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UNRESPONSIVENESS BY PATIENT
Assessment of unresponsiveness is a crucial link in activating early life-saving techniques. Unresponsiveness is checked by calling the patient’s name and shaking the patient’s shoulder. If the patient remains unresponsive, the nurse needs to call for help and take immediate measures to ensure airway, breathing, and circulation until the code team arrives.
Guidelines established by the American Heart Association require a written, chronological account of a patient’s condition while cardiopulmonary resuscitation (CPR) is being performed. This is usually charted on the code record, which documents detailed observations and interventions as well as drugs administered to the patient. (See “The code record,” page 62.) The nurse needs to remember to follow Advanced Cardiac Life Support guidelines when responding to a code.
Some facilities use a resuscitation critique documentation to identify actual or potential problems with the CPR process. This documentation tracks personnel responses and response times as well as the availability of appropriate drugs and functioning equipment.
Essential Documentation
The nurse should never rely on memory. All events should be recorded as they occur. Writing “recorder” after the nurse’s name indicates that the nurse documented the code but did not participate. The nurse needs to:
Document the date and time that the code was called.
Record the patient’s name, the location of the code, the name of the person who discovered that the patient was unresponsive,
the patient’s condition, and whether the unresponsiveness was witnessed.
Record the time that the health care provider or nurse practitioner was notified, his or her name, and the names of other members who participated in the code, as well as the time that the family was notified.
Note the exact time for each code intervention and include vital signs, heart rhythm, laboratory test results (arterial blood gas or electrolyte values), type of treatment (CPR, defibrillation, or cardioversion), drugs (name, dosage, and route), procedures (intubation, temporary or transvenous pacemaker, or central venous line insertion), and the patient’s response during these interventions.
Indicate the time that the code ended and the patient’s status. Some facilities require that the health care provider leading the code and the nurse recording the code review the code record and sign it.
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