I feel so dumb... I got flustered - about a patient in respiratory distress

VICEDRN, BSN, RN · Sep 17, 2012

First, calm yourself and the patient. Place patient on appropriate 02 which means NRB

Second, locate the ER MD and quite simply say, I need you to come and see this patient now please. Unless of course, s/he is doing a code right then.

Third, recruit others to help you look for ER MD and notify the charge nurse of your situation.

Fourth, honestly appraise whether this is something you think you can get used to seeing in the future because the ER is full of people like your patient.

Good luck!

lilbearzmom · Sep 17, 2012

Definitely needed a RT consult. I'm wondering why one wasn't called if you were confused about what to do with a patient who was SOB with her other clinical presentations. She needed to be put on NIPPV- BiPAP stat. Good luck!

35Nurse · Sep 17, 2012

I'm a new grad beginning my first job as an ER RN and I enjoyed reading this post. I had one instructor tell me, the only time that question is stupid is when you don't ask. I have heard from many nurses that they aren't scared of anything more then a new nurse that doesn't ask questions. I'm glad you asked about this. I do have a question... I have always thought that if a patient is satting fine but the H&H is in the toilet then the sat really isn't that helpful at that instant. The rationale is if the H&H is 1/2 of what is should be but all are saturated with 02 then of course your going to get a decent sat BUT they don't have enough RBC's to adequately oxygenate the rest of their body. Is that correct?

*4!#6 · Sep 17, 2012

I had a patient like this up on the floor and we called a Rapid Response. The patient was taken to the ICU and then later on intubated.

JMBnurse · Sep 17, 2012

I was always told...when you have a patient like this...."call your friends"....

mariebailey, MSN, RN · Sep 17, 2012

Do you have standing orders for MS? If not, get an order. Ativan works great as well (and helps with the anxiety that's making the respiratory distress worse). And have to agree with pp, get help if you need it! 4 months in a new area nurse is a very short time.
Best of luck, you will be more confident next time.

Question from someone not in acute care: Is it routine & safe to administer a benzo for a patient with moderate to severe pneumonia in the acute care setting? How likely is it to exacerbate respiratory depression?

DSkelton711 · Sep 18, 2012

I love this thread as it has been very informative. I never worked ER but in NICU (neonatal). It truly is about having proper IV access, draw labs, support breathing and getting your co-workers and RT and MD in to help ASAP. Each experience will make you a better prepared nurse for the future.

sapphire18 · Sep 18, 2012

Agree with others who say to call RT, and the MD as well as fellow nurses. Sounds like the next step was BiPAP, get an ABG yesterday, get an ABG after on BiPAP, depending on clinical response and ABGs the pt would then be intubated. Airway...breathing...circulation. Next priority would be a line so you could get that blood in!

Anna Flaxis, BSN, RN · Sep 18, 2012

The rationale is if the H&H is 1/2 of what is should be but all are saturated with 02 then of course your going to get a decent sat BUT they don't have enough RBC's to adequately oxygenate the rest of their body. Is that correct?

Correct. Which explains why the patient was dyspneic and anxious even with sats in the mid 90s. She was probably tachycardic as well.

Anna Flaxis, BSN, RN · Sep 18, 2012

It sounds to me like the patient had already been seen by a physician. Antibiotics had been ordered, and the nurse had an order for a type and cross, and presumably, a transfusion. The ED physician should have placed a central line, knowing the patient was critical enough to go to the ICU.

What boggles my mind is that the patient in respiratory distress was on a nasal cannula. She clearly needed high flow oxygen, and NRB may have been more than adequate to ameliorate her symptoms. She may not have even needed bipap at all.

Edited to add: Not trying to make you feel bad, OP! It takes a while to get the hang of things.

TheSquire, DNP, APRN, NP · Sep 18, 2012

I have always thought that if a patient is satting fine but the H&H is in the toilet then the sat really isn't that helpful at that instant. The rationale is if the H&H is 1/2 of what is should be but all are saturated with 02 then of course your going to get a decent sat BUT they don't have enough RBC's to adequately oxygenate the rest of their body. Is that correct?

Yes, but before you go calling rapid response (if you're not in the ED, where your coworkers are your rapid responders), check your patient. I've had patients with atrocious H&Hs who are fine on 2LperNC, where I've had others that needed the NRB if not more.

