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Clinical Learning ActivityNGR 6714Samantha SotoNovember 15, 2013Name of Experience: Post Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientGlobal Goal: MICU RNs will develop competency in the care of post cardiac arrest patients with therapeutic hypothermia treatmentThe Site: Sunshine HospitalNature of the Experience: The experience will include two preparatory assignments, four hours of class, and three days of clinical with a preceptor RN. Class time will consist of review of a post cardiac arrest patient with therapeutic hypothermia case study and hospital protocol. Clinical time will include the use of a skills checklist along with a tool to help with task completion for the first four hours of therapeutic hypothermia. All MICU RNs will complete a summative evaluation within one week of their clinical experience. Who the learners will be: all MICU RNs current and new hiresSunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientLearning ObjectivesAfter completing this course, The MICU RN will be able to:Perform proper equipment check and room preparationComplete neurological exam including: Glasgow Coma Scale, Corneal Reflex, and Pupillary responseProvide patient and family education related to therapeutic hypothermiaAdhere to appropriate infection control protocols and proceduresProvide proper sedation and shivering management Provide appropriate positioning of patient as per protocolPractice skin breakdown prevention protocolProvide appropriate and effective hemodynamic monitoring of patient as per protocolsProvide timely and safe medication administration and titrations as per protocolComplete appropriate documentationSunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientStudent Preparation Check Off List and Activities Syllabus1. Prior to initiation of the clinical component of this course, the MICU RN will attend and complete the following activities:Read and complete post-test related to this article prior to class. Must have quiz completed to turn in to enter class. Article has a CEU availableDeckard, M., & Ebright, P. (2011). Therapeutic hypothermia after cardiac arrest: What, why, who, and how. American Nurse Today, 6(7), 23-28. The article will be sent to you via work email as an attachment a few days prior to class. RN to review policy and procedure #3765 related to care of the therapeutic hypothermia patient. Please download from policies and procedures icon on desktop and also bring to class. Class: A case study review titled, Post Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia Patient will be held Tuesday 12/10/13 from 8am-12pm in room 502. A second class will be held Wednesday 12/11/13 at the same time and same place. Please sign up via the Learn at Sunshine Hospital education system, as we only have 15 seats per class. If you are scheduled to work both of these days please see your supervisor to arrange your schedule accordingly. Please bring paper and pencil. Also drinks and snacks are permissible. Prior to leaving class, the educator will schedule and coordinate clinical experience with MICU. RN to precept with same patient for entire protocol, 3 days. Do not leave class without having your clinical days scheduled. 2. For the clinical component of the course, there will be a skills check off list for each MICU RN to complete that requires a preceptor signature. This will be given to you at the end of class and will be returned when you take the final exam. You must present your completed check off list in order to take your exam. 3. Post clinical, final evaluation to take place via exam on any day M-F 8-4:30, room 502, within one week of completing clinical rotation. You must pass the final evaluation with a score of 85% or better. 4. Complete course evaluation of experience and instructor when final exam is completed. Sunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientStudent Preparation Case Study Mr. K, a 60 year old Caucasian male, has just arrived to the MICU post cardiac arrest approximately one hour ago. The ED RN reports to you that Mr. K was mowing his lawn with a push mower when his wife witnessed him collapse. As she came upon him, he was not breathing and did not have a pulse. She called 911 and initiated CPR. As EMS arrived they found Mr. K to be in ventricular fibrillation and he was defibrillated once with spontaneous return of circulation (SROC) but lack of consciousness and bradypnea with O2 sat 80% persisted. He was intubated by EMS with a 7.5mm endotracheal tube (ETT) and given supplemental oxygen via ambu bag-tube ventilation. He also