Last time I was at work I had a CNA call me at the station as she was doing vitals and she said my patient had an o2 sat of 60% on 4l of o2. I brought a nonrebreather mask with me when I went into the room and put it on the patient. The patient appeared to be OK otherwise- she stated she felt fine and was not having any increased SOB. She was sleeping at the time her vitals were taken she she wasn't up and about. Her o2 sat increased to 96% and her HR decreased from 111 to 104 with the oxygen. I called her doctor. He asked me how she was otherwise and I told him her resp rate, that she felt fine otherwise and was not having any SOB. He told me to put the nasal cannula back on at 4L and to "leave her alone". I tried that- I put her back on the 4L and her sat droped to 80's before I tried a venti mask at 50% and the best I got was 85% so I put her back on the nonrebreather again. (I checked her previous o2 sats for other shifts and had previously been satting at about 90% on 4L). That's pretty much the end of story here. The nurse that took over was kind of freaking out about myself and the doctor not being in agreement so I asked my charge nurse who agreed with me, She asked the next shift's charge nurse who also agreed with me. Any opinions?

What did her lungs sound like? Was she a post-op? Has she been in bed most of the time?

I think you did the right thing by increasing the O2. But someone had better take a closer look at why her sats are dropping so dramatically on 4L.

Her lungs where wheezy and coorifice. I informed the MD of that also. I called respitatory- they he also agreed to leave her on the nonrebreather. I mde sure they gave her her treatments on time. She wasn't post op- she was there for a "COPD flair." She had been in bed most of the time and up to the bathroom.

Sometimes we have to "go against the grain" when caring for our pts. I am glad you were able to get this person's sats up.

I was taught that COPD pts were to almost never receive O2 higher than 2L.

I was taught that COPD pts were to almost never receive O2 higher than 2L.

me too, something about they can overcompensate.

I was taught that COPD pts were to almost never receive O2 higher than 2L.

I was taught that COPD pts are never to receive more than 6 lpm. I just looked it up in my old med surg book to be sure & it says 6 .

When I worked hospice inpt, we routinely had doc's order COPDers on 15l. Some went on for months that way.

I see, so you'd have put the patient back on the 2-6L and leave her with an O2 sat of 60-70%, right? We have many COPD patients in our hospital. The ones receiving the most oxygen and on bipap are the COPDers. It is possible to have too much o2 for a COPD patient... that's why I tried the venti mask at 50% o2 but it still wasn't enough. Has anyone left a patient satting at below 70% that wasn't a hospice patient?

ahh. with COPDers you have to look at their baseline sats. Some live quite comfortably in the 80s.

And I have put COPDers on nonrebreathers with the MD's blessing. You have to weight the benefits vs risks.

OK I see that point. I'm sure a lot of older people at home who are pretty much fine don't have the best O2 sats like we make them have in the hospital. That doctor had previously written an order to titrate her O2 sat to above 88%. That is lower than usual... usually they write to titrate it to over 92%... but I'm sure most people are fine at 89%. But... The only way to get it over 88% was on the nonrebreather.

Sometimes you have to do what you have to do to keep their sats up - COPD or not. Most copd'ers do live in the 80's, but let's face it, you can't live on 60-70%. You did the right thing in my opinion. We all know that too much O2 isn't good for someone who retains CO2, and the venturi was probably temporary anyway. I've seen this before too, and usually after a couple of hours and a few breathing tx's, the cannula can go back on.

These pulse ox thingys can be a bit of a pain in the orifice sometimes. If the patient's heart rate is irregular the equipment will sometimes give you false readings. I don't remember all the technical stuff about it, but these pulse ox things are driven by not only the patient's pulse rate but the regularity and intensity and each beat. Whenever a O2 sat with a pulse ox is in question or doesn't match your physical assessment, ABGs are always the way to go.

If a COPD'er is having trouble with sats, we titrate o2 based on ABGs; what's the use of keeping them above 90% o2 sat when they are retaining so much co2 that they are passing out (as I have seen before, but only in hospice patients)? Our MDs usually want COPD pts to be between 88-92% on O2. Sometimes lower, but if that is the case, they need to write the order for that.

Given the situation, I think you did the right thing, ESPECIALLY when you brought in RT. I think I would have attempted to get some parameters from the doc (so, what parameters do you want to give me for her o2 sats?--and then document if he REFUSES to give them) and get ABGs. Like someone else noted, the pulse oximeters are not always the most accurate, particularly if the pt has some peripheral circulation issues or heart arrhythmias. In an ideal world, that's what I would have done. In terms of the reality of the demands of floor nursing, I think you did what you could.

If this is a chronic problem, though, especially with a certain physician or group of physicians, it needs to be addressed, either through your department manager, or risk management. If a doc isn't reponding to requests for clarification and parameters of treatment, he's negligent. Period. Sometimes implementing an across the board standard, with the physician having to specify if he wants care that is specialized to that individual patient, is the best way IMHO to get these lazy or incompetent docs to treat their patients appropriately.