I feel so dumb... I got flustered - about a patient in respiratory distress - page 4

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... Read More

  1. Visit  wildlaurel profile page
    1
    I agree with several of the other posts, call RT - get them to assess the patient. If the patient had a hx of COPD - you have to be careful about over oxygenating. Go to the EDP and say, "I'm really concerned about this patient and need you to come assess her again." A central line would have been called for if she was septic or had poor vascular access. I'm not so sure you could have gotten anything beyond a 22 in someone like that - she was probably vasoconstricted if her H&H was that low...so don't beat yourself up about that. Nursing - all nursing, but especially ED nursing - is a team sport! You're not a marathon runner out there by yourself. You could also call your charge nurse and tell them you need help. I've been an ED nurse for 4 years now and I sometimes still call someone more experienced than me and say, "I need a nurse who's been doing this longer than me." Ativan would have calmed the pt some - she was probably oxygen starved and that is a scary feeling.
    tewdles likes this.
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  3. Visit  dirtyhippiegirl profile page
    0
    Quote from 9livesRN
    No ac, no foot, I'd go EJ before drilling!
    Eeeeeh. I can see a preference for an EJ over an IO if you need blood work done STAT and/or are expecting to need blood work done STAT and can't art stick for whatever reason. But at the end of the day, an EJ still takes more skill/luck/decent veins than an IO -- as a burn nurse, I'd pick an IO over an EJ because I'm worried about fluid resus, and quick.

    /also, sometimes you get a RT that is just as newbish and scared as you are.
    //or just dumb
    ///one good RT is as good as ten decent docs, 'tho
  4. Visit  Anna Flaxis profile page
    0
    Quote from whichone'spink
    I'm curious as to why her H&H was low to begin with. Does it have something to do with her COPD? Did she have a history of G.I. bleeding? I've taken care of patients with COPD who had crappy blood counts, but not so bad that they needed transfusions. So I'm just curious what her H&H was in the crapper.
    Typically, people with COPD will have an elevated crit. People with chronic kidney disease will have a decreased crit due to decreased erythropoeisis.

    I wish the OP would come back and give us more info! The picture I see, based on the original post, is someone in early compensated hemorrhagic shock. The pnuemonia is a confounding factor, but the fact that the nebs were ineffective in reducing the patient's dyspnea and anxiety tells me that the symptoms were more related to the low H&H than an obstructive cause. I wonder if the doc did a rectal exam to check for occult blood?
  5. Visit  Esme12 profile page
    0
    Quote from 9livesRN
    Ej's are awesome

    No ac, no foot, I'd go EJ before drilling!
    I am not sure that lying this anxious patient down, at this point, would be the most prudent action. Many facilities do not allow RN's to do EJ IV's.
  6. Visit  sakura07 profile page
    0
    -Activate code blue if pt express trouble breathing and loss of conscious
    -Follows Airway Breathing Circulation
    -Put patient HOB upright; instructs slow deep breath; since she has 2L NC you could bump it up to 6L. Your help would arrive soon with RT member.
  7. Visit  TheSquire profile page
    2
    Quote from sakura07
    -Activate code blue if pt express trouble breathing and loss of conscious
    As stated earlier in the thread, Rapid Response and Code Blue tends not to exist in the ED, which is a (usually) self-sufficient critical care unit. You just stick your head out of the room and yell for help.
    Altra and hiddencatRN like this.
  8. Visit  samadams8 profile page
    0
    Quote from ~*Stargazer*~
    Typically, people with COPD will have an elevated crit. People with chronic kidney disease will have a decreased crit due to decreased erythropoeisis.

    I wish the OP would come back and give us more info! The picture I see, based on the original post, is someone in early compensated hemorrhagic shock. The pnuemonia is a confounding factor, but the fact that the nebs were ineffective in reducing the patient's dyspnea and anxiety tells me that the symptoms were more related to the low H&H than an obstructive cause. I wonder if the doc did a rectal exam to check for occult blood?
    We need more information. The nebs may or may not help, based on what the agent was that was given in the nebs--but it seems like less of a "zebra" if you will, that she had a V/Q mismatch due to her pneumonia. Less areas in the lungs for optimal gas exchange. The shift in oxyhemoglobin of course could further complicate the situation. This is why I say this person needs a unit bed ASAP. There often isn't the time for honing in on the various factors and how they effect the individual in the ED.

    The biggest thing one sees in respiratory distress is anxiety. And we all would benefit from more information. Without an exam and the appropriate data (eg., ABG) makes it difficult to tweak corrections. An ABG would tell us if there is a primary compensated or uncompensated respiratory acidosis. It may also give us some metabolic insight. I mean it's inferred that she needs tx for a primary respiratory distress-->O2, (? does she have any fluid accumulation backing up into her lungs? It's hard to get O2 through for exchange if there is fluid backing up into the lungs--you can up the O2 to kingdom come, and it's not going to get through, so, IF that were a factor, it would have to be dealt w/ even if they ended up intubating and artificially ventilating her.) OTOH, is she in need of some wisely titrated volume. If so, the blood--> more hgb along with the protein-based fluid may help balance her hemodynamics. Without looking at the patient and more data, it is hard to appropriately treat her.

