Acute Coronary Syndrome (Code Patient) Anney Hall

Transcription

1 Scenario Title Patient Name Acute Coronary Syndrome (Code Patient) Anney Hall Medical Record # DOB: Age: Level (year 2, last term of program) Course: Nur 212 Author, w/ Doris Jepson RN, BSN, CCRN (CGCC) djepson@cgcc.cc.or.us Keywords - Theory Acute Coronary Syndrome; Vagal Response Keywords- Skills CPR, Med Administration, Focused Assessment, Defibrillator, IV Starts, Rhythm Analysis, Airway Management, Oxygen Administration Participant assignments: First Responder* Patient s Primary Care Nurse Call Code and Initiate CPR, Manage airway and ambu bag Second Responder Verify Code called and Code Cart Coming, Place Backboard, Assist CPR; Rotate with First Responder approx. every 2 minutes Third Responder* Retrieve Code Cart, Hand Ambu Bag to First Responder, Attach Cardiac Monitor, Set up and hand equipment to code team members, Assists Other Responders as needed Fourth Responder Functions as Team Leader, Rhythm Analysis, Mans Defibrillator, Checks for pulse with changes, orders Administration of Meds, Recalls H s and T s to identify treatable cause Fifth Responder* IV access and continued patency, hangs IVF, Administers and Circulates meds, Assists with Rhythm Analysis Sixth Responder Recorder, communicate findings and information with code team, make sure chart in room and chaplain is notifying family, physician called, review code status of patient *Students being evaluated with this scenario Patient Case History: Medical / Surgical History: Annie is a 65-year-old female admitted during the night with acute coronary syndrome. She has had stable angina for several years. Last night as she readied for bed, she developed a severe ache in her left chest that radiated to her jaw. The pain was rated as an 8/10 and was unrelieved by 3 Nitroglycerin tablets. Her husband called 911. The paramedics administered oxygen, a fourth NTG tablet and Morphine Sulfate 2mg IV, before transporting her to the emergency room. Upon arrival, she was pain free, but was admitted to the telemetry unit for observation. Patient has a history of Coronary Artery Disease, Stable Angina, and Hypothyroidism. Surgical History: Left mastectomy 5 years ago. She had a bunionectomy 2 days ago and has bandages in place. Allergies: Ace inhibitors cough Height: 5 1 Weight: 110# Meds: Aspirin 325mg po daily Levothyroxine 0.1mg daily Metoprolol 25mg po bid Atorvastatin 10mg daily Nitroglycerin 0.4mg SL q5min x3 prn chest pain Vicodin 7.5/ tabs po q4-6h prn pain

2 VS: BP 102/76 HR 54 RR 16 T 37.1 SpO 2 96% Labs: Na 140; K 3.5; Troponin 0.02 Physician Orders: 1. Admit to telemetry unit for Dr. Jepson 2. DX ACS 3. Routine telemetry monitoring and VS 4. Saline lock; no IV starts in left arm 5. Oxygen 2L/NC 6. Diet Cardiac 7. Activity Bedrest 8. Aspirin 325mg po daily 9. Levothyroxine 0.1mg daily 10. Metoprolol 25mg po bid 11. Atorvastatin 10mg daily 12. Nitroglycerin 0.4mg SL q5min x3 prn chest pain 13. Vicodin 7.5/ tabs po q4-6h prn pain 14. Notify Physician: SBP >140<90, DBP >90<50; HR>120<50; RR>22<8; T>38.5; UOP <30 ml/hr x 8 hours Initial Computer Set Up VS: BP 60/0 HR 20 RR 6 T N/A SpO 2 68% Lungs: Lt:Clear Rt:Clear Bowel sounds Heart: Ectopy: Rhythm: Sinus bradycardia, rate 20 Waiting: Other: Report to start scenario: Annie was admitted to the unit at 2 AM and did not sleep well. She is very tired this morning and wants to be allowed to sleep. Her VS are stable, monitor shows Sinus Bradycardia with a rate in the 50 s. She has a saline lock in her LFA. She has had no chest pain since her episode at home. Her first troponin is 0.02 and a second one is pending. Doctor has ordered bedrest since she had a bunionectomy 2 days ago. She was just put on the bedpan and will put on her call light when she is done. [This nurse goes into the control and immediately peaks her head back out the door] You better check on Annie. Heart monitor is alarming but she probably just has a loose lead. Priorities (in order) SN Interventions Patient Responses Assess Patient Unresponsiveness Establish effective CPR Call for help; push Code button, get off of bedpan and initiate CPR 2 person CPR, use Ambu bag when available, switch compressor about q2min. None, Slumped over, still sitting on bedpan None

