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

nurseprnRN, BSN, RN · Sep 18, 2012

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.

hiddencatRN, BSN, RN · Sep 18, 2012

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!"

tewdles, RN · Sep 18, 2012

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.

Anna Flaxis, BSN, RN · Sep 19, 2012

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.

TLS1 · Sep 19, 2012

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

edmia, BSN, RN · Sep 19, 2012

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

9livesRN, BSN, RN · Sep 19, 2012

Back to the basics not breathing wheel why? Couldn't she take a deep breat?Was her hands cold. Did you try the pulse ox in the ears, feet, or warm her hands? Low H&H can turn out with a low peripheral pulse ox measurement, that's when ABG come into hands.Was the patient anxious, coughing, lungs clear, good chest rise, good sounds? Did you try an inspirometer?Mouth breather? Try a venty mask at a low rate, then to the max? Non rebreather mask?What has she taken prior to admission? Pain meds? History? COPD? Asthma? Difficulty breathing?CPAP at home? Oxygen dependent?Look for hospital hx was the patient here before for that?Allergies? New meds?Last dr visit? Taken meds as supposed to?When it comes to IV's fat, skinny, black, white, did you try a venoscope? Or guided vein access?It's hard to get blood out of a stablished line 22's even worse if positional or after even minutes after inserted (our policy says blood drawn ok once line stablished, only once, did you check upper arms, feet?Heart meds can have that affect on people, specially amiodarone, hydralazine... And so onThat is what I learned as a new nurse with a little bit of experience here and there...Hope you find your answers...

9livesRN, BSN, RN · Sep 19, 2012

Ej's are awesome :)

No ac, no foot, I'd go EJ before drilling!

9livesRN, BSN, RN · Sep 19, 2012

Been there done that, and have had family in that situation... Your assessment is crucial in the overall outcome, the scenario you gave us lack pt hx medical hx and tx hx, the best assessment grants a r/o consequently leading to a best outcome, think holistic in a minute!

whichone'spink, BSN, RN · Sep 19, 2012

This has been helpful to me (as well as the OP I'm sure), because I could have a resp. distress patient, say, in my first three hours of orientation in the ED. I hope and pray I can keep my cool and help a patient like this.

Guest343211 · Sep 19, 2012

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!

Since she showed better numbers with less activity, I agree with the above. DOE and not getting your breath is VERY anxiety provoking. People think that giving a calming agent will depress breathing, but if she is getting O2, getting ready to be transfused, is started on antibiotics, has a clear and effective airway, get the ABG, she may benefit from the judicious use of MSO4 or ativan--and then titrate the O2 cautiously. There are degrees to respiratory distress with adults--more delineated on the tolerance spectrum than with kids and babies. The latter do not deal well with respiratory distress and go down quicker than a bat of an eye--little to no lead time.

She's not great, but she is holding her own. If her films show consolidation and there is consistency with dx of pneumonia, well, you aren't going to clear that up in an hour or so. Did you see her film? Was she moving air anywhere when you listened to her--using accessory muscles? Would she have benefited from a nebulizer treatment of some sort? Albuterol or some other agent? OTOH did she have crackles or wheezes or an S3? Does she need diuresis? Although they like to steer away from steroids in pneumonia, there are many times when they can be helpful. But see, the ED docs don't necessarily have a lot of time to do the whole intensivist gig, and that's why a patient like her would be best off in a unit. Yea. I know you have to wait to get the bed, but if you just have a bunch of chronic, no biggy kind of patients, well, she needs to be moved to the unit as a first priority. We can get them under control and set better in the unit--usually. I would get the line in and transfuse her if you have to wait for a bed. But first you have to look at her ABG and full presentation.

This is why the critical care unit is a good place to learn. You learn to look at the whole person and the hemodynamics or other systems dynamics, figure things out, and treat, step by step. People don't get that ED's often don't have time to play like they are the ICU. I mean they do to a point, and then they move them on for this very reason.

I also agree that different things can be approached differently at different places. :)

The above poster's advice is good; b/c pt is above 90% when she is calm and upright. If she is really struggling to breath and you have limited orders, you have to get someone in there that can check her again so that appropriate orders can be written and followed.

The low h/h is one thing; but the ABG will tell you if she is in respiratory acidosis--if so, so long as she can tolerate O2 (not knowing her whole Hx) the NP, PA, or Doc can give you the OK for titrating up on O2. The gas will help, as will careful ausculation and review of film, and the rest of her presentation. I mean what was her BP and HR? Sure they could be up for a number of reasons, including ^ temp; however, as I said, when a person has dyspnea, they become anxious. And OTOH, was she on the vascularly dehydrated side? See the details matter, and in the unit, it's all about details--which is why it's good to stabalize and move her to a unit bed.

Do they have istats there? So, yep, I'd get the ABG, see if she could benefit from a neb or if she needed diuresing or whatever is appropriate specific for her. And I agree with others--getting another access is a good idea. (I disagree that foot sticks can be a piece of cake--as in all vascular accesses, it depends on the patient--really it does. Where there other people that could help you get a line in? Again remember, with dyspnea and all the sticking and ABGs, well, that's going to make the poor lady more anxious.

I mean, for players like this, in the ED, it's tough to do full assessments--especially as frequently as you can in a unit. These frail folks with comorbid stuff going on need a unit bed and continuous assessment and evaluation. It's hard to do that in the ED--you have to focus your exams and run around to 50 other folks.

So I say get the basics going, and get her an ICU bed ASAP. Can't tell you how many times ED ends up bringing people up coding. A lot of that is due to the fact that certain pts need progressive stabilization--like they are supposed to get in an intensive care unit. Holding areas are one thing in the ED, but the in the unit, generally, nurses and docs can hone in on their sickies and progressively address issues--and the pts improve or they don't--but it's a more controlled environment--unlike the ED. These patients don't need to be in revolving door areas; and that's a lot of what ED is like--continuous revolving doors spinning patients in and out.

Anna Flaxis, BSN, RN · Sep 19, 2012

The OP states in the orignal post that the patient already had 2 neb treatments.