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Code management (for printing)

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Alhane Enriquez
Alhane Enriquez

The document provides an overview of code management for nurses. It describes what a code is, the roles of the code team including the physician, nurse, and respiratory therapist. It outlines the responsibilities during a code such as initiating CPR, intubation, defibrillation, and administering medications. It also discusses managing the family, criteria for stopping resuscitative efforts, and documentation requirements. The overall document serves as a training guide for nurses on their functions and skills needed during a medical emergency.

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Code management (for printing)
You find yourself going through a typical day in your shift, when suddenly you hear the hospital operator announce…
“YOUR ATTENTION PLEASE, YOUR ATTENTION PLEASE… CODE 82! CODE 82! WARD 3B!”
Few seconds later, the sound of the rolling E-Kart fills the hallway and you see the hospital code team; clad in face masks, rapidly take off running to the scene.
As a new nurse, you are aware that a medical emergency is being unfolded right at that moment. You dream to be in that scene, taking part of the resuscitative measures and helping to direct the many interventions that will be employed during the event.
This course gives you an overview of your functions as a nurse in an emergency situation and an outline of the nursing skills, detrimental in the management of a CODE.
CODE MANAGEMENT BASIC SKILLS TRAINING FOR NURSES LUNG CENTER OF THE PHILIPPINES Copyright © 2007
What is a CODE?
THE CODE TEAM • Physician • Critical Care Nurse • Respiratory Therapist • Nurse Supervisor • Nursing Aide • Security Officer
The Code Team shall be responsible for: •Responding immediately to all Code alerts. •Conducting the code according to current Advanced Cardiac Life Support (ACLS) protocols. •Recording any pertinent data on the patient’s record.
The nursing unit, clinic, and/or department on which the Code occurs, shall be responsible for initiating Basic Life Support (BLS) until the Code Team can respond.
Responsibilities of the Physician 1. Informing the patient’s family of the situation. 2. Making arrangements for an ICU bed if needed. 3. Completing the medical record if the patient expires, documenting the events leading up to the patient’s death, cause of death, date and time of death, coroner’s case, autopsy requested, and physician signature.
Responsibilities of the Code Team Nurse • Managing the E-Kart • Administration of medications • Assisting in Endotracheal Intubations • Defibrillation • Reviewing documentations post code and follow up to ensure complete documentation
Responsibilities of the Charge Nurse 1. Overseeing traffic control on the unit. 2. Ensuring that emergency equipment is brought to the bedside. 3. Delegating duties to appropriate personnel to ensure the unit’s continued function. 4. Serving as the recorder for the resuscitation efforts or delegating an appropriate person to do so. 5. Carrying out orders by physician. 6. Documenting and completing the chart. 7. Contacting the admitting office if the patient needs to be transferred to a critical care bed. 8. Evaluating the situation to see if additional personnel are needed to ensure that the Patient Care Area continues to function.
CODE 82 Responds to Medical Emergencies at the Speed of Life… Because every second counts.
THE CHAIN OF SURVIVAL 1. Early Access to Care. 2. Early Cardiopulmonary Resuscitation (CPR) 3. Early Defibrillation. 4. Early Advanced Care. These 4 steps can increase survival as much as 90% if initiated within the first minutes after sudden cardiac arrest. Survival decreases by about 10% each minute longer.
