
 

What are your next actions?

Pulse and breathing is present so we will not begin CPR starting with compressions.

Unstable Bradycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is not hypoxemic at this time and already has 2LNC on.
  3. Cardiac monitor, blood pressure, oximetry – Sinus Bradycardia, BP 90/50 (confirmed this is low for the patient), 98% on 2LNC
  4. IV Access – 20 gauge in the left and right antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
  6. Consider hypoxic and toxicologic causes – Myocardial Ischemia/infarction, calcium-channel blockers, beta-blockers, digoxin, hypoxia, hyperkalemia
 

Persistent Bradyarrhthmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – No
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions could you perform next?

  • Atropine 1mg bolus – Atropine was successful

If atropine was not effective or contraindicated:

  • Transcutaneous pacing
  • Dopamine
  • Epinephrine
  • Labs – electrolytes and cardiac biomarkers
  • Urinalysis
  • Fluids
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care – Cardiac or Medical PCU
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

]]> Inpatient ACLS Unstable Tachycardia Megacode: The Most Effective Strategies https://nursecheung.com/aclsmegacode-ip-unstabletachycardia/ Sat, 07 Jan 2023 17:14:18 +0000 https://nursecheung.com/inpatient-acls-unstable-tachycardia-megacode-the-most-effective-strategies/

ACLS or Advanced Cardiac Life Support is a set of clinical guidelines that are used to treat cardiac arrest and other life-threatening medical emergencies.

One of the most common arrhythmias that ACLS providers will encounter is unstable tachycardia.

In this blog post, we will discuss the most effective strategies for managing unstable tachycardia using the ACLS megacode.

Adult inpatient Unstable Tachycardia Megacode Scenario

The following is a scenario in which you would use the emergency department adult unstable tachycardia megacode:

You are a healthcare provider working in the cardiovascular intermediate care unit. You are caring for a post-motor vehicle trauma patient with a chest tube. The patient’s wife runs into the nurse’s station yelling that her husband needs help.

Demonstrate what you would do next upon arrival

Initial Impression

The patient is a 30-year-old male lying down in a hospital bed. He is anxious, pale, weak, and dizzy. He states his chest feels funny.

Primary Assessment Survey (A, B, C, D, E)

Airway: The airway is patent. The flow through the trachea is not impaired.

Breathing: Oxygenation is showing 96% on room air.

Circulation: Blood pressure is 84/60, heart rate is 160 bpm, the rhythm check shows narrow complex supraventricular tachycardia and the pulse is present.

Disability: The patient is alert but anxious and diaphoretic.

Exposure: No obvious signs of trauma, bleeding, burns, markings, or medical alert bracelet.

Change in Condition

After assessment of the initial impression and primary assessment, the patient’s palpitations become worse and he is short of breath.

What are your next actions?

  1. Check responsiveness: Tap the shoulders and shout, “Are you okay?” The man responds but is becoming increasingly weak.
  2. Activate the emergency response system. Shout for backup and announce what room you are in.
  3. Check for breathing: Look for visible chest rising and falling. Breathing is rapid and present.
  4. Check for a pulse: Place your fingers on the inside of the patient’s neck, just below the angle of the jaw. You will palpate the carotid pulse for no more than 10 seconds. Pulse is present but fast.
 

What are your next actions?

Pulse and breathing are present so we will not begin CPR starting with compressions.

Unstable Tachycardia Algorithm

Identify and Treat the Underlying Cause

  1. Maintain patent airway, assist with breathing if necessary – Airway is patent and breathing is spontaneous
  2. Oxygen (if hypoxemic) – The patient is on 4LNC after a change in condition
  3. Cardiac monitor, blood pressure, oximetry – narrow complex supraventricular tachycardia, BP 84/60, 94% on 4LNC
  4. IV Access – 20 gauge in the right and left antecubital
  5. 12-Lead ECG if available and doesn’t delay therapy – Not readily available
 

Persistent Tachyarrhythmia Causing

  • Hypotension? – YES
  • Acutely altered mental status? – NO
  • Signs of shock (low blood pressure, altered mental status, cold moist skin, weak or rapid pulse, rapid breathing, decreased urine output) – YES
  • Ischemic chest discomfort? – YES, the patient states chest discomfort from palpitations
  • Acute heart failure (heavy breathing, suffocating sensation, struggle to breathe while lying down, tight chest, arrhythmia, cough, fluid retention, loss of consciousness)? – YES
 

Interventions

What interventions are available for you to perform next?

  • Synchronized Cardioversion – Consider sedation
  • Adenosine IV – First dose 6mg rapid IV push followed by NS flush, Second dose 12 mg if required
 

What are we Missing?

The chest tube is a vital piece of equipment during our assessment that may be a contributing factor. Previously during our initial assessment, there was minimal drainage. Now the drainage is over 1,500 mL.

Outcomes

The patient was taken to the Operating Room and found to have a hemothorax.

Next steps for this patient:

  • Post-operative care
  • Chest tube management
  • Physical therapy and walking schedule
  • Labs – electrolytes and cardiac biomarkers
  • Fluids including blood products
  • Chest x-ray
  • Cardiac Consultation
  • Transfer to a higher level of care
 
 

You will begin the transfer to a higher level of care. Your scenario has concluded.

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