I feel so dumb... I got flustered - about a patient in respiratory distress - page 3

by LalaJJB

15,833 Views | 64 Comments

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... Read More


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    Quote from 35Nurse
    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.
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    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.
    Last edit by ~*Stargazer*~ on Sep 18, '12
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    Quote from 35Nurse
    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.
    sserrn and ~*Stargazer*~ like this.
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    Quote from LalaJJB
    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!
    Sugarcoma likes this.
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    Correctomundo about the low crit being of critical importance in your assessment. I can't count how many times somebody's told me that there's no problem because the sat is 92%. But the patient desats enormously with any exertion (like coughing, moving in bed, using a bedpan, anything) because there are so few red cells carrying oxygen that even minimal demand on them desats a lot of them.

    Agree with getting all the help you need, giving more oxygen, pleading with the blood bank to send it stat, and getting an EKG to look for cardiac depression d/t lack of Os in the coronary arteries. Also do your utmost to have this person rest, rest, rest so as not to develop any incremental oxygen demand. Anticipate everything she'll need to do, and insofar as you are able, do it for her or see if it can wait until she has the reserves to do it. Every bit of oxygen her muscles steal to support turning over or sitting up is oxygen that won't be available to her brain, heart, and kidneys. Watch for effects on those important parts. Act locally, think globally.
    Sugarcoma likes this.
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    Quote from bankssarn
    Does your facility have the option to call a Rapid Response? Where I work, we can call a RR if a patient is declining, yet they're not yet at Code Blue status. A RR will get you a doc, ICU nurse and a RT. It's a wonderful intervention.
    In the ER, you call a "Rapid Response" by sticking your head out of the patient's room and saying "I need some help in here!"
    ChristineN, stephynic21, missdanap, and 5 others like this.
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    I will give a shout out to the poster who recommended morphine and ativan to palliate the symptoms of a person with an acute exacerbation of a chronic and life limiting illness.

    SOB leads to anxiety which increases distress...so if we treat the anxiety we can impact the dyspnea. Morphine will slow the respiratory rate and allow a deeper breath while easing the work of breathing.
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    Quote from tewdles
    I will give a shout out to the poster who recommended morphine and ativan to palliate the symptoms of a person with an acute exacerbation of a chronic and life limiting illness.

    SOB leads to anxiety which increases distress...so if we treat the anxiety we can impact the dyspnea. Morphine will slow the respiratory rate and allow a deeper breath while easing the work of breathing.
    I bolded the part above that I have seen in my practice; typically for people with end stage COPD, or those on palliative care.

    I haven't often seen Ativan or morphine ordered in the ED to decrease dyspnea. It may be different elsewhere, but typically the physicians that I have worked with are not comfortable using these interventions on unstable or potentially unstable respiratory patients in the ED setting.
    tewdles, TheSquire, and sserrn like this.
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    I just want to reiterate! You are the primary and it's up to you to use your team as resources. Everyone in the ED is there for the same reason the pt's. The previous nurse didn't get adequate access, the previous doctor didn't get an order for a central etc. No problem because your on it. Other people have said it but RT's are great teachers CALL them and say this is what I've done this is where I'm at and this is what I'm thinking/seeing. They can present to MD while you collect and coordinate the collection of diagnostics like EKG, Chest X-ray and evaluate can my pt tolerate morphine, Ativan to decrease oxygen demand? Before you know it the doctor will be there. You will then be able to bring the doctor up to speed on the pt's change of condition and determine POC. Identify the Glory go to RN/tech that can get iv's on pt's seizing blindfolded with one hand behind his/her back and say .. Teach me!! You know more than you think you do. The next pt that presents like this will be smoother, promise
  10. 1
    ABCs first of all.

    Put a NRB mask on her.

    Advocate for BiPap if still struggling.

    Larger IV for sure. Anywhere.

    And ask for help! Never try to do it all alone, you've only been there for 4 months! You should still be able to grab someone ASAP if you need it.

    Always: breathe and stay calm.

    Sent from my iPhone using allnurses.com
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