WHEN TO CALL A CODE? • Primary Survey •Assess for RESPONSIVENESS •Assess for BREATHING •Assess for CIRCULATION • Secondary Survey •Pre and Post RESUSCITATION MEASURES
Assess Responsiveness Responsive Not Responsive > vital sign > call for help fast > assess/inform AP > position > document > open airway
Assess Breathlessness BREATHING NOT BREATHING > recovery position > Rescue Breath > vital sign ( facemask/ > assess/inform AP resuscitation bag) > Document > Continously Monitor
Assess Circulation (+) Pulse (-) Pulse > continue pressure > Activate the ventilation Code Team support > Perform cardiac compression
Primary Survey Activate Code 82 Start CPR Prepare for Intubation Post Assist Code 82 Team Resuscitation Activities
BASIC CODE 82 PHYSICAL SETUP NURSE SUCTION CPR SUPERVISOR NURSE CODE TEAM LEADER
BASIC CODE 82 PHYSICAL SETUP BST NURSE SUCTION CPR SUPERVISOR NURSE BST CODE TEAM LEADER BST BST
What happens if a Code 82 is going on and another call for a code team is needed in another area? 1st call 2nd call 3rd call MICU ER PACU
When NOT to call a CODE? DNR CANCER ET / TRACH
The Medical Crash Cart Other names: E-Cart E-Kart Service Cart Code Cart Critical Care Cart
Basic Components of CODE 82 E-Cart • Cardiac Monitor • Defibrillator • Emergency Meds • Laryngoscope • Ambubag • Miscellaneous medical supplies • Cardiac Board
Code management (for printing)
Activities During a Code CPR Endotracheal Intubation Defibrillation Administration of Medications
CPR •When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you're helping an unconscious person who isn't breathing. •CPR does not restart a heart that has stopped, but it can keep a victim alive until more aggressive treatment can be administered.
ENDOTRACHEAL INTUBATION Endotracheal intubation is performed to establish and maintain a patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration, and assist with the clearance of secretions.
Nursing Responsibilities in Endotracheal Intubation • Assembling materials needed • Proper patient and bed positioning • Ensuring O2 source and suction equipment • Ensuring ET is secured • Proper collection of ETA specimen and sending to laboratory • Chest X-ray post intubation
SECURING AN ENDOTRACHEAL TUBE
Code management (for printing)
DEFIBRILLATION It is the administration of electric shock for a patient on cardiac arrest when the presenting rhythm is pulseless VT or VF.
Ventricular Fibrillation A turbulent, disorganised electrical activity of the heart in such a way that the recorded electrocardiographic deflections continuously change in shape, magnitude and direction.
VENTRICULAR TACHYCARDIA A fast rhythm that originates in one of the ventricles of the heart. This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation and sudden death.
DEFIBRILLATION METHOD 1. Verify cardiac arrest. Ensure ongoing & effective BLS [CPR and airway management] 2. Ensure the ECG monitor is properly connected. 3. Identify VF or pulseless VT. Ensure all patient and device movement is eliminated. 4. Gel the entire metal surface of both paddles. 5. Place the paddles on the chest wall. The sternum pad is placed to the right of the sternum just below the right clavicle (not on the clavicle or sternum). The apex pad is placed at the level of the apex of the heart in the area of the anterior. 6. Charge the defibrillator or paddles to the desired energy level. 7. “Verbally and visually clear the patient!” In simple terms, make absolutely sure that no one is in electrical contact with the patient. 1. Provide firm, downward pressure (25 pounds of force) onto the chest 2. Discharge the selected energy by pressing 2 buttons simultaneously.
ADMINISTRATION OF MEDICATIONS
The administration of medications is a chief responsibility of a nurse in an event of a code. • Anticipation of the drug to be administered • Dosage & Route of administration •When to use an agent (indications) •Why an agent is used (actions) •How to use an agent (dosing) •What to watch out for (precautions) • Obtain a patent IV access • Announce the drug and dosage before and after administration
CESSATION OF CODE ACTIVITIES Criteria for stopping the Code activities: 1 – When sinus rhythm is detected on the ECG, Vital Signs in acceptable limits 2 – When code lasted for more than 30 minutes with no sign of sinus activity on the ECG. 3 – When patient’s immediate and significant family member verbally stops the activities and agreed to sign waiver / DNR. 4 – When flat ECG tracings are seen despite 15-20 minutes of continued CPR and “maximum” dose of Epinephrine is administered.
