“Every code is different and some are done better than others…”

We are super excited to introduce to you Helen who is a Critical Care Registered Nurse who has written for The Nurse Break. She will cover a range of QnA questions for nurses and graduates and students, explore what it is like to ‘Run a Code’, and talk about all things High Flow Nasal Prong therapy (HFNP) in the paediatric population.

Disclaimer: Opinions/Comments are my own and not the views of my employer.

About Helen

Hi everyone, my name is Helen, I am 40 years old, married with two beautiful teenage daughters and live in Melbourne, Victoria.  I started my nursing career at the age of 27 when a lady that I was working with in a factory with told me that ‘I had entirely too many brains to be working in a place like that and I should go and do something with my life!’ 

I had never really thought about what I wanted to do with the rest of my life up until that day. I thought about what made me happy and what I enjoyed and came to the conclusion that I liked helping people and nursing seemed like a logical thing for me to do. 

I was very naïve about the whole process of becoming a nurse. I had no concept of what it took to start my career.  With my children aged 2 and 5, I applied to the university to sit the STAT test as a mature aged student, passed that and was accepted into the university for my bachelor of nursing degree.  At the time, I was living in Mildura and did all of my study through La Trobe University.  On completion of my degree, I was accepted into a grad year at the Angliss Hospital in Upper Ferntree Gully. 

My young family and I left our country town and moved to Melbourne for my career.  My grad year consisted of 3 x 4 month rotations, surgical, rehab and emergency (ED).  I loved each and every place that I worked, they all made me feel so welcome and that I belonged. 

After my graduate year…

After my grad year I was accepted into a post-graduate degree of Midwifery course.  I worked 2 days a week on a the maternity ward while doing my degree which took 12 months and also worked in ED during this time.  At the end of my post grad, I continued to work in ED on bank and also did agency work in ED and midwifery.

After a few months I got full time work in ED at Maroondah where very quickly undertook my Transition to Speciality Practice (TSP) and then moved on to my post-graduate diploma in Critical Care – Emergency stream.  I completed my diploma and 12 months later became a Clinical Nurse Specialist (CNS) in ED.  Currently, I split my time between ED and ICU, both areas compliment each other but are also very different in their workloads.  I am in the process of dropping ICU and moving back to ED full time.

What’s some advice/thing’s nurses can do to better prepare themselves to get a job and work in your field?

Get as much experience as you can in your Grad year.  Time management is a big one, learning to prioritise the important things and take action when needed. Take short courses. Many of them are offered free of charge by your hospitals and will give you some extra knowledge and skills that can help. For example: Basic ECG course, IV Cannulation course

Night shift tips

I actually quite enjoy night shift.  My biggest tip is keep up your fluids and try and keep your eating reasonably healthy (that’s hard).  Personally I don’t sleep / nap before my first shift but I know many nurses that do.  You kind of just have to see what works for you.  I sleep well through the day but generally only for 6 hours or so.  I don’t tend to take anything to aid in sleeping but again, I know many who do.  Listen to your body!! If you are struggling, try exercise, it’s a great way to pep you up.  I also try not to sleep after my last night shift.  I will keep myself busy at home through the day and go to bed around 7PM, this tends to get me back into a day cycle easier but sometimes it works better than others.

If I have had a really adrenaline inducing morning in ED prior to my shift ending, I will need to chill for a while before I go to bed.  I read a book or watch a movie and this is usually enough to do it.

What do you carry on you during a shift?

This is an easy one, I travel light.  In emergency you never know what is going to happen at any given moment, you could be sitting talking with a patient one minute and then pinning down a drug affected, agitated patient the next.  You don’t want to have things weighing you down or worse still things that make it easy for you to be grabbed or strangled with.

I have on me at all times a pen, my work ID, my name badge and a pen torch.  I carry my stethoscope around my neck but it is the first thing that comes off if I have to run to a code. I also always have a bottle of water and fill it at the start of the shift (mind you I don’t always get to drink it).

What’s in your lunch box!

I personally always take my own meal to work, as I don’t like what is on offer in our canteen and there is nothing open on night shift anyway.  Depending on what shift I am on as to what I take.

AM shift – I get up and shower, have breakfast at home.  I take some fruit / yoghurt to work for morning tea.  For lunch it is either a wrap with meat and salad or left over dinner from the night before so usually meat and veggies.

PM shift – I like a sleep in so I will usually have a late breakfast at home and then take my lunch and dinner to work with me.  Lunch as per day shift and dinner will usually be meat and veg.

ND shift – This is the bad one hahahaha.  I tend to take one meal, usually meat and veg and sometimes I will also take something for breakfast.  This is usually on my last ND shift as I try not to sleep.  I also usually take something to share with the team.  Sometimes its something yummy like chips or chocolate or something a little healthier like fruit or dips.

What is one piece of advice for students you would give who are worried about starting a graduate year?

