As you are heading into clinicals or your first nursing job, there is plenty to be nervous about. One of the things I was always most nervous about was “what if the patient codes?????? Will I recognize it if it’s happening…what do I do…how do I get help?” My goal here today is to talk you down a bit, so that you feel less anxious about experiencing your first code blue and provide you with tips so you’ll know what to do. You got this!

I remember the first time one of my patients coded. I was a pretty new nurse in the ICU and I was taking care of a patient who’d had a “big belly” surgery, meaning that it was a BIG surgery. The patient’s main issue was an infarcted bowel which can cause soooo many problems in your patient. One of the problems this patient was having was that he was extremely septic, and the other was that the cell lysis that occurred with his ischemic/infarcted bowel resulted in dangerously high potassium levels.

It is as clear to me today as it was then…the patient was intubated and woke up just a little and was coughing against the ventilator. Next thing I know, he was in v-fib arrest. THANK GOODNESS two seasoned nurses were in the room with me! One of them pushed the code button, I grabbed the pillows and positioning supports off the bed and the other nurse started compressions…all of this happening simultaneously. The crash cart arrived within seconds, RT was at the bedside and the code was underway. I was terrified.

Recognizing a code blue

If your patient is on a monitor, then recognizing a code situation is often due to the alarm going off, but it’s important to note that the monitor may think your patient is in V-Tach, but really they’re just brushing their teeth. When ANY monitor alarm goes off, it is vital that you put EYES ON THE PATIENT. Get in the room and assess. If your patient is chatting with his friends but the monitor shows asystole…then their leads are off. If it looks like V-Tach, but he’s scratching at a rash on his chest, he probably doesn’t need cardioversion. And if your patient has Parkinson’s, be aware that the tremors can look like V-Fib…so the moral of the story is…always look at your patient!

Let’s say your monitor goes off and you rush into the room to assess the situation. Once you have seen a patient who is actively coding, you will immediately be able to recognize it…but that first time might have you questioning your ability to recognize a life-threatening situation. Trust me…when your patient is in a lethal cardiac rhythm (or no rhythm at all) it is pretty apparent. There’s really no delicate way to state this, so I’ll just say that if your patient’s heart is in a lethal rhythm, they will look deceased or very close to it. Note that in this post we are talking about the immediately lethal arrhythmias (asystole, pulseless V-tach, V-fib and PEA) Signs to look for include:

  • pallor or grey tones to the skin
  • cool, clammy skin
  • slack jawed
  • glassy eyed or eyes rolled back
  • no response to vigorous or painful stimulation
  • release of bowels
  • gasping or “guppy breathing” (also referred to as “agonal breathing”)
  • overall lifelessness
  • and obviously, no pulse!

Responding to the code blue

So, let’s say you see your patient and he fits this general description…what do you do? Even without taking your ACLS class,  you can still intervene appropriately to help this patient!

  • Get help in there STAT! Either push the code button or YELL for the crash cart…don’t be shy. Pressing the code button is THE best way to get help because it alerts everyone to come to the code…the physician, the pharmacy, lab, and a whole bunch of other nurses. If, for whatever reason, you can’t get to the code button quickly (maybe there’s a bunch of equipment in the way), then YELL for the cart or yell “CALL A CODE.” It will definitely get everyone’s attention.
  • Get the patient into position for CPR. This means getting them to the floor or getting the bed flat STAT. The beds have a CPR lever…know where this lever is on ALL the beds your facility uses. Press that lever and get the patient flat!
  • Start compressions! You’ve taken BLS and you know how to do this. This is another time when you do not want to be shy. Get in there and press HARD and press FAST. Do not worry about hurting the patient…you are trying to save their life, and quality chest compressions is what you need! YOU WILL FEEL THEIR RIBS CRUNCH AND BREAK under your hands…do not stop! Focus on your form and if you have to sing “staying alive, staying alive” under your breath then do it!
  • By this time, you have helpers in the room. The VERY next thing to do is to get the backboard under the patient (unless they’re on the floor) and get the pads on. Depending on how long you were doing compressions, it may be time to switch out.
  • If your patient was on a ventilator, the respiratory therapist or another nurse will be manually bagging your patient at this point (the patient must be taken off the ventilator…due to the high pressures of CPR, this will trigger ‘high pressure’ warnings on the vent making it ineffective). If your patient was not intubated, then your team will also be manually bagging the patient and probably planning to intubate.
  • From here on there will be (hopefully) an entire team of people there to participate in the code. As the new nurse or student nurse, the best thing you can do is get in line for compressions and watch/learn from what is happening around you. Listen to the code leader as they will periodically ask for compressions to be held for a pulse check and then state “resume compressions” when it is time to get back on the chest. Do not be shy about asking for a switch if you get tired…in order for CPR to work, the compressions have to be STELLAR! It is actually pretty exhausting to do quality CPR. Remember…HARD and FAST! The rest of the code will likely be run according to ACLS guidelines but note that the doc can essentially order whatever interventions she wants, but will typically follow ACLS recommendations with a few extras thrown in (bi-carb, calcium, dextrose…depending on the patient’s situation).

Being prepared BEFORE the code

When there’s an emergency with your patient, there is NOTHING more anxiety-producing than realizing you are not prepared. Here are a few easy things you can do each clinical day or each shift to ensure you are ready for anything!

  • Know your patient’s code status. It may sound like a no-brainer…but in the heat of the moment you want to be SURE your patient is a full-code vs a DNR vs a limited code.
  • Make sure suction is set up and functional in your room. This is Nursing 101…but you’d be surprised how often it’s not done. Suction is one of those things that when you need it, you REALLY need it.
  • Ensure the oxygen is functioning. If your patient has an oxygen mask nearby, MAKE SURE it’s accessible. I cannot count the number of times I have reached for the oxygen mask when my patient is dropping his O2 saturation levels only to find the mask hopelessly tangled and ensnarled in the 500 other things at the bedside.
  • Make sure there is an ambu-bag close by!  In the ICU, every room has a bag…on the floors, they might be in the hallways every couple of rooms. Know where they are at all times!
  • Locate the CPR lever on all beds…most likely your facility uses several types of beds for different types of patients. Make sure you know where this lever is on all your beds. It is typically bright red and labeled CPR.
  • Know where the code button is in each room…including the patient bathroom and the hallways. If your patient goes down while you’re ambulating him, you want to know how to get help fast!
  • Know where the crash cart is located on your unit. If a code is called, and you’re the closest one to the cart…grab it and go! (PRO TIP: Be sure to unplug it first!).

Does that help lessen your anxiety about your first code blue? For the current BLS and ALCS guidelines, visit the American Heart Association website.

Got a story to share about your first code? Share it in our Facebook Group, Thriving Nursing Students!


Get this on audio in episode 153 of the Straight A Nursing podcast!


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