Rapid Response Basics
A change in vital signs, acute confusion, uncontrolled agitation or a "gut feeling," that something is not right are all...
what is.... A reason to activate a rapid response!
What is the first step when you find a patient unresponsive?
What is... Check for responsiveness (LOC and a pulse) and call for help!
if no pulse and a full code... YOU ARE STARTING CPR while calling for help
This is the very first action the nurse should take when a patient reports new chest pain.
What is... assess the patient and their pain and get a set of vital signs
You walk into the room and your patient displays shallow breathing, you count a respiratory rate of 6. ASIDE from activating a rapid response, what is your first intervention
What is... provide breaths via a bag valve mask! (One breath every 6 seconds)
BEFAST is an acronym for recognizing signs of a stroke, what does it stand for?
What is... B: balance/ coordination issues, E: Eye issues, F: Facial drooping/ numbness, A: Arm weakness/ numbness, S: Speech slurred or difficult to understand, T: Time (activate help immediately) OR Thunderclap headache (worst headache of your life)
T has evolved to both :)
How would you activate a rapid response?
What is... ***111 (provide the location of the alert)
What is the rate and depth of high-quality compressions?
What is... 100-120/minute, 2 inches
What test should be completed within ten minutes of a patient reporting new chest pain?
What is... an EKG!
If the reason for RRT activation is chest pain, delegate someone to go get the machine so it is ready for use right away!
When a patient is in respiratory arrest, you should provide ________ breath every ________ seconds via bag valve mask.
What is... one breath every 6 seconds!
This assessment tool is used to grade the severity of a patient's stroke. It is done at symptom onset, in specific intervals, and then once a shift. The RN must be certified before they can perform this assessment.
What is... NIH Score
What is the number one determinate between calling a rapid response and calling an adult cardiac arrest?
What is... pulse vs. no pulse!
What is the ratio of compressions to breaths for a patient without an advanced airway (not intubated)?
30:2
When a patient is admitted for chest pain as the primary diagnosis, what serial lab value do you anticipate drawing?
What is... troponin
This oxygen device can deliver up to 15L/min and can be used when your patient is presenting with severe hypoxia.
What is... a non-rebreather mask!
After activating a RRT, what is one of the first things you should check if your patient presents with stroke like symptoms?
what is... a blood sugar!
severe hypoglycemia can mimic stroke symptoms!
When calling a rapid response, the nurse (and surrounding support staff) should anticipate having what essential items available in the room?
What is... WOW with chart open, Code cart with monitor turned on/ leads on the patient, complete set of VS, Glucometer...
What is the ratio of compressions to breaths for a patient who is intubated?
What is... high quality of compressions are continuous, only stopping every two minutes for a pulse check. Breaths are delivered via bag valve mask continuously every 6 seconds
Nausea, sweating, shortness of breath, chest pain and jaw pain are all signs of...
What is... MI!
This piece of a equipment is necessary if your patient ever requires intubation and should ALWAYS be set up in the room when preparing to admit a new patient.
What is... A suction set up! (Canister, tubing, and wall suction)
When a code stroke is activated, where should you anticipate bringing your patient?
What is ... to CT Scan
What is the role of the primary RN (and support staff) when the Rapid Response Team arrives?
What is... remain with the patient and be prepared to assist. The RRT RN may need help obtaining labs, administering medications, obtaining an EKG, transferring the patient, etc.
as the PRIMARY RN: be prepared to give a quick summary to the responding RRT team including the reason for the call, reason for hospital admit, recent labs, medications, and any additional details that will assist them in determining next steps.
This medication is given every 3-5 minutes during a cardiac arrest...
What is... epinephrine!
Your patient complains of chest pain! You activate a RRT and complete an EKG. The EKG shows a new STEMI! Where do you anticipate this patient going...?
What is... the cath lab!
Chest pain associated with shortness of breath can indicate what "clot-related" lung emergency?
What is... Pulmonary Embolism!
Why do we bring a patient for a CT scan when they first present with stroke-like symptoms?
What is... to rule out a bleed (hemorrhagic stroke).
when a patient presents with stroke symptoms, the question is, "are they a candidate for TNK (clot busting medication." Aside from establishing a time of last-known-well and reviewing their history to determine if they can get this medication, we need to check for a bleed. the quick CT scan is to determine if there is a hemorrhagic stroke or not so the provider can further decide if they can give TNK. (Tnk is a clot buster; we can not give it with a bleed)
This uses an algorithm that incorporates various data points like vital signs, lab results, and nursing assessments to generate a score, ranging from 0 to 100. Higher scores indicate the patient is at risk of adverse events such as a rapid response activation or even unexpected death!
What is.... Deterioration Index
If a patient presents with either of these two lethal cardiac arrhythmias... Expect the need to DEFIBRILLATE!
What is... V-fib and Pulseless V-tach!
What interval will be elevated on a rhythm strip if the patient is having an ACTIVE MI!!
What is... ST elevation!
You are caring for a patient with COPD who requires continuous Bipap. They have not been compliant with wearing the mask and are now lethargic. You note they are too sleepy to take their afternoon meds. What lab value should you be concerned about? What is your next step for this patient?
What is.... CO2 level!
If they have not been compliant with their bipap and are now lethargic they are most likely retaining CO2. High retained CO2 = risk for respiratory failure. You are activating a RRT immediately to prevent further deterioration.
A patient with a history of A-fib is admitted for a GI bleed. Because of this, the provider has placed all blood thinners on hold. Aside from the bleed, what else is our patient at risk for? why?
What is... a stroke!
Afib increases the risk of stroke because the irregular beating of the heart allows blood to pool and clot. If the clot breaks free it enters the brain causing a stroke. The blood thinners prevent this from happening. When the blood thinners are placed on hold, the risk of stroke returns!