Don’t stress!! We have all been there and we know that you are new we are here to support you.  Ask questions, if there is anything you are not sure about, no matter how silly you think it is or how much you think you should already know it, ask!  Don’t be afraid to ask for help.  Everyone needs help at times, the people around you are your team, they are not mind readers though.  You have to be able to stand up and say ‘I need some help’ and it will be there.

Humidified HFNP in Paediatrics

High Flow Nasal Prong therapy (HFNP) is a form or non-invasive respiratory support.  It can be used in adults as well as children and can be very effective when used appropriately.  The indication for use in children is to prevent or relieve symptoms of hypoxaemia and respiratory distress often associated with bronchitis or pneumonia. 

Children often have little reserve to support them working so hard for so long.  In children with persistent hypoxaemia (Oxygen saturations (SpO2) less than 90%) and signs of moderate / severe respiratory distress despite the use of oxygen therapy, HFNP should be considered.  

Signs of respiratory distress in children can include

• Tracheal tug
• Nasal flaring
• Intercostal / subcostal recession
• Abdominal breathing
• Head bobbing
• Stridor

The HFNP works by adding humidification and working at a high flow rate which enables you to reduce the patient’s work of breathing or respiratory effort as well as being able to give oxygen.  In children under the age of 1 year you will also need to place a naso-gastric tube to avoid gastric distension.

The flow rate of the HFNP is determined by the child’s weight.  You give 2L/kg/min up to 12kg and then an extra 0.5L/kg/min for each Kg thereafter (to a max of 50L flow)

Ie – a child weighing 15Kg would have 12 x 2 = 24
                                                                 3 x 0.5 = 1.5

                                                                24 + 1.5 = 25.5
       So your flow would be 25.5 or rounded to 25

You would commence your HFNP at a lower flow rate and titrate it up to the desired flow as quickly as the child tolerates.  Once you are at your desired flow rate, add in your oxygen.  This method of oxygenation is better than oxygen direct from the wall as it allows you to see the actual % of oxygen you are giving. 

With room air being an FiO2 (Fraction of inspired oxygen) of 21% oxygen, you can see with the machine the actual FiO2 being delivered to the patient.  You want to keep the FiO2 as low as possible to achieve the desired saturation of oxygen.

As the nurse looking after a child with HFNP, your observations must include but are not limited to:

• Activity and alertness
• Work of breathing
• Respiratory rate
• Heart rate
• SpO2
• Flow rate
• FiO2 O2
• Humidifier temperature
• Confirm presence of sterile water, change bag if necessary
• Check position of prongs, patency of tubing, inspection of nasal mucosa
• Assessment of abdomen for signs of abdominal distension

Within 2 hours, you should expect to see a 20% reduction of the patients respiratory and heart rates, a 40% reduction in the FiO2 required to maintain target SpO2.  Signs of respiratory distress should also diminish.

If these things are not happening you may need to consider more invasive respiratory supports.

Code Code Code

When a patient codes it is always a stressful time but as nurses it is our job to remain calm and focused.  In an ideal situation, there are many hands on deck to help you.  You would have…

• Airway nurse – Assists with bag valve mask (BVM) ventilation, sets up for and assists the Airway Dr. with intubation.
• Circulation nurse – Insertion of IV’s, Cardiac compressions, manages the defibrillator, cardiac monitoring, monitoring the SpO2, BP, HR, RR and call them out for the scribe and rest of the team
• Drug nurse  – Better if you can have 2.  Will be in charge of drawing up / administering the drugs needed in the code
• Scribe nurse – Document all events in the code, assist the code leader with information such as duration of CPR, amounts of drugs given ect.
• Airway doctor – Manages the airway – BVM, intubation.
• Drug doctor – Ordering / administering drugs (not essential as the code leader or airway Dr. can also order and nurse can administer but an added bonus if you have the staff)
• Code leader (usually but not always a doctor) – Ideally, will stand at the end of the bed and oversee the entire code.  They will be looking at reversible causes and putting things into effect to rectify them

Ideally, the roles are sorted at the start of each shift so that when an emergency occurs, everyone already knows what is expected of them. Every code is different and some are done better than others. 

There is an algorithm that is followed when a patient is unconscious and not breathing properly.  Depending on what type of heart rhythm the patient has as to weather or not they are defibrillated.  As a nurse working in the resuscitation area, you are trained to recognize those rhythms and know which is to be shocked and which is not. 

The machines can analyze the rhythm for you but that takes time and you have to stop doing CPR while it is analyzing which is detrimental to the patient so it all comes down to the training and knowledge of the people in the room. 

The algorithm is followed until the patients heart starts beating again on its own or the decision is made to cease treatment.

It’s really important to debrief with your colleagues post events like this.  Even if they go well it is a very stressful time and everyone will cope differently.  Make sure you check in with your team and make sure everyone is doing ok.

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