I feel so dumb... I got flustered - about a patient in respiratory distress - page 5

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  Anna Flaxis profile page
    1
    And that's why continuing monitoring is so important. If a person is a retainer, you will see them go into narcosis. It's pretty obvious, and if you catch it quickly, it's not really not too hard to reverse. The risks of denying O2 to a person because they "might be a retainer" are so much greater than the alternative.

    It can be difficult to monitor patients very closely in the ED setting, unless you are one on one with them, but the only one on ones in my ED are your Level 1 acuitys. You can have a critically ill patient and three other not-so-sick people who need labs and diagnostics and medications and warm blankets and sandwiches and have to go to the bathroom etc etc. Or you can have a critically ill patient and another one comes rolling in, and there aren't any other nurses to be found because they're all busy too, so there you are.

    In the ICU, you have your two. You have orders written by an intensivist with protocols in place for just about every scenario. In the ED, it's far more by the seat of your pants, and so it's not a safe place to keep a critically ill patient for any longer than absolutely necessary.

    In the ICU, you're thinking big picture, longer term. In the ED, you're thinking "what do I need to do right NOW to keep this person alive?".

    I think all of the detailed pathophys stuff in this thread is great, but the OP is a new nurse AND new in the ED, and the information they need is specific to the environment in which they practice, as well as their level of experience. This is a beginner/novice nurse in the ED. That is the level of information that they need right now, IMO.
    TheSquire likes this.
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  3. Visit  samadams8 profile page
    0
    Quote from ~*Stargazer*~
    And that's why continuing monitoring is so important. If a person is a retainer, you will see them go into narcosis. It's pretty obvious, and if you catch it quickly, it's not really not too hard to reverse. The risks of denying O2 to a person because they "might be a retainer" are so much greater than the alternative.

    It can be difficult to monitor patients very closely in the ED setting, unless you are one on one with them, but the only one on ones in my ED are your Level 1 acuitys. You can have a critically ill patient and three other not-so-sick people who need labs and diagnostics and medications and warm blankets and sandwiches and have to go to the bathroom etc etc. Or you can have a critically ill patient and another one comes rolling in, and there aren't any other nurses to be found because they're all busy too, so there you are.

    In the ICU, you have your two. You have orders written by an intensivist with protocols in place for just about every scenario. In the ED, it's far more by the seat of your pants, and so it's not a safe place to keep a critically ill patient for any longer than absolutely necessary.

    In the ICU, you're thinking big picture, longer term. In the ED, you're thinking "what do I need to do right NOW to keep this person alive?".

    I think all of the detailed pathophys stuff in this thread is great, but the OP is a new nurse AND new in the ED, and the information they need is specific to the environment in which they practice, as well as their level of experience. This is a beginner/novice nurse in the ED. That is the level of information that they need right now, IMO.
    All good points Stargazer. Personally, I think more ICU nurses should spend more time in the ED, and more ED nurses should spend more time in the ICU. It is good for learning all the way around.
  4. Visit  Anna Flaxis profile page
    0
    Quote from samadams8
    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.
    Just saw this. At my facility, type and cross has to be two pink top tubes, the patient must have a blood band placed at the time of the draw, and the tubes must be labeled in a specific way, and it goes to the blood bank, not the lab. They would/could not run a type and cross off an ABG syringe. They are very strict about the whole thing.

    As for the ABG, you need an MD order at my facility as well. Maybe it's different where the OP works. It sounds like it's different in the ICU where you work.
  5. Visit  Anna Flaxis profile page
    1
    Quote from samadams8
    All good points Stargazer. Personally, I think more ICU nurses should spend more time in the ED, and more ED nurses should spend more time in the ICU. It is good for learning all the way around.
    Agreed! I think it might also contribute to more good will and greater cooperation between the two departments.
    samadams8 likes this.
  6. Visit  samadams8 profile page
    0
    Quote from ~*Stargazer*~
    Just saw this. At my facility, type and cross has to be two pink top tubes, the patient must have a blood band placed at the time of the draw, and the tubes must be labeled in a specific way, and it goes to the blood bank, not the lab. They would/could not run a type and cross off an ABG syringe. They are very strict about the whole thing.

    As for the ABG, you need an MD order at my facility as well. Maybe it's different where the OP works. It sounds like it's different in the ICU where you work.
    What I mean is that you don't use the typical ABG syringe. You get the blood, transfer it with a large gauged needle.

    You don't necessarily need the heparinized syringe for the ABG--especially if they can take it and run it right away--or if you have access to an istat right there.
    Last edit by samadams8 on Sep 19, '12
  7. Visit  bornplaydie profile page
    0
    brainkandy87 and others... Just a new grad listening in on the conversation, but thanks for sharing your experience. Your well thought out answer really helps solidify the point of thinking ahead, and preparing for the next step and possible worst case scenario.
  8. Visit  Anna Flaxis profile page
    0
    Quote from samadams8
    What I mean is that you don't use the typical ABG syringe. You get the blood, transfer it with a large gauged needle.

