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

TheSquire, DNP, APRN, NP · Sep 19, 2012

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.

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.

Anna Flaxis, BSN, RN · Sep 19, 2012

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.

Guest343211 · Sep 19, 2012

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.

Guest343211 · Sep 19, 2012

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

Anna Flaxis, BSN, RN · Sep 19, 2012

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.

Guest343211 · Sep 19, 2012

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.

Anna Flaxis, BSN, RN · Sep 19, 2012

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.

Anna Flaxis, BSN, RN · Sep 19, 2012

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.

Guest343211 · Sep 19, 2012

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.

guest112 · Sep 19, 2012

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.

Anna Flaxis, BSN, RN · Sep 19, 2012

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.

Augusthy LATHA · Sep 20, 2012

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.