POST RESUSCITATION ACTIVITIES 1. Obtaining 12-Lead ECG 2. Obtaining Chest X-Ray 3. Request for Laboratory workups 4. Inserting NGT 5. Inserting Foley Catheter 6. Coordinating with Admitting section for transfer to ICU 7. Coordinating with ICU Nurse for plan of transfer 8. Coordinating with Respiratory Services for VR parameters 9. Coordinating with Dietary Division 10.Patient preparation and coordination with relatives 11.Documentation 12.Transfer of patient 13.Pharmacy and CSSR reconciliations
DOCUMENTATION Code Team Leader -Written orders -Code notes -Transfer referrals Charge Nurse -All pertinent data pertaining to the event -Medications administered -Completing the Chart -Nurse’s notes / Charting
NURSES’ NOTES 07/16/07 F -Cardiopulmonary Arrest 9:40am D -Patient’s relative rushed to station and reported of patient’s unconsciousness, stating, “Patay na yata ang tatay ko!” -Seen on bed unresponsive, with hands cupped over chest -Breathing ( - ), Pulse ( - ) 9:40am A -Activated Code 82 immediately. -Positioned flat on bed immediately and initiated CPR, ambubagging at 10L O2 flow. 9:41am -Code team arrived and assisted with intubation. 9:45am -Defibrillation administered by code team at three episodes, noted sinus activity after third shock.
(cont.) A -Emergency medications administered by member of code team / MTR -12-lead EKG done, tracings seen by AP 10:14am -Chest X-Ray requested, plate seen by AP -Laboratory specimen for ETA G/S, C/S sent 10:14am -Requested Lab for Trop-T, CPK-MB, Na, K, BUN, Crea -Coordinated with relatives of MICU transfer, conveyed support and gave reassurance 10:30 -NGT inserted, Consent Form duly signed by relatives 10:40 -Informed Dietary Dept of change in diet & MICU bed -IFC inserted, Consent Form duly signed by relatives 10:40 -IV Fluids regulated accordingly 10:40 -Coordinated with Admitting Section for MICU transfer -Coordinated with MICU NOD for transfer
(cont.) A -Coordinated with SRS personnel of VR parameters 10:55am -Transfer Notes completed by AP -Placed on stretcher and prepared patient for transfer -Patient’s dentures and wristwatch endorsed to relatives 11:00am R -Successful resuscitation lasting for about 20 min 11:10am -Wheeled to MICU accompanied by AP -On ambubagging per ET @ 15 LPM, unconscious, with latest VS; BP 160/90, CR 142/min, Temp 36.4ºC O2 Sat 94% -Endorsed to MICU receiving nurse accordingly BC A. Co, RN
Managing the Family Members
Normally, the family is quickly escorted away from the scene, presumably for the following reasons: 1. The family’s outpouring emotions may be disruptive 2. The family interferes with the resuscitation efforts 3. The family tends to scrutinize the activities and interventions for signs of incompetence 4. Code team considers to protect the family members from irreparable psychological harm from witnessing the event
Dispelling the Myths… Terry L. Tucker’s study, (Critical Care Nurse) Baltimore, USA •It has been observed that families are rarely disruptive •Family members rarely interrupt code activities, don’t really scrutinize the activities of the code team for signs of incompetence •Family members feel they provide an element of emotional and psychological support for the patient. •Families of patients who don’t survive the event feel a level of comfort in knowing that everything that could be done to save the patient was done, thereby facilitating the grieving process.
Dispelling the Myths… Terry L. Tucker’s study, Baltimore, USA •No report of significant psychological damage from witnessing the attempted resuscitation of a loved one. •Most families believe it’s their right to be present and that their presence is important to the patient. •Provides the family member or significant other an opportunity to say goodbye, relay their love, apologize or reconcile their relationship, or simply give permission before the patient takes leave.
Providing Guidelines… Opening the doors?