    You don't necessarily need the heparinized syringe for the ABG--especially if they can take it and run it right away--or if you have access to an istat right there.
    Ah, I see, that makes sense. Never thought of that!

    Still, you have the issue of needing a doctor's order for the ABG. If the doc won't order the ABG, then you're kind of stuck looking for venous access.
  9. Visit  Augusthy LATHA profile page
    0
    First of all. Team work is important. Critical pt requires help from more than one new nurse. Everyone works together, and that will save a patient's life. Someone calls Resp. therapist
    for RX and the other call RT to help with starting new IV line on the difficult stick patients. It is like a chain reaction, they help you to handle your situation for a safe recovery and you do the same with their situation.
  10. Visit  princessCRN profile page
    0
    There is definitely no need to panic, remember when your patients see you acting anxious, or nervous it makes the situation worst for them. If a patient's sats is dropping below normal levels, breathing pattern is irregular, poor cap refill, irritable, skin color changing and barely relieved with O2 2L get the MD or anyone who can provide further help. In the emergency room is where you try to save a life, point is what could be more important than a patient who's stats are declinig so if the situation arises again do your part as the nurse then get help immediately.



    We learn everyday so find something positive out of the situation and dont feel bad!
  11. Visit  samadams8 profile page
    2
    Quote from princessCRN
    There is definitely no need to panic, remember when your patients see you acting anxious, or nervous it makes the situation worst for them. If a patient's sats is dropping below normal levels, breathing pattern is irregular, poor cap refill, irritable, skin color changing and barely relieved with O2 2L get the MD or anyone who can provide further help. In the emergency room is where you try to save a life, point is what could be more important than a patient who's stats are declinig so if the situation arises again do your part as the nurse then get help immediately.We learn everyday so find something positive out of the situation and dont feel bad!
    Absolutely. This is why you must present your assessment data to the doc, np,pa... If you go to them w/ one or a few pieces of information, it doesn't mean as much as when you cluster data and present the picture w/ the relevant information.


    Just look at all the nurses that have responded to your post. If we all see the picture as you presented it, and we all mostly feel like this pt needs an abg, etc, what makes you think the doc, np, or pa won't as well?

    Nursing is about knowing your stuff and advocating for pts and families. You can do it. Go get em!
    tewdles and Altra like this.
  12. Visit  ~Mi Vida Loca~RN profile page
    2
    In this situation my first call would have been to RT and second call to my charge while I stayed with my patient. I am a huge fan of utilizing our ancillary staff and it took me a while but I became a big fan of utilizing the charge. In fact, I would have had my rear end handed to me in this same situation had I not called the charge. I walked into a patients room once and she started tanking right in front of me. I started doing what I could, (she was septic and was going hypotensive) I got her trendelburg and was hanging fluids while calling my charge and right away they were in there (it was shift change so she was giving report to the new charge) and we grabbed a tech and they got the doc and we got another line in there and more fluids and I had the help and support to make me feel like I was not alone. Afterwards the Doc came to me and gave me a hug and thanked me for being on top of the patient and saving her life by realizing what was going on and being on top of it, especially during a busy shift change. Since then I have never hesitated to ask for help if I felt out of my league.
    DC Collins and LalaJJB like this.
  13. Visit  DC Collins profile page
    0
    Quote from brainkandy87
    You page the MD and get your co-workers to help you. I don't care what they are doing. If someone is circling the drain, you go grab someone. If they feel inconvenienced, too bad.

    -----

    In your situation, I would've called RT to assess (and draw an ABG if not already done) and worked on getting a large bore IV in her while you had another nurse find the MD to come assess.
    Communication is key! Tell your charge nurse if your coworkers aren't available. The CN can eval the situation and make that pt a priority so that another nurse can come help you. Plus most ED CNs are experienced enough to 1) Know what to do, and, 2) Not freak out.

    But I wholeheartedly agree. Get RT in there right away. If the pt really is circling the drain, if you can't reach anyone, another RN, CN, RT, doctor, push 'the button', whatever you have for an emergency notification. That will not be ignored. Better to have to explain why later than to have the pt go south.

    MOST important: Relax. Over time such things will be like a day at the fair for you. Give it about a year in the ED. That's what I was told by coworkers when I started, and darn if they weren't right.

    DC :-)
  14. Visit  DC Collins profile page
    0
    Additional thought inspired by what someone wrote above. Yes, nursing is about knowing your stuff. That comes with time. But IMHO even more important about nursing is knowing what you *don't* know. Then call for help. MAKE someone help. Doing so takes guts, so work on that aspect of your working day.

    DC :-)


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