AHA iSample Charting / Documentation for Mega Coding

Name: Mrs. Rhea Fernandez

Age: 65 years old
Sex: Female
AP: Dr. Cruz
Diagnosis: Cataract on Right eye (For Surgery)
(VOMIT TECHNIQUE)
V VISUALIZE / VERBALIZE (Assessment Skill)
0700H - Received patient lying on bed, on supine position with one pillow support on the nape
area with complains of difficulty of breathing, feels nausea and vomiting and feels
light-headed.
Vital signs taken and recorded; BP: 70/40mmHg, PR: 40bpm; RR: 12cpm; T: 35
degrees Celsius and O2 saturation of 90%.
O OXYGEN ADMINISTRATION (Standard protocol to maintain supplemental oxygen
status)
0710H Provided with supplemental O2 via nasal prong @ 3LPM hooked to wall inlet, s
notable dryness of the nares and nasal flaring. Latest O2 saturation is @ 98%
I INTRAVENOUS / INTRAOSSEUS FLUID ADMINISTRATION
Sites available for Intraosseus Distal femur, Distal/Proximal Tibia/
Anterior Superior Iliac Crest
0712H IV line inserted @ left antecubital vein patent and intact with #1 PNSS I L @
120cc/hour, infusing well. Second line infusion prepared for.
M MONITOR PATIENTS CONDITION
0713H Hooked to cardiac monitor with 3 lead parameters, attached with defibrillator
patches, on stand-by and ready to charge.
Noted with Sinus Bradycardia on cardiac monitor, vital signs retaken, BP:
70/40mmHg, PR: 40bpm, RR: 16cpm and O2 Sat: 98%, noted unstable.
T TREATMENT OF PRIOR CASE (SINUS BRADY)
0714H Atropine 0.5mg via IV given and is flushed with 20cc NSS, arm elevated.
Time interval @ 3-5 mins.
0717H Persistent Sinus Bradycardia still noted with PR: 42bpm and BP: 70/40mmHg,
still unstable. Transcutaneous Pacing prepared.
0718H TCP done @40 mAmps with the HR: 80bpm with notable capture.
With complains of minimal dizziness.

0720H -

0722H -

0723H 0724H -

0725H -

0726H -

0727H -

0728H -

0729H -

0730H -

0732H 0733H -

Noted Unresponsive.
Code Blue activated.
No palpable pulse.
High quality CPR started at 30:2 in 5 cycles.
Code team arrives.
Compressions resumed, bag-mask ventilations maintained, no notable air
exchange resistance.
IV on moderate fast-drip, line patent and intact.
Stopped compression, rhythm analyzed.
Noted with Monomorphic Ventricular Tachycardia
No palpable pulse detected, BP: 70/40 unstable O2 saturation maintained @98%.
Resumed with high-quality compressions @ 30:2 by 5 cycles.
Defibrillator patches attached and charged @ 360J
Shock administered @ 360J, compressions resumed airway maintained.
Noted with Monomorphic Ventricular Tachycardia
No palpable pulse, unstable BP: 70/40.
High-quality compressions resumed and defibrillator patches charged @ 360J
Shock administered @ 360J, compressions resumed, airway maintained.
1st dose of Epinephrine 1:10000 preparation given and the IV is flushed with 20cc
NSS with arm elevated.
Noted with Refractory Monomorphic Ventricular Tachycardia.
No palpable pulse and the BP: 70/60mmHg, still unstable.
High-quality CPR resumed, defibrillator patches charged @360J.
Shock delivered @ 360J, compressions resumed and airway still patent.
1st dose of Amiodarone 300mg given and the IV is flushed with 20cc NSS
And arm is elevated.
Asystole noted on monitor. Flat line protocol activated.
No palpable pulse, leads are all in place and ECG magnified.
Asystole confirmed.
High-quality CPR is maintained, airway patent.
2nd dose of Epinephrine 1: 10000 preparation given and the IV is flushed with
20cc NSS and arm elevated.
No air exchange resistance, clear lung fields upon auscultation upon each bagmask ventilation rendered. Pulse detected during CPR ruling out tension
pneumothorax. No muffled sounds auscultated ruling our cardiac tamponade.
Sinus Tachycardia noted, with palpable weak, thready pulse.
BP: 70/40mmHg still unstable, IV increased on fast-drip and Dopamine
5mcg/kg/min prepared.
BP: 70/50mmHg, still unstable, Dopamine infusion administered.
Epinephrine 2mg/min infusion prepared and on-standby.
Called in Dr. Lorenzo for intubation, set prepared.

0735H -

0736H -

0738H 0740H -

0800H -

Endotracheal intubation done by Dr. Lorenzo, noted with positive and equal
bilateral air entry at the level of 24cms, attached to continuous bag-mask
ventilation.
Noted unresponsive with GCS of 3/15, comatose, hyperthermic.
Therapeutic hypothermia performed, infused with normal cold saline maintained
@4 degrees Celsius @30cc/kg to run in 12-24 hours.
Temperature maintained @ 34 degrees Celsius, confirmed by esophageal
thermometer.
With post-intubation orders noted from Dr. Lorenzo.
Hook patient to mechanical ventilator with the following set-up of: (optional)
Stat CXR, done. Results relayed.
Blood drawn for ABGs, electrolytes and cardiac markers. Results followed up.
12- Lead ECG ordered, interpreted by Dr. Carandang.
NGT inserted, gastric aspirate noted to be whitish. Maintained at closed distal
end.
Foley catheter inserted and hooked to urobag draining to amber colored urine.
IV lines maintained @ 120cc/hr, Dopamine drip infused and maintained. Second
line on stand-by.
Called in Dr. Cruz, intensivist, for case referral.
Watched for unusualities and cared for.
Transported to ICU for closed monitoring.
Endorsed to NOD for continuum of care.

Signed: Klins B. Oliver, RN