About
The heart is unable to produce an effective pumping action resulting in impaired circulation.
Assess
Absence of respirations, pulse, consciousness. Can be preceded by chest pain, discomfort, fatigue, faintness, sweating, diaphoresis, shortness of breath, difficulty in breathing.
Complications
Death, acid base disturbances, hypoxia leading to altered neurologic status or persistent vegetative state.
Diagnosis
- Decreased cardiac output related to heart muscle malfunction.
- Ineffective gas exchange related to lack of oxygenation/ lack of respirations.
Goals
- The client will resume a normal rhythm.
- The client will resume respirations.
- The client will be free from injury and complication.
Interventions
- Call a code to notify other personnel.
- Start CPR.
- Place client on backboard in the supine position, raise the bed to a comfortable working height.
- Establish patent airway. Perform bag to mouth respirations. Plan to intubate.
- Perform chest compressions per current guidelines.
- Apply ECG monitoring equipment and defibrillation pads. Defibrillate as indicated by physician.
- Establish IV access and draw labs to be sent stat. Hang a 0.9NS IV bag to keep vein open.
- Administer medications as indicated by physician ( lidocaine, epinephrine, amiodarone, atropine, etc.)
- Record all interventions on a log with one timekeeper.
- Recorder should be prepared to indicate length of time in between defibrillation, medication administration, etc as needed by physician.
- Call family or next of kin to be with patient and/or update client condition. Maintain HIPAA and/or confidentiality guidelines with phone communication.
- Provide family support if at bedside.
- Determine underlying cause of cardiac arrest
- Plan to transfer client to intensive or critical care if pulse returns.
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