CODE MANAGEMENT BASIC SKILLS TRAINING FOR NURSES LUNG CENTER OF THE PHILIPPINES Copyright © 2007

More Related Content

Code management (for printing)

  • 2. You find yourself going through a typical day in your shift, when suddenly you hear the hospital operator announce…
  • 3. “YOUR ATTENTION PLEASE, YOUR ATTENTION PLEASE… CODE 82! CODE 82! WARD 3B!”
  • 4. Few seconds later, the sound of the rolling E-Kart fills the hallway and you see the hospital code team; clad in face masks, rapidly take off running to the scene.
  • 5. As a new nurse, you are aware that a medical emergency is being unfolded right at that moment. You dream to be in that scene, taking part of the resuscitative measures and helping to direct the many interventions that will be employed during the event.
  • 6. This course gives you an overview of your functions as a nurse in an emergency situation and an outline of the nursing skills, detrimental in the management of a CODE.
  • 7. CODE MANAGEMENT BASIC SKILLS TRAINING FOR NURSES LUNG CENTER OF THE PHILIPPINES Copyright © 2007
  • 8. What is a CODE?
  • 9. THE CODE TEAM • Physician • Critical Care Nurse • Respiratory Therapist • Nurse Supervisor • Nursing Aide • Security Officer
  • 10. The Code Team shall be responsible for: •Responding immediately to all Code alerts. •Conducting the code according to current Advanced Cardiac Life Support (ACLS) protocols. •Recording any pertinent data on the patient’s record.
  • 11. The nursing unit, clinic, and/or department on which the Code occurs, shall be responsible for initiating Basic Life Support (BLS) until the Code Team can respond.
  • 12. Responsibilities of the Physician 1. Informing the patient’s family of the situation. 2. Making arrangements for an ICU bed if needed. 3. Completing the medical record if the patient expires, documenting the events leading up to the patient’s death, cause of death, date and time of death, coroner’s case, autopsy requested, and physician signature.
  • 13. Responsibilities of the Code Team Nurse • Managing the E-Kart • Administration of medications • Assisting in Endotracheal Intubations • Defibrillation • Reviewing documentations post code and follow up to ensure complete documentation
  • 14. Responsibilities of the Charge Nurse 1. Overseeing traffic control on the unit. 2. Ensuring that emergency equipment is brought to the bedside. 3. Delegating duties to appropriate personnel to ensure the unit’s continued function. 4. Serving as the recorder for the resuscitation efforts or delegating an appropriate person to do so. 5. Carrying out orders by physician. 6. Documenting and completing the chart. 7. Contacting the admitting office if the patient needs to be transferred to a critical care bed. 8. Evaluating the situation to see if additional personnel are needed to ensure that the Patient Care Area continues to function.
  • 15. CODE 82 Responds to Medical Emergencies at the Speed of Life… Because every second counts.
  • 16. THE CHAIN OF SURVIVAL 1. Early Access to Care. 2. Early Cardiopulmonary Resuscitation (CPR) 3. Early Defibrillation. 4. Early Advanced Care. These 4 steps can increase survival as much as 90% if initiated within the first minutes after sudden cardiac arrest. Survival decreases by about 10% each minute longer.
