<p>TITLE: PROTOCOLS FOR USE BY THE RAPID RESPONSE TEAM REGISTERED NURSE </p><p>Performed By: RN who has successfully completed Core PICU nursing competencies. </p><p>Purpose: To provide protocols for use by the Rapid Response Team (RRT) Registered Nurse </p><p>Policy Statements: 1. The protocols listed in this policy may be initiated by the RRT RN prior to physician notification as the patient condition warrants. The RRT Intensivist is to be notified as soon as possible after initiating a protocol. These Protocols DO NOT APPLY TO EMERGENCY DEPARTMENT, SPECIAL CARE NURSERY, PICU, ICC, AND NEONATAL INTENSIVE CARE UNITS. 2. Each time a protocol that requires a medical order is initiated, an order MUST be written on the physician’s order sheet (Example: Stat ABG for severe respiratory distress per Nursing Protocol/J. Doe RN) 3. The RN may delegate specific tasks to staff within their scope of practice. 4. An RN who has completed the PICU core competencies may initiate the RRT RN protocols. </p><p>General Information: 1. If the RRT Intensivist is unavailable or not accessible, the patient’s attending physician or partner, the Emergency Department physician, or House physician (where available) is notified and consulted. 2. The RRT RN position is intended to support clinical decision-making in the non-critical care areas. 3. The RRT RN may initiate the protocols in a non-critical care area. 4. The RRT RN may transfer a patient to a monitored area when performing a consultation. 5. Additional information pertaining to specific procedures may be obtained from procedure policies. </p><p>Procedure: 1. Based on assessment, the RRT RN identifies a situation/patient condition that warrants initiation of a protocol. 2. An order for each protocol initiated is written on the physician’s order sheet. Example: Stat ABG for severe respiratory distress per Nursing Protocol/J. Doe RN 3. The supervising RRT Intensivist is informed that the protocol was initiated and the patient status. 4. Patient is monitored based on the protocol initiated, response to protocol, and physician orders. 5. Initiate a “Dr Blue” when a team response stat is indicated.</p><p>Documentation Guidelines: On form(s) appropriate to area, (may be in progress note) document 1. RRT RN assessment of patient including concern by floor staff 2. Outline protocols initiated 3. Written order on physician order sheet. 4. Patient response to intervention 5. Physician notification/attempts to contact physician Rapid Response Team Protocols</p><p>RESPIRATORY Nursing Protocols CARDIOVASCULAR Nursing Protocols 1. O2 to keep saturations > 90%. 1. Peripheral IV and/or keep open an existing IV with normal saline. 2. Monitoring as indicated 2. STAT chest x-ray with reading. . Oximetry . Cardio respiratory 3. For Chest pain: . Apnea . Obtain STAT 12 lead EKG and report results to supervising 3. Suction as needed. physician. . Cardiac monitoring (e.g.: Lead II)</p><p>4. For a patient in respiratory distress . O2 to keep saturation 90%. . B/P-Pulse-Resp. every 5 minutes . Call Respiratory Therapy for and document. Respiratory Care Assessment and give any previously ordered 4. For symptomatic hypotension (40mm treatment STAT x1. Hg drop in systolic baseline), call supervising Intensivist STAT and: . Respiratory treatment X1 of . Utilize MODIFIED Trendelenburg Albuterol 2.5 mg (0.5 mls) in 2.5 position by elevating legs and mls of NS nebulized using 8 – 10 L leaving head flat. DO NOT use of O2 flow Trendelenberg position as it may increase respiratory distress and . ABG or VBG testing one time. cause refractory bradycardia or hypotension. . STAT chest x-ray with reading. . Bolus with 10 mls/kg NS IV. . Monitor B/P-Pulse-Resp. every 5 5. May return to last stable ventilator minutes and document until patient setting if patient fails ventilator weaning is no longer symptomatic, returns to as evidenced by: baseline, or is transferred to a Respiratory rate monitored bed. O2 saturation 90% . Use non-invasive automatic cuff or Level of consciousness doppler stethoscope to monitor B/P. Anxiety . Remove topicals that may cause Contact Respiratory Care for hypotension such as Nitroglycerin Respiratory Care Assessment and to patch/paste, Duragesic, or Catapres Return patient to last stable ventilator patch. Setting. . Hold oral antihypertensive until physician is consulted. 6. Transfer to higher level of care if indicated. 5. For suspected/active bleeding order and draw: . STAT CBC and send to lab . Type and screen and hold pending CBC results. . If Hgb 8, send type and screen to lab and set up 2 units packed cells</p><p>6. Transfer to higher level of care if indicated.</p>