Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 16-7

Performing Emergency Manual External

Defibrillation (Asynchronous) (Continued)

Comments

9.If the patient remains in VF or pulseless VT, instruct all

personnel to stand clear of the patient and the bed,

including the operator.

10. Discharge the current by pressing both paddle charge but-
    tons simultaneously. If using remote defibrillator pads,
    press the discharge or shock button on the machine.


11. After the shock, immediately resume CPR, beginning with
    chest compressions. After five cycles (about 2 minutes),
    reassess the cardiac rhythm. Continue until advanced care
    providers take over, the patient starts to move, you are too
    exhausted to continue, or a physician discontinues CPR.
    Advanced care providers will indicate when a pulse check
    or other therapies are appropriate.


12. If necessary, prepare to defibrillate a second time. Energy
    level on the monophasic defibrillator should remain at 360
    J for subsequent shocks (AHA, 2005b).


13. Announce that you are preparing to defibrillate and follow
    the procedure described above.


14. If defibrillation restores a normal rhythm:
    a. Check for signs of circulation; check the central and
    peripheral pulses, and obtain a blood pressure reading,
    heart rate, and respiratory rate.
    b. If signs of circulation are present, check breathing. If
    breathing is inadequate, assist breathing. Start rescue
    breathing (one breath every 5 seconds).
    c. If breathing is adequate, place the patient in the recov-
    ery position. Continue to assess the patient.
    d. Assess the patient’s level of consciousness, cardiac
    rhythm, breath sounds, and skin color and temperature.
    e. Obtain baseline ABG levels and a 12-lead ECG, if
    ordered.
    f. Provide supplemental oxygen, ventilation, and
    medications, as needed.


15. Check the chest for electrical burns and treat them, as
    ordered, with corticosteroid- or lanolin-based creams. If
    using ‘hands-free’ pads, keep pads on in case of recurrent
    ventricular tachycardia or ventricular fibrillation.


16. Remove gloves, if used. Perform hand hygiene.


17. Prepare the defibrillator for immediate reuse.

ExcellentSatisfactoryNeeds Practice