3 Set up for code management Resume CPR and code management Code management Code management of Rhythm Change Open code cart, hand off supplies to other personnel: Ambu bag hooked to 100% O2, IV NS hung at slow to moderate rate, Connect monitor/defibrillator to patient. Other priorities are documentation, call operator to attempt to notify MD Rhythm. Resume CPR for 5 cycles or 2 min, Problem Solve cause and how to treat. Attempt to give Atropine mg IV but IV site is infiltrated. New IV site must be started with NS IV hung. Make sure good quality CPR. Rhythm, provide CPR while charging defibrillator, announce and observe All Clear and defibrillate Analyze, Resume CPR for 5 cycles or 2 min; administer epinephrine 1 mg IV q3-5 min when IV site available. Make sure good quality CPR. Rhythm, provide CPR while charging defibrillator, announce and observe All Clear and defibrillate Analyze Rhythm, Check pulse, VS and respiratory effort. Provide rescue breaths with Ambu Bag. Administer Atropine 0.5mg IV push fast. None Operator should call in after a minute if student does not call. Operator should verify if it is a real code and MD name. None, Sinus Brady rate 20; weak, thready pulse, SB/P 60, RR 6 None, heart rate and are inadequate. Cause: Patient had vagal response when using bedpan. Now IV site is infiltrated and have no way to administer Atropine. This continues about 10 minutes until the IV site is in place. Shocks q2min and at least one dose of epinephrine has been given and circulated. Good CPR all the while. Then: None, No spontaneous breaths. Sinus Brady rate 30; good pulse, SB/P 74. Administer Atropine --If give slow put into asystole. --If give 1 mg put HR up to 120 and keep B/P low. --If administer fast, Increase rate to 70, but keep SB/P 80. Phone report to MD Phone report given to MD. MD calls in, report given,

4 Post resuscitation care Brief pause in rescue breaths. Provide oxygen 100% NRB. Analyze Rhythm, Check pulse, Check VS and respiratory effort. states: I m just driving up in the parking lot be there soon. Spontaneous resp, rate 12, Monitor NSR, rate 70, B/P 80/50, SaO2 98% with supplemental oxygen. MD Arrives Brief update given. MD arrives and wants dopamine infusion at 5 mcg/kg/min hung and patient transported to ICU. Goes to phone and calls ICU for bed: -- Lori, this is Dr. Jepson. I ve got a telemetry patient that just coded and I need a bed now. Can you or one of the nurses come help transport the patient Room 461. Thanks. Hangs up and says: I ll head to the ICU & start writing orders. Post resuscitation care Emotional Care of Husband Monitor patient, prepare for immediate transport to ICU. Dopamine should be hung at rate of 9 ml/hr (K=0.533)Clean up stool. Finish documentation, inc. names of participants. Husband calls. Provide truthful, comforting answers. Resp. rate gradually increases to 16 and SaO2 to 100% over next minute. Begins to respond weakly to verbal stimulus. Can I talk to my wife? What happened? Is she going to be alright? Transport to ICU Brief report to ICU nurse. ICU nurse arrives Faculty Notes (theory, medications, etc.) 1. When CPR must be interrupted, break should be for as short a time as possible AHA guidelines state rate of compressions:ventilations is 30:2; compressions should be fast and hard at 100/min; once ET tube is placed, ventilations are 8-10/min and not synchronized with compressions AHA guidelines state that only single shocks are delivered (no stacking). Voltage is as follows: 360 joules for monophasic defibrillators; joules for biphasic truncated exponential waveform; 120 joules for rectilinear biphasic waveform AHA guidelines state that after a shock is delivered, CPR is immediately resumed for 5 cycles or 2 minutes, then is analyzed. For Simulation purposes, students will analyze after shock is delivered. 5. Antiarics or vasopressors may be administered during CPR or right after a check. 6. Epinephrine is always first drug administered in arrest s. 7. Medications administered IV during a code are pushed rapidly AHA guidelines state that IV fluids are not bolused unless hypovolemia is suspected.

5 Debrief Priorities (facts, feelings, behaviors, priorities, noticing, interpreting, responding, evaluating and reflecting-what went well, what would you do differently) 1. How do you think you did as a group? 2. Review individual efforts. 3. Identify an area for improvement. 4. Discuss possible causes of arrest. 5. Ask total amounts of documentation nurse (defib, epi, etc.) and time between shocks. 6. Ask how long from when patient first found to start of CPR? 7. How might the code situation have been avoided? (Working IV site) 8. Discuss communication with husband how that went. Possible Increased Complexities for this scenario: 1. Monitored could have included PEA after conversion from V/fib. References: AHA Guidelines for CPR and Emergency Cardiovascular Care (Nov. 2005) Suggestions for Future Advanced Scenarios: 1. Funded by the US Department of Labor