    Often pt's come in with mixed comborbid issue.

    Hers seem to be:

    1. respiratory related to poor ventilation/perfusion-->pneumonia--harder to get gas exchange due to decreased areas in the lungs, which are able to cause gas exchange.
    2. increased metabolic demands--immunological--r/t acute infection
    3. decreased O2 carrying capacity--> low H/H.

    So, I agree Stargazer, to go further, we'd need more information.
  9. Visit  samadams8 profile page
    0
    Also, I am wondering what the hold up was for administering blood. T&C, OK. But if you couldn't get another line in her-- 20g or > is better for blood transfusion b/c of hemolysis and clotting, wasn't there anyone else around that could help you do this? Although an 18-gauge needle is standard, a needle or catheter as small as 23-gauge can be used for transfusion if needed. It's just that the smaller the gauge, the slower the flow rate and the higher is the risk of clotting. You have to be careful to avoid excessive pressure leading to hemolysis when very narrow lines are used. But if she needs the blood, well, she needs the blood. You can dilute the red cells with saline (as it protocol in adults in many places) or ask the blood bank to split a unit, so that you are giving only half at a time if it will be running slowly. You also have to watch these transfusions more than what is protocol, b/c they tend to stop, and time is a factor. You just have to be careful, b/c this patient is a medical player with questionable issues going on related to her core system functions. She's not a surgery or trauma patient, so while she needs blood, you have to give it very carefully. It's a tricky balance--meeting volume needs for optimal hemodynamics while also not overloading the patient.

    The other benefit of spliting the unit is to do what we have referred to as the blood and lasix then blood sandwich. Not knowing the women's cardiac and overall lung and kidney function, although she would benefit from the blood and perhabs the volume, you may have to intervene to tweak what goes in and what comes out. Protein based fluid (such as in blood products) will give her better intravascular volume, which can help decrease systemic vascular resistance; at the same time, excess fluid has to be judiciously moved out through gentle diuresis. Thus the use of the "sandwich."

    Like I said, there is more time to look and deal with these things, specific to the patient and her core systems, once she is in a good intensive care unit. She's on the fragile side, so she needs to be in a place where all these things can be carefully and continuously assessed and tweaked.
    Last edit by samadams8 on Sep 19, '12
  10. Visit  Anna Flaxis profile page
    0
    Yes, we definitely need more information. Keep in mind that in the ED, the primary focus is on stabilization and moving the patient to the next appropriate level of care, whether that is discharge home, admission to the hospital, or death. Patients do not stay in the ED.

    The original poster's question was what s/he could have done, as a lone nurse, to help the patient's breathing. For starters, s/he could have given the patient more oxygen. 4LPM via nasal cannula is nothing. It provides only 25-45% (depending on who you ask) oxygen concentration, in contrast to the 60-90% (again, depending on who you ask) that an NRB would provide, plus you'd have it at 15LPM. You could move up to NRB, then titrate back down as the symptoms are alleviated.

    For the purposes of stabilization in the ED, a nonrebreather mask is the next appropriate step and a priority intervention for the emergency nurse. ABGs would definitely be helpful, but ABGs are not standing orders in my ED, and I wouldn't be surprised if that was also the case where the OP works. Even if they were, it would not be the priority intervention. Breathing comes before diagnostic tests.

    To those who worry about CO2 retention, if the person needs oxygen, you give it. Hypoxia develops rapidly, while CO2 narcosis takes time.

    I agree that if the patient's respiratory status was not improving, the physician needed to be notified and come re-evaluate the patient, and write new orders appropriate for the patient's condition, and the patient needed to be in the ICU as soon as possible. This is one of the frustrations of patient care in the ED at times, is when you're sitting on a patient waiting for a bed, knowing that you don't have the resources to provide the care they're in need of, and you're being pressured to take on another unstable patient that just came in via ambulance.
  11. Visit  TheSquire profile page
    3
    Quote from samadams8
    Also, I am wondering what the hold up was for administering blood. T&C, OK.
    Pt was a hard stick....as stated in the original post.
    Quote from samadams8
    But if you couldn't get another line in her. 20g or> is better for blood transfusion b/c of hemolysis and clotting. Although an 18-gauge needle is standard, a needle or catheter as small as 23-gauge can be used for transfusion if needed. It's just that the smaller the gauge, the slower the flow rate and the higher is the risk of clotting. You have to be careful to avoid excessive pressure leading to hemolysis when very narrow lines are used. You can dilute the red cells with saline (as it protocol in adults in many places) or ask the blood bank to split a unit, so that you are giving only half at a time if it will be running slowly. You also have to watch these transfusions more than what is protocol, b/c they tend to stop, and time is a factor. The other benefit of spliting the unit is to do what we have referred to as the blood and lasix then blood sandwhich. Not knowing the women's cardiac and overall lung and kidney function, even though people may benefit from the blood and the volume, you may have to intervene to tweak what goes in and what comes out. Protein based fluid will give you better intravascular volume, which can help decrease systemic vascular resistance, but them excess fluid has to be judiciously moved out through gentle diuresis.
    ...which is all well and good, up in the ICU.