received a #18 IV catheter to his right antecubital vein. Mr. K has no known allergies and a history of COPD, CAD with 2 coronary stents, DMII, HTN, and ETOH abuse. The RN reports that his wife states his alcohol use has increased recently and he is up to a 12 pack of beer per day mixed with shots of Jim Beam. His wife reports that he is not always compliant with his medications, but this is what is on the medication list she pulls from his wallet:baby ASA 81mg po dailyPlavix 75mg po dailyMetoprolol 50mg po BIDLantus 20 units SQ q hsAdvair inhaler once dailyThe ED physician has deemed that Mr. K meets criteria for post cardiac arrest therapeutic hypothermia protocol and his wife states, “he would want everything done.” The ED begins cooling patient with bags of ice placed on his body. He is taken to CT for a stat non-contrast head scan and then transferred to the MICU. At this point, approximately one hour has passed since his collapse. The clock is ticking with a four hour goal to reach hypothermic goal of 32 degrees C.Question 1According to the Post Cardiac Arrest Therapeutic Hypothermia protocol for Sunshine Hospital Health System, what inclusion criteria are applicable below? Select as many as you think pertain to the protocol. a.Patient with comab.Patient has had return of spontaneous circulation for greater than 30 minutesc.Sepsis is NOT cause of arrestd.Patient has vomiting and diarrheaQuestion 2According to the Post Cardiac Arrest Therapeutic Hypothermia protocol for Sunshine Hospital Health System, which of the following are contraindications for this protocol? Select as many as you think pertain to the protocol. a.Pregnancyb.Major surgeryc.Hypertensiond.Atrial FibrillationQuestion 3Where can you download and print the Post Cardiac Arrest Therapeutic Hypothermia protocol and related tools from?a.The internetb.The library websitec.The policy and procedure icon on your desk topd.The public hospital websiteQuestion 4How much time do we have to reach goal temperature?a.2 hrs.b.7 hrs.c.24 hrs.d.4 hrs.Once you are made aware that you will be the receiving RN for Mr. K, a therapeutic hypothermia patient, you immediately run to prepare his room with the following:ambu bag3 suction set ups and 1 with yankeurTympanic thermometerGlucometerMRSA swabEKG leads, pulse ox, BP, and 2 red cablesSet monitor to cycle BP q 5 min, until arterial line placedZero bed with cables and sheetsAsk doctor if they want any drugs at bedsideCheck your cart for supplies like syringes, needles, 2x2 gauze, alcohol wipes, saline flushes, blood tubes, tapeArtic sun machine-turn on and make sure it does not need water and it is working properlyArtic sun cooling padsFoley catheter w/thermometer2 pressure bags with 500ml NS bags, tubing, and transducer cables for arterial line and CVPIV suppliesSupply box prepared with central line, arterial line, and CVP kit suppliesLopez valve for OGUltrasound machine used for line placementQuestion 5You should never turn your equipment on before the patient gets to the unit. T / FQuestion 6After one hour of cooling your patient you notice that there is a puddle of water on the floor. What should you do? _____________________________________________________After a non-contrast head CT that is negative for any bleeding, the patient arrives to the MICU where 2 RNs, the intensivist, a physician assistant (PA), and a respiratory therapist (RT) are waiting to receive the patient. The patient is placed on the ventilator by RT and is suctioned both subglotic and via inline catheter. He is removed from ED portable monitoring and placed on MICU monitoring for EKG, BP, O2 sat, and respiratory rate until his central line, arterial line, and CVP are placed. A tympanic temperature, blood sugar (BS), height, weight, and MRSA swab of the nares are all collected. He weighs 91kg. Cooled normal saline 0.9% is initiated as per protocol because it has not been started in ED. Blood and urine are collected for baseline studies, not collected in ED and patient is placed in the supine position with head of bed at 30 degrees. He should be turned every two hours to prevent skin break down. You stop to perform a quick head to toe assessment and place the OG tube. Cooling ice packs are removed and Artic Sun cooling pads are placed on patient’s legs and torso. Foley catheter with thermister is placed and connected to Artic Sun cooling machine. Artic Sun machine is turned on and cooling continues. Between the other RN and yourself you are able to complete documentation in intermittent episodes and perform neuro checks every 2 hours. Question 7What is the goal temperature range for this