Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 11

I got a call to go see one of my HH patients, who I am very familar with, because the family reported that her/his 02 sats were hanging in the 70's all day and even though she/he was not SOB they... Read More

  1. by   Cattitude
    Quote from jnette
    that's my point.. do you call a doc and get an order first before you turn up the 02? how have most of you done this.. orders first or 02 first?

    i asked our owner if we did nont have any "standing orders" for emergency situations such as these. evidently not. i think there should be some. of course that would entail a lot of docs, right? she said she would inquire of the bon about this.

    either way, i know i did the right thing and would do so again. i guess i could always call the ed and request to speak to a doc, any doc, and get an ok. just seems like such a waste of time, and makes our own nursing judgement null and void. :stone
    i would say definitely have standing prn orders. i'm going to run it by my supvr also. but as with everything else, they usually make the policies after something happens...
  2. by   Sheri257
    Quote from Noryn
    The paramedic was right in rationale but I also agree with the poster who was concerned that the pt did not want an increase in oxygen. The O2 sat reading alone is not that important. It is a nice tool that we have, but there are so many limitations hence why we get ABGs on pts. The most important thing was how was this pt tolerating the o2 sat.

    I for the life of me cannot understand how just an o2 sat reading of 73% makes you incompetent to make decisions. Now if the pt was lethargic or confused that is another story all together. So what is the cut off mark for an O2 sat? One of the posters in an interrogation stated that 92% + is normal. So if I have a chronic COPD pt their normal sat is above 92%? At what point does the low O2 sat make someone incompetent? 85% or 80%?
    This is an excellent point. I don't think anyone has talked much about O2 sat errors either. Setting aside the ABG's and the fact that the patient was vented in this particular case, just for the sake of discussion ...

    What about errors in O2 sat readings? I've personally seen variances of 6 points just by using different machines. I know RT's who have complained about this problem also.

    So, hypothetically, if the baseline is 80 but that baseline comes from one machine, and another machine says 74 but ... that could simply be a six point equipment variation ...

    Do we say that patient is incompetent and ignore their wishes? Especially with no mentation changes?

    :typing
    Last edit by Sheri257 on Jan 31, '07
  3. by   leslie :-D
    pulse ox's are the last tool i look at.
    one time i had a pt in acute chf.
    ap 160, rr 50, diaphoretic, hypotensive, using accessory muscles yet his pulse ox read 96%
    i was trying to send him out (he was pt in an inpt hospice) and the paramedic kept on saying, "but his pulse ox is 96%!".
    i kept on reminding him to look at the patient and not the machine.
    grrrrr.
    anyway, he was admitted with exacerbation of chf.
    so pulse oximeters do not tell the entire story, nevermind its' accuracy.

    leslie
  4. by   Sheri257
    Quote from earle58
    pulse ox's are the last tool i look at.
    one time i had a pt in acute chf.
    ap 160, rr 50, diaphoretic, hypotensive, using accessory muscles yet his pulse ox read 96%
    i was trying to send him out (he was pt in an inpt hospice) and the paramedic kept on saying, "but his pulse ox is 96%!".
    i kept on reminding him to look at the patient and not the machine.
    grrrrr.
    anyway, he was admitted with exacerbation of chf.
    so pulse oximeters do not tell the entire story, nevermind its' accuracy.

    leslie
    Yet, it seems that the case here was a paramedic ONLY looking at the pulse ox and ignoring the patient's wishes based on that.

    :typing
  5. by   angel's RN
    Hey DutchGirl--Not tring to say you don't know what you are doing. I WOULD NOT have your job for $200.00 an hour!! I have every high respect in the world for someone who does HH or Hospice. I was just pointing out what I see in CCU every day - chronic COPD'ers that are on a vent at least once a month, and the family just doesn't get it. Please don't misunderstand me!! Contune & keep up the good work!!
  6. by   burn out
    Quote from jnette
    Agree wholeheartedly.

    Whew ! Just read this ENTIRE thread BECAUSE........... I recently came across a very similar situation in which I was the HH nurse and I was called to teh pt's home because patient stated she was not able to get her breath, was not able to breathe well. She is CPOD with long hx. of pnx.

    Get there and find that she had just been released from the hospital the noc before..for double pnx. This patient had both lungs, however. Check her VS, temp of 101.7, HR 136, lung sounds adventitious as all get out and no steth was needed to know that she was in serious trouble. 02 sat was 80. Mentation was ok still, but she was visibly struggling to breathe.

    I took it upon myself to increase her usual 2L NC to 4L, and called 911.


    My agerncy owner later questioned me about increasing her 02 "without an order" and while she was supportive, and didn't ream me out for it, she did say that this could have cost her HER license as well as mine, and shut down the agency.

    So.... MY question in all this is this... where does NURSING JUDGEMENT come into play, or is it all a myth???

