Novel Nursing Terminologies for the Rapid Response System

International Journal of Nursing Terminologies and Classifications, Apr-Jun 2009 by Wong, Elizabeth

PURPOSE. Nursing terminology with implications for the rapid response system (RRS) is introduced and proposed: critical incident nursing diagnosis (CIND), defined as the recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication; critical incident nursing intervention, defined as any indirect or direct care registered nurse-initiated treatment, based upon clinical judgment and knowledge that a registered nurse performs in response to a CIND; and critical incident control, defined as a response that attempts to reverse a life-threatening condition.

DATA SOURCES. The current literature, research studies, meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article.

DATA SYNTHESIS. The current nursing diagnoses, nursing interventions, and nursing outcomes listed in the North American Nursing Diagnosis Association International Classification, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC), respectively, are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of such standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations when activating the RRS.

CONCLUSIONS. The North American Nursing Diagnosis Association International Classification, NIC, and NOC are urged to refine their classifications and include CIND, critical incident nursing intervention, and critical incident control The RRS should incorporate standardized nursing terminology to describe patient care during life-threatening situations.

IMPLICATIONS FOR NURSING PRACTICE. Refining the diagnoses, interventions, and outcomes classifications will permit nursing researchers, among others, to conduct studies on the efficacy of the proposed novel nursing terminology when providing care to patients during life-threatening situations. In addition, including the proposed novel nursing terminology in the RRS offers a means of improving care in such situations.

Search terms: Critical incident control, critical incident nursing diagnosis, critical incident nursing intervention, rapid response system, standardized nursing terminology

An 83-year-old male was admitted to the medicalsurgical unit in mild distress with diagnoses of chronic obstructive pulmonary disease, morbid obesity, and non-insulin-dependent diabetes mellitus. During nursing rounds on the night shift, he was found to be cyanotic with a weak or possibly absent palpable pulse. As several registered nurses (RNs) were available, they effectively managed this life-threatening event by giving medications, increasing his oxygen concentration, and contacting the respiratory therapist and the physician. The patient was successfully resuscitated by the RNs and was transferred to the intensive care unit in critical condition.

It is evident, from a review of this life-threatening event, that a single RN could not simultaneously perform all of the necessary nursing interventions to save the patient's life. Without the support of the RN colleagues, this patient may have had a less favorable outcome, as prolonged hypoventilation can eventually lead to cardiopulmonary arrest and death. Fortunately, this outcome was prevented by rapid action of the RNs involved. In this particular clinical scenario, the team that saved the patient's life was an informal resuscitation team, which involves united action by available staff when a life-threatening event is recognized.

Background Information

Informal resuscitation teams have been performing life-saving treatments for centuries (Safar, 1996). In the late 1950s and early 1960s, Safar, Escarraga, and Elam (1958) and Kouwenhoven, Jude, and Knickerbocker (1960) wrote two landmark articles that outlined the important benefits of artificial mouth-to-mouth respiration and closed-chest cardiac massage, respectively. Following the publication of these two articles, an explosion of academic and clinical research over the last four decades has led to progress in treating patients with life-threatening conditions. In the United States, the American Heart Association has set the standard for cardiopulmonary resuscitation by implementing certification classes that encompass basic life support (BLS), advanced cardiac life support (ACLS), and pediatrie life support Formally trained providers who successfully complete the course receive a certificate. As a condition of employment in a hospital, every RN must have BLS training, and RNs employed in critical care areas usually have ACLS training. The current protocol followed when a patient is found to be apneic or pulseless is to dial a designated telephone number in order to summon a formally trained designated team of responders to the patient's bedside to perform BLS, ACLS, or pediatrie life support in an effort to save the patient's life.

An important aspect of the case presented above was that the life-threatening event was relatively sudden, dramatic, and overt; a cardiopulmonary arrest was averted by the rapid, decisive action of the nursing staff. Such life-threatening events, however, do not always occur rapidly, dramatically, or overtly. Often, numerous subtle changes in vital signs or level of consciousness are exhibited that portend a cardiopulmonary arrest long before such a critical event actually occurs. A study of events leading up to a cardiopulmonary arrest revealed that identifiable physiological deterioration took place within 6 hr (Schein, Hazday, Pena, Ruben, & Sprung, 1990), 8 hr (Franklin & Mathew, 1994; Hulman et al., 2002), and even 24 hr (Buist et al., 1999) before a cardiopulmonary arrest occurred. The most common physiological changes noted in these studies included alterations in breathing pattern (hypoventilation or hyperventilation), pulse rate (bradycardia or tachycardia), or level of consciousness (confused or obtunded) (Buist et al., 1999; Franklin & Mathew, 1994; Hillman et al, 2002; Schein et al., 1990).