type of patient? _____________Question 8Baseline blood studies are not relevant to the therapeutic hypothermia protocol.T / FQuestion 9The patient must receive cooled saline for a total of 30ml/kg. T / FQuestion 10After baseline blood studies are collected, how often do nurses need to collect blood work?q 10 hrs.q 6 hrs.q 3 hrs.Q 1 hr.Question 11How often do nurses document temperature?Q 1 hr.Q 4 hr.Q 2 hr.Q 30 minutesYour assessment reveals the following:Neuro: pupils are pin point and nonreactive, nor do they track you or have corneal reflex, he does not have gag or cough reflex when suctioned, cannot follow any commands, he does respond to painful stimuli after a very vigorous sternal rub by the physician, his Glasgow coma scale is poorCardiac: NSR, irregular, with frequent PVCs at a rate of 115. No external edema and peripheral pulses are 2+GI: hypoactive BS and has had one large episode of incontinence that is brown and loose, OG inserted and placed to low intermittent suctionResp: ETT #7.5mm, on ventilator at FiO2 80%, PEEP 5, Vt 550, R 14/14, sounds clear diminished in all lobes, and appears to be vent dependentGU: #16 Foley w/thermister placed with clear yellow urine returned in adequate amountsMS: all extremities are flaccidEENT: ETT tube in tracheaSkin: he has some bilateral bruising to his arms where he fell, a #18 IV in the R ACPsyc: family waits outside the room in ICU family waiting room. They are tearful and afraid. Question 12Families of patients undergoing the Post Cardiac Arrest Therapeutic Hypothermia protocol should not be allowed to visit the patient or be informed about the protocol.T / FQuestion 13How often do we perform neurological exams? ___________________Question 14The Glasgow Coma scale is not a necessary part of this patient’s assessment.T / FAs cooling continues you make note that you have approximately 3 hours left to reach target hypothermia temperature of 32 degrees C. You leave the other RN to continue providing care while you take a moment to speak to his family. You briefly educate the family on how therapeutic hypothermia decreases oxygen consumption and helps to preserve brain function. Mrs. K states her understanding, but she is obviously upset. Upon returning to the room with her you explain that hand hygiene is a crucial part of his care. You show her where the hand gel is and ask her to please gel in and also as she leaves. She stays for 5 minutes and states that she needs to return to the family waiting room because she needs to make some phone calls. She gels her hands and exists. The other RN has placed a second temporary IV access to facilitate the entire therapeutic hypothermia process and cold saline infusion. You delegate to the secretary to please make sure there has been a chest x-ray for verification of ETT placement and to place a stat order for KUB to verify the OG tube placement, EKG, and Echocardiogram. As the entire process continues the other RN assists the PA in placing a triple lumen central venous catheter and arterial line. You have already prepared the pressure bags for both the CVP and arterial line so you are able to hook them up and use them with the physician’s permission. Another chest x-ray will need to be ordered to confirm line placement. You begin sedation as soon as possible and follow protocol. About 2 hours have passed and his wife is finally allowed to visit again. During her visit she states to you, “Why is he shivering?” You reply by saying, “shivering is his bodies attempt to make heat, but in this case we do not want him to shiver. According to Presciutti, Bader, and Hepburn (2012) shivering increases O2 consumption, can increase HR, RR, BP, intracranial pressure, and it slows our attempt to get him to goal temperature.” You begin administering the shivering portion of the protocol and give Nimbex 10mg IV bolus. You make note that this is the second bolus of Nimbex the patient has received because there is a bolus within the sedation portion of the protocol as well. Question 15Sedation management begins with what three drugs?Fentanyl, midazolam, and propofolMidazolam, cisatracurium, and precedexPrecedex, fentanyl, and rocuroniumPropofol, precedex, and rocuroniumQuestion 16Name two reasons why it is important nurses assist in the control of shivering management. _____________________________________________Question 17What is the neuromuscular blockade of choice according to the protocol? _________________Fluids and vasoactive agents are guided by the patient’s hemodynamic status. NS 0.9% should run at 80ml/hr unless hemodynamics reveal otherwise. The other nurse looks at the