  • 17. WHEN TO CALL A CODE? • Primary Survey •Assess for RESPONSIVENESS •Assess for BREATHING •Assess for CIRCULATION • Secondary Survey •Pre and Post RESUSCITATION MEASURES
  • 18. Assess Responsiveness Responsive Not Responsive > vital sign > call for help fast > assess/inform AP > position > document > open airway
  • 19. Assess Breathlessness BREATHING NOT BREATHING > recovery position > Rescue Breath > vital sign ( facemask/ > assess/inform AP resuscitation bag) > Document > Continously Monitor
  • 20. Assess Circulation (+) Pulse (-) Pulse > continue pressure > Activate the ventilation Code Team support > Perform cardiac compression
  • 21. Primary Survey Activate Code 82 Start CPR Prepare for Intubation Post Assist Code 82 Team Resuscitation Activities
  • 22. BASIC CODE 82 PHYSICAL SETUP NURSE SUCTION CPR SUPERVISOR NURSE CODE TEAM LEADER
  • 23. BASIC CODE 82 PHYSICAL SETUP BST NURSE SUCTION CPR SUPERVISOR NURSE BST CODE TEAM LEADER BST BST
  • 24. What happens if a Code 82 is going on and another call for a code team is needed in another area? 1st call 2nd call 3rd call MICU ER PACU
  • 25. When NOT to call a CODE? DNR CANCER ET / TRACH
  • 26. The Medical Crash Cart Other names: E-Cart E-Kart Service Cart Code Cart Critical Care Cart
  • 27. Basic Components of CODE 82 E-Cart • Cardiac Monitor • Defibrillator • Emergency Meds • Laryngoscope • Ambubag • Miscellaneous medical supplies • Cardiac Board
  • 29. Activities During a Code CPR Endotracheal Intubation Defibrillation Administration of Medications
  • 30. CPR •When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you're helping an unconscious person who isn't breathing. •CPR does not restart a heart that has stopped, but it can keep a victim alive until more aggressive treatment can be administered.
  • 31. ENDOTRACHEAL INTUBATION Endotracheal intubation is performed to establish and maintain a patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration, and assist with the clearance of secretions.
  • 32. Nursing Responsibilities in Endotracheal Intubation • Assembling materials needed • Proper patient and bed positioning • Ensuring O2 source and suction equipment • Ensuring ET is secured • Proper collection of ETA specimen and sending to laboratory • Chest X-ray post intubation
  • 35. DEFIBRILLATION It is the administration of electric shock for a patient on cardiac arrest when the presenting rhythm is pulseless VT or VF.
  • 36. Ventricular Fibrillation A turbulent, disorganised electrical activity of the heart in such a way that the recorded electrocardiographic deflections continuously change in shape, magnitude and direction.
  • 37. VENTRICULAR TACHYCARDIA A fast rhythm that originates in one of the ventricles of the heart. This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation and sudden death.
  • 38. DEFIBRILLATION METHOD 1. Verify cardiac arrest. Ensure ongoing & effective BLS [CPR and airway management] 2. Ensure the ECG monitor is properly connected. 3. Identify VF or pulseless VT. Ensure all patient and device movement is eliminated. 4. Gel the entire metal surface of both paddles. 5. Place the paddles on the chest wall. The sternum pad is placed to the right of the sternum just below the right clavicle (not on the clavicle or sternum). The apex pad is placed at the level of the apex of the heart in the area of the anterior. 6. Charge the defibrillator or paddles to the desired energy level. 7. “Verbally and visually clear the patient!” In simple terms, make absolutely sure that no one is in electrical contact with the patient. 1. Provide firm, downward pressure (25 pounds of force) onto the chest 2. Discharge the selected energy by pressing 2 buttons simultaneously.
  • 40. The administration of medications is a chief responsibility of a nurse in an event of a code. • Anticipation of the drug to be administered • Dosage & Route of administration •When to use an agent (indications) •Why an agent is used (actions) •How to use an agent (dosing) •What to watch out for (precautions) • Obtain a patent IV access • Announce the drug and dosage before and after administration
  • 41. CESSATION OF CODE ACTIVITIES Criteria for stopping the Code activities: 1 – When sinus rhythm is detected on the ECG, Vital Signs in acceptable limits 2 – When code lasted for more than 30 minutes with no sign of sinus activity on the ECG. 3 – When patient’s immediate and significant family member verbally stops the activities and agreed to sign waiver / DNR. 4 – When flat ECG tracings are seen despite 15-20 minutes of continued CPR and “maximum” dose of Epinephrine is administered.