Also, responding in general to prior comments - in the ED, your go-to O2 interventions should not include escalations through the venti mask - it's Room Air ---> Nasal Cannula ---> NRB ---> BiPap ---> Intubation, and an RN should be able to step up through to the NRB on their own (with MD notification, of course). Stepping down's another matter, but that's once you've gotten respirations under control.

Esme12, ASN, BSN, RN · Sep 18, 2012

I can't believe I'm posting about this considering I've been an ER nurse for 4 months now... but i got really scared last week and I need advice.
Last week I was coming on shift and getting report about a patient who has a hx of pneumonia x2 weeks ago. She came to the ED that day with difficulty breathing. Her room air sats were at like 88%, she was put on 2L via NC and her sats went to 92%. If she did any sort of activity her sats would go to like 82-85%. She was then put on 4L NC. Her sats rose to 94-95% if she was still and the head of the bed was at like 90 degrees.
Anyway, her chest xray showed a mild pneumonia developing in her left lung, her hemoglobin and hematocrit were in the toilet and she needed blood and in a bad way. SHe had an IV, but it was a 22g in her AC and it wouldn't draw worth dirt. We needed to type and cross her, but she was a tough stick and the previous nurse couldn’t even to a blood draw. She had 2 doses of abx and 2 neb treatments at this time but her breathing sucked. Finally I got type/cross and blood was ordered.
The reason I am writing this is to figure out what I could do for her breathing. I know that giving her blood would help her tremendously, but in the mean time, what do I do. She was getting all worked up and anxious because she couldn’t catch her breath and I was silently freaking out! I’m sure she was getting septic because she met at least 2 of the SIRS criteria. I was getting SO scared that she was going to quit breathing and then I would panic and forget everything I’ve ever learned about nursing.
My question is: If a patient is in respiratory distress, what do I do especially if the MD is nowhere to be found and my RN co-workers are busy with their patients? I’m new and I don’t want people to die on my watch.
Thankfully for this patient, she got an ICU room before her breathing got too bad. She was also perfusing fine and her O2 sats were reasonable if she wasn’t doing anything. I’m just scared for when I get a patient who is in respiratory failure and I have nobody to turn to. PLEASE HELP ME!!

First of all....remember you are NEVER alone. There is ALWAYS someone who can help you unless of course you are in the middle of a disaster but that is not what we are talking about here). They maybe busy.....but they can help you.

When you have a patient circling the drain.....stop, take a deep breath, take your own pulse first (this will make sure you stay calm) and get the MD. This patient should have been stabilized more before transport to the ICU....as an ICU nurse as well I would not be happy that this patient was transported in resp distress (and a stable, maintainable airway) without further intervention by the ED other than O2 per NC @ 2lpm.

Without knowing what other medical history this patient had and what co-morbities are present these are my thoughts.

First...maybe you weren't no "silently freaking out".....patients have a fine tuned radar to sniff out fear and newness in their providers. Take a moment and gather yourself.....it's going to be alright.

It is clear this patient needed further intervention. I would bump up the O2 to 4 liters.....double it.... tell the patient she is OK and go get the MD. She needs something to "calm her" I would guess a little whiff of morphine or MAYBE......a little dab of Ativan like O.5 IV or even sublingual. Just a touch to help the patient out. I would focus on another IV line.

Blood can be given through a #22g.....some facilities are very unhappy about this but it is done and it can be done safely. I have worked in some ED's where the MD washes their hands of the patient once admitting orders are obtained but the fact is as long as the patient is in that ED he is responsible. Engage your charge/supervisor/co-workers in getting that MD in the room to re-evaluate this patient....ASAP.

If she continued with her SOB I would call respiratory to do ABG's and to "check the O2".....get their opinion about what this patient needs. Sounds like she actually would have been better with Bi-Pap.

Not every facilitation has MD's that are willing to place central line in the ED unless they are really backed into a corner. Not every facility allows IO's (intraosseous) to be performed routinely. Many nurses answer how things are at their facility. Many find it difficult to believe that things are done differently from facility to facility in one area let alone a different state/demographic all together.

So...FIRST and FOREMOST, stay clam. Call respiratory and get abg's. Bump the O2 AFTER the abg's. Find another line. Get the patient something for anxiety. If the MD gives you grief tell him you are NOT transporting a patient without a stable airway......that you refuse to code this patient in the hallway/elevator......ALONE...... get your charge nurse involved.

It will come to you in time!!!! Good Luck!