monitor and notifies you that the patient’s MAP is 65. You begin NS 0.9% 500ml bolus over 30 minutes as pre protocol. After 30 minutes his MAP is <70 and CVP is 9. We begin Levophed infusion at 3mcg/minute as per protocol. The therapeutic hypothermia protocol holds further instruction for hemodynamic goals. It has been 3 hours since the patient experienced cardiac arrest and his current intra-bladder temperature is 35 degrees C. Our laboratory studies are returning and reveal low electrolyte levels and hgb of 7.0. Mr. K will require transfusion of pRBC and electrolyte replacement for K+2.0, Mag+1.3, iCa+0.85. Electrolyte protocol replacement is specified within the therapeutic hypothermia protocol and should be referenced to when refilling electrolytes. Question 18Electrolyte replacement for the therapeutic hypothermia patient is the same as the ICU electrolyte replacement protocol.T / FQuestion 19The therapeutic hypothermia protocol does not allow us to give blood products.T / FWe are now 3.5 hrs post cardiac arrest and Mr. K has met his cooling goal. He is 32 degrees C. For the next 24 hours the RN will continue to manage hemodynamics, manage sedation, manage paralytics, administer medications, provide family education, prevent skin breakdown, and report any changes. For the rest of the protocol time his blood work will continue to be checked every 6 hours and his electrolyte replacement protocol will change once he begins to rewarm. His rewarming will begin exactly 24 hours from the time cool temp goal was met. He will have a new goal temperature for rewarming of 36 degrees C. Nursing responsibilities do not diminish throughout the entire protocol. The patients are cooled for 24 hrs, warmed for 24hrs, and then gradually awoken. Once he has been rewarmed for 24 hrs we will begin weaning paralytics and sedation. After approximately 72 hours a reliable prognosis can then be made by the ICU physician. Question 20Rewarming begins when? ________________Question 21What temperature is the rewarming goal? ______________Question 22At what temperature do we begin weaning sedatives and paralytics? ______________Question 23Nurses working with therapeutic hypothermia patients should wash and gel their hands meticulously to prevent infection.T / FQuestion 24After how many hours is a reliable neurological prognosis made?10 hrs. 24 hrs. 48 hrs. 72 hrs. ReferencePresciutti, M., Bader, M., & Hepburn, M. (2012). Shivering Management During Therapeutic Temperature Modulation: Nurses' Perspective. Critical Care Nurse, 32(1), 33-42. doi:10.4037/ccn2012189Lee Memorial Health System, Lee County Florida. Critical Care Services.(2012). Induced hypothermia for cerebral salvage of cardiac arrest patients. Retreived from: policy & procedure manual online/intranet form #3765Sunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientStudent Preparation Case Study Answer Key1.a, b, c2.a, b3.c4.d5.F6.unplug the equipment immediately, clean water on floor, and get another Artic Sun ASAP7.32 degrees C8.F9.T10.b11.d12.F13.q 2 hrs14.F15.a16.^ O2 consumption, ^BMR, ^HR, ^BP, ^RR, ^ICP, slows cooling17.Nimbex18.F19.F20.24 hr after cooling goal met21.36 degrees C22.36 degrees C23.T24.dSunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientSkills Checklist & Competency Validation ToolPerformance EvaluationLearning ObjectiveDate CompletedRN signaturePreceptor SignaturePerform proper equipment check and room preparation1Complete neurological exam including: Glasgow Coma Scale, Corneal Reflex, and Pupillary response2Provide patient and family education related to therapeutic hypothermia3Adhere to appropriate infection control protocols and procedures4Provide proper sedation and shivering management5Provide appropriate positioning of patient as per protocol6Practice skin breakdown prevention protocol7Provide appropriate and effective hemodynamic monitoring of patient as per protocols8Provide timely and safe medication administration and titrations as per protocol9Complete appropriate documentation10Sunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientFinal Exam1.According to the Post Cardiac Arrest Therapeutic Hypothermia protocol for Sunshine Hospital Health System, what inclusion criteria are applicable below? Select as many as you think pertain to the protocol. a.Patient with comab.Patient has had return of spontaneous circulation for greater than 30 minutesc.Sepsis is NOT cause of arrestd.Patient has vomiting and diarrhea2.According to the Post Cardiac Arrest Therapeutic Hypothermia protocol for Sunshine Hospital Health System, which of the following are contraindications for this