  • 42. POST RESUSCITATION ACTIVITIES 1. Obtaining 12-Lead ECG 2. Obtaining Chest X-Ray 3. Request for Laboratory workups 4. Inserting NGT 5. Inserting Foley Catheter 6. Coordinating with Admitting section for transfer to ICU 7. Coordinating with ICU Nurse for plan of transfer 8. Coordinating with Respiratory Services for VR parameters 9. Coordinating with Dietary Division 10.Patient preparation and coordination with relatives 11.Documentation 12.Transfer of patient 13.Pharmacy and CSSR reconciliations
  • 43. DOCUMENTATION Code Team Leader -Written orders -Code notes -Transfer referrals Charge Nurse -All pertinent data pertaining to the event -Medications administered -Completing the Chart -Nurse’s notes / Charting
  • 44. NURSES’ NOTES 07/16/07 F -Cardiopulmonary Arrest 9:40am D -Patient’s relative rushed to station and reported of patient’s unconsciousness, stating, “Patay na yata ang tatay ko!” -Seen on bed unresponsive, with hands cupped over chest -Breathing ( - ), Pulse ( - ) 9:40am A -Activated Code 82 immediately. -Positioned flat on bed immediately and initiated CPR, ambubagging at 10L O2 flow. 9:41am -Code team arrived and assisted with intubation. 9:45am -Defibrillation administered by code team at three episodes, noted sinus activity after third shock.
  • 45. (cont.) A -Emergency medications administered by member of code team / MTR -12-lead EKG done, tracings seen by AP 10:14am -Chest X-Ray requested, plate seen by AP -Laboratory specimen for ETA G/S, C/S sent 10:14am -Requested Lab for Trop-T, CPK-MB, Na, K, BUN, Crea -Coordinated with relatives of MICU transfer, conveyed support and gave reassurance 10:30 -NGT inserted, Consent Form duly signed by relatives 10:40 -Informed Dietary Dept of change in diet & MICU bed -IFC inserted, Consent Form duly signed by relatives 10:40 -IV Fluids regulated accordingly 10:40 -Coordinated with Admitting Section for MICU transfer -Coordinated with MICU NOD for transfer
  • 46. (cont.) A -Coordinated with SRS personnel of VR parameters 10:55am -Transfer Notes completed by AP -Placed on stretcher and prepared patient for transfer -Patient’s dentures and wristwatch endorsed to relatives 11:00am R -Successful resuscitation lasting for about 20 min 11:10am -Wheeled to MICU accompanied by AP -On ambubagging per ET @ 15 LPM, unconscious, with latest VS; BP 160/90, CR 142/min, Temp 36.4ºC O2 Sat 94% -Endorsed to MICU receiving nurse accordingly BC A. Co, RN
  • 48. Normally, the family is quickly escorted away from the scene, presumably for the following reasons: 1. The family’s outpouring emotions may be disruptive 2. The family interferes with the resuscitation efforts 3. The family tends to scrutinize the activities and interventions for signs of incompetence 4. Code team considers to protect the family members from irreparable psychological harm from witnessing the event
  • 49. Dispelling the Myths… Terry L. Tucker’s study, (Critical Care Nurse) Baltimore, USA •It has been observed that families are rarely disruptive •Family members rarely interrupt code activities, don’t really scrutinize the activities of the code team for signs of incompetence •Family members feel they provide an element of emotional and psychological support for the patient. •Families of patients who don’t survive the event feel a level of comfort in knowing that everything that could be done to save the patient was done, thereby facilitating the grieving process.
  • 50. Dispelling the Myths… Terry L. Tucker’s study, Baltimore, USA •No report of significant psychological damage from witnessing the attempted resuscitation of a loved one. •Most families believe it’s their right to be present and that their presence is important to the patient. •Provides the family member or significant other an opportunity to say goodbye, relay their love, apologize or reconcile their relationship, or simply give permission before the patient takes leave.
  • 51. Providing Guidelines… Opening the doors?
  • 52. CODE MANAGEMENT BASIC SKILLS TRAINING FOR NURSES LUNG CENTER OF THE PHILIPPINES Copyright © 2007