Question

Current Concern: When the nurse enters his room to administer his morning medications, she notices that Butch does not respond verbally. When she approaches him, she notices that his color is pale and is diaphoretic. His radial pulse is faint and thready, and his respiratory rate is labored with a rate of 30/minute. Butch calls out, “Please help me!” and becomes unresponsive. The nurse is unable to palpate a carotid pulse and has no spontaneous respirations. She begins CPR while another staff calls 911. Paramedics arrive five minutes later and determine that he is in ventricular fibrillation. He is intubated, a peripheral IV is established and epinephrine and amiodarone are administered. He is transferred to the emergency department, and upon arrival, he is found to be in asystole. After 10 minutes of CPR, and additional boluses of epinephrine and amiodarone, he remains in asystole. The emergency room physician collaborating with the healthcare team ends aggressive measures. Butch’s cardiac rhythm is asystole, and his death is pronounced. When his wife arrives 15 minutes later not knowing if Butch is dead or alive, she is approached by the nurse who communicates what has just transpired. Rita is in shock and disbelief because he looked so good when she visited him yesterday. She insists on staying in the room. There is no other family in the area, and Rita is all alone.

1. Relevant data from current concern

2. Clinical significance

Answer 1

1. Relevant data from current concern

• Patient is unresponsive. color is pale and is diaphoretic. His radial pulse is faint and thready, and his respiratory rate is labored with a rate of 30/minute.The nurse is unable to palpate a carotid pulse and has no spontaneous respirations.
• He has ventricular fibrillation. He is intubated, a peripheral IV is established and epinephrine and amiodarone are administered.
• After 10 minutes of CPR, and additional boluses of epinephrine and amiodarone is administered .
• Cardiac rhythm is asystole and the patient is expired.

2. Clinical significance

• Palpation of carotid pulse when the patient becames unresponsive.
• Immediate CPR after palpation.