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!!
Quote from LalaJJB
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!!
You needed a doctor, an RT, and another nurse or a tech in the room with you. That you were alone with this critically ill patient who needed interventions beyond your scope of practice and level of training and experience is really at the crux of the matter.
Remember, airway, breathing, and circulation in that order. She had a patent airway, but was not ventilating (breathing) effectively because of the lack of red blood cells (circulation). Your priority interventions are to put her on NRB and get that blood transfusion going *yesterday*!
Do you guys have lab techs/phlebotomy services? If so, get a lab tech in there to get your type and cross. If not, get a tech or another nurse in there to help you get the sample and get it to the blood bank as quickly as possible. If you can get the sample with an IV start, great, but you've already got a patent IV, so hang a liter and keep that line open! Use what you've got! Getting some more fluid in her might help find a vein for better peripheral access, and it will help if the doctor decides to place a central line. Warm her up with some blankets to help those veins pop up. Gather your supplies for the blood transfusion; blood tubing, a pump, a mini bag of saline, any consent forms you need, so that you can start the transfusion the moment the blood is ready.
While you're doing these things, continue to monitor for s/s of deterioration and be ready for RSI.
Edited to add: Sats in the mid 90s on 4L NC, HOB at 90 degrees, anxiety and feeling of dyspnea, does not paint a picture of someone who is perfusing just fine! Do not be afraid to put the NRB on someone like this. If she is a retainer, you can fix that later. She needs more O2 now. It's no different from someone with a cardiac history who is in septic shock. You will still aggressively fluid resuscitate, and worry about fluid overload later.
Last edit by Anna Flaxis on Sep 17, '12
First, calm yourself and the patient. Place patient on appropriate 02 which means NRB
Second, locate the ER MD and quite simply say, I need you to come and see this patient now please. Unless of course, s/he is doing a code right then.
Third, recruit others to help you look for ER MD and notify the charge nurse of your situation.
Fourth, honestly appraise whether this is something you think you can get used to seeing in the future because the ER is full of people like your patient.
Last edit by VICEDRN on Sep 17, '12
: Reason: added thought