    I realize that this semi-old and well-hashed-out-thread was featured in the nursezine this morning and a bunch of you saw it for the first time and want to comment on all sorts of complicated stuff. Fine and dandy. However, this is a thread started by a nurse new to the ED, the point of which is to provide steps for EMERGENT interventions to make the patient not die so quickly before they can be sent up to ICU. Down in the ED it's a case of "20g or better for blood transfusions". Getting into this complicated stuff that won't/shouldn't happen in the ED dilutes the teaching points that need to be (and already have been) imparted.
    Last edit by TheSquire on Sep 19, '12 : Reason: missed a word essential for understanding
    Altra, Anna Flaxis, and hiddencatRN like this.
  12. Visit  Anna Flaxis profile page
    0
    Quote from samadams8
    Also, I am wondering what the hold up was for administering blood. T&C, OK.
    My understanding is that the holdup was that the nurse needed to draw a type and cross, the existing 22g. would not draw, and the patient was a hard stick. It took a long time and a lot of work to find a vein that would draw. The doc should have just thrown in a central line once he or she recognized this patient would need an ICU bed. The type and cross could have been drawn at that time.
  13. Visit  samadams8 profile page
    3
    Quote from ~*Stargazer*~
    Yes, we definitely need more information. Keep in mind that in the ED, the primary focus is on stabilization and moving the patient to the next appropriate level of care, whether that is discharge home, admission to the hospital, or death. Patients do not stay in the ED.

    The original poster's question was what s/he could have done, as a lone nurse, to help the patient's breathing. For starters, s/he could have given the patient more oxygen. 4LPM via nasal cannula is nothing. It provides only 25-45% (depending on who you ask) oxygen concentration, in contrast to the 60-90% (again, depending on who you ask) that an NRB would provide, plus you'd have it at 15LPM. You could move up to NRB, then titrate back down as the symptoms are alleviated.

    For the purposes of stabilization in the ED, a nonrebreather mask is the next appropriate step and a priority intervention for the emergency nurse. ABGs would definitely be helpful, but ABGs are not standing orders in my ED, and I wouldn't be surprised if that was also the case where the OP works. Even if they were, it would not be the priority intervention. Breathing comes before diagnostic tests.

    To those who worry about CO2 retention, if the person needs oxygen, you give it. Hypoxia develops rapidly, while CO2 narcosis takes time.

    I agree that if the patient's respiratory status was not improving, the physician needed to be notified and come re-evaluate the patient, and write new orders appropriate for the patient's condition, and the patient needed to be in the ICU as soon as possible. This is one of the frustrations of patient care in the ED at times, is when you're sitting on a patient waiting for a bed, knowing that you don't have the resources to provide the care they're in need of, and you're being pressured to take on another unstable patient that just came in via ambulance.

    Excellent reply! And yes, if a person needs O2 they need it. I too would consider moving to a mask. But what you say in terms of ED compared with ICU is totally true. You know sometimes nurses in the ICU don't realize that things run differently in the ED. Thus they get miffed and feel dumped on when ED wants to move a patient, but they can at times forget that the move is for the patient's own good. Trouble often is that transferring other patients out of the unit to make room is trickly and there needs to be better supervisory bed management. This is one of the pias of being a supervisor that is annoying--that and staffing issues.

    The only major issue I have seen with people getting too much oxygen in an ED or unit setting is with infants that have something like hypolastic left heart. But it's rare enough. I have seen those kids crumble b/c of the pathophysiology and getting too much O2.

    As far as COPDers, I haven't seen this be so much of an issue at, except after stabilization. If they are acute/critical enough and they need O2, you have to give it to them.
    tewdles, Esme12, and Anna Flaxis like this.
  14. Visit  samadams8 profile page
    1
    Quote from ~*Stargazer*~
    My understanding is that the holdup was that the nurse needed to draw a type and cross, the existing 22g. would not draw, and the patient was a hard stick. It took a long time and a lot of work to find a vein that would draw. The doc should have just thrown in a central line once he or she recognized this patient would need an ICU bed. The type and cross could have been drawn at that time.
    Maybe it's just the unit nurse in me, but I would get the ABG and blood for the T&C off of that if I had to. If respiratory is doing it, fine. We've done this before. If it's one stick, you don't worry about the syringe with the heparin in it, and you run it right away. Either way, she is going to have to be stuck again.

    I don't know. They are less aggressive with CL's in many places nowadays--unless the person is full out coding. At the very least, put an art line in her.

    I think the OP just needs more time to get tougher and maybe more assertive, and I admit I could be wrong on this, so I mean no offense at all. I mean there is a reason ED and ICU nurses tend to be pushy. LOL
    tewdles likes this.


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