protocol? Select as many as you think pertain to the protocol. a.Pregnancyb.Major surgeryc.Hypertensiond.Atrial Fibrillation3.Where can you download and print the Post Cardiac Arrest Therapeutic Hypothermia protocol and related tools from?a.The internetb.The library websitec.The policy and procedure icon on your desk topd.The public hospital website4.Families of patients undergoing the Post Cardiac Arrest Therapeutic Hypothermia protocol should not be allowed to visit the patient or be informed about the protocol.T / F5.How often do we perform neurological exams? ___________________6.What is the cooling goal temperature range for this type of patient? _____________7.How much time do we have to reach goal temperature?a.2 hrs.b.7 hrs.c.24 hrs.d.4 hrs.8.Baseline blood studies are not relevant to the therapeutic hypothermia protocol.T / F9.Sedation management begins with what three drugs?a.Fentanyl, midazolam, and propofolb.Midazolam, cisatracurium, and precedexc.Precedex, fentanyl, and rocuroniumd.Propofol, precedex, and rocuronium10.Name two reasons why it is important nurses assist in the control of shivering management? _____________________________________________11.After baseline blood studies are collected, how often do nurses need to collect blood work?a.q 10 hrs.b.q 6 hrs.c.q 3 hrs.d.q 1 hr.12.What is the neuromuscular blockade of choice according to the protocol? _________________13.The patient must receive cooled saline for a total of 30ml/kg. T / F14.How often do nurses document temperature?a.q 1 hr.b.q 4 hr.c.q 2 hr.d.q 30 minutes15.Electrolyte replacement for the therapeutic hypothermia patient is the same as the ICU electrolyte replacement protocol.T / F16.Rewarming begins when? ________________17.What temperature is the rewarming goal? ______________18.At what temperature do we begin weaning sedatives and paralytics? ______________19.Nurses working with therapeutic hypothermia patients should wash and gel theirhands meticulously to prevent infection.T / F20.After how many hours is a reliable neurological prognosis made?a.10 hrs. b.24 hrs. c.48 hrs. d.72 hrs.21. You should never turn your equipment on until the patient gets to the unit. T / F22. The Glasgow Coma Scale is not a necessary part of this patient’s assessment. T / F23. After one hour of cooling you notice a puddle of water on the floor under the Artic Sun machine. What do you do? __________________________________________24. The therapeutic hypothermia protocol does not allow us to give blood products.T / FSunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientFinal Exam Answer Key1.a,b,c2.a,b3.c4.F5.q 2 hr6.32 degrees C7.d8.F9.a10.^O2 consumption, ^HR, ^BP, ^RR, ^ICP, slows cooling11.q6hr12.Nimbex13.T14.d15.F16.24hr post cooling goal met17.36deg C18.36deg C19.T20.d21.F22.F23.unplug equipment, clean water up, find another cooling machine ASAP, notify physician if necessary24.FSunshine Hospital Health SystemCritical Care ServicesPost Cardiac Arrest: Nursing Management of the Therapeutic Hypothermia PatientCourse Evaluation of Experience, Instructor, and PreceptorInstructor: Samantha SotoPreceptor: _____________Please complete this course evaluation by placing an “X” or check mark in the box that indicates your opinion for each statement. DO NOT PUT YOUR NAME ON THIS FORM! This is an anonymous evaluation. Rating System:1=Strongly Agree 2=Agree 3=Undecided 4=Disagree 5=Strongly DisagreeInstructor Evaluation12345The instructor made me feel welcome and comfortable. The instructor was prepared. The instructor answered my questions. The instructor was enthusiastic about teaching this topic.The instructor engages RNs in class and discussion.Preceptor EvaluationMy preceptor was enthusiastic about precepting me. My preceptor was prepared for clinical.My preceptor treated me with respect. My preceptor encouraged me to participate in the care of the patient. My preceptor answered my questions. My preceptor assisted my in completing my skills check off list.My preceptor allowed me to take breaks appropriately. Course EvaluationPreparatory assignments were relevant to this course. Preparatory assignments helped me understand the clinical experience.The case study class was useful in learning about providing nursing care to this type of patient. The clinical experience was a beneficial and valuable method to learning how to care for this type of patient. The skills checklist was practical and useful. The “First Four Hours” tool was beneficial.What recommendations would you give to improve this course?Please feel free to make comments: ................
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