    I will defend my decision to increase her 02 regardless. But I need to know WHEN we can do what we feel is right for the patient without an MD order.

    So many of you have said you all would have done the same, or HAVE done the same.. but I've not heard many or any of you say that you first obtained an MD order to increase a pt's 02 in an emergency situation, be it in the hospital setting or out in the field.

    I could really use some clarification on that end of it. Thanx!

    Nursing judgement came into play when you were called to the house by the family. The biggest question the nurse has to ask is "WHAT IS MAKING THE SAT SO MUCH LESS THAN NORMAL?" AND the most common picture for a COPD'er is co2 retention with accompanying low o2 levels which is standard treatment in this situation to increase the oxygen..it is that gut feeling thing that you have to go with. This also depends on the rest of the assessment, breath sounds, temp, vital signs etc it is not based solely on the sat.
  7. by   morte
    Quote from jnette
    Agree wholeheartedly.

    Whew ! Just read this ENTIRE thread BECAUSE........... I recently came across a very similar situation in which I was the HH nurse and I was called to teh pt's home because patient stated she was not able to get her breath, was not able to breathe well. She is CPOD with long hx. of pnx.

    Get there and find that she had just been released from the hospital the noc before..for double pnx. This patient had both lungs, however. Check her VS, temp of 101.7, HR 136, lung sounds adventitious as all get out and no steth was needed to know that she was in serious trouble. 02 sat was 80. Mentation was ok still, but she was visibly struggling to breathe.

    I took it upon myself to increase her usual 2L NC to 4L, and called 911.


    My agerncy owner later questioned me about increasing her 02 "without an order" and while she was supportive, and didn't ream me out for it, she did say that this could have cost her HER license as well as mine, and shut down the agency.

    So.... MY question in all this is this... where does NURSING JUDGEMENT come into play, or is it all a myth???

    I will defend my decision to increase her 02 regardless. But I need to know WHEN we can do what we feel is right for the patient without an MD order.

    So many of you have said you all would have done the same, or HAVE done the same.. but I've not heard many or any of you say that you first obtained an MD order to increase a pt's 02 in an emergency situation, be it in the hospital setting or out in the field.

    I could really use some clarification on that end of it. Thanx!
    the difference between your scenario and the op, op patient WAS NOT struggling to breath......your case would be the classic "easier to defend upping the o2, than a dead patient"....if it happens again, call the doc (after calling 911,lol) and get the order......
  8. by   canoehead
    jnette- does your boss have you call the doc before you start CPR, or does she rely on nursing discretion, lol.
  9. by   wtbcrna
    Is there a way to turn this debate into a poll to see where the majority of people fall? It would also be interesting if we could tie in the response to what area of nursing you worked in also...Just a thought
  10. by   Sheri257
    Question for the paramedics:

    Does the act of calling 911 and low O2 sats which, may or may not be reliable, override the patient's rights to refuse treatment if mentation is intact?

    From reading some of the posts, it seems that some of the paramedics think it does but, I was wondering if they could clarify their position and why.

    Does anyone know what the law says in this situation?

    :typing
  11. by   LuvWounds
    no i don't think it was at all about being ignored. We all know that COPD pt should be on a dose of O2 due to the fact that the cn't recycle if you will the CO. To much O2 is toxic to their body. Why would they come in atomatically just boost it up to 6 no thats just trying to be mr/ms mocho. I have some friends who are emt and medics they tell me all the time that they beleive nurses don't know ****, so thats the mind set they arrive on the scene with.YES by all means he/she should be reported.
  12. by   NeosynephRN
    Quote from NEWATTHIS
    no i don't think it was at all about being ignored. We all know that COPD pt should be on a dose of O2 due to the fact that the cn't recycle if you will the CO. To much O2 is toxic to their body. Why would they come in atomatically just boost it up to 6 no thats just trying to be mr/ms mocho. I have some friends who are emt and medics they tell me all the time that they beleive nurses don't know ****, so thats the mind set they arrive on the scene with.YES by all means he/she should be reported.

    I am sorry..but this is a load..I am not a nurse yet..I graduate in May..but I am an EMT-B. I do not see that the medic was trying to be "macho" they were probably just following their protocols. When I was in school for my EMT..we were taught about COPD, about the increase in O2 would decrease the drive to breathe, we were however taught that above all we need to treat to maintain life...if that meant turning up O2 and possibly decreasing their drive...so be it..at least they would be alive.
    I also have issue with the fact that you think we all arrive on scene with an attitude and believe that nurses do not know anything...we are trained in different things as an EMT/Medic then you are as a nurse..the mindset is different. There are many things that I have been trained to do as a nurse, that I was not trained in as an EMT..and visa versa....so no many nurses do not know squat about in field care...just as EMS many times do not know squat about what nurses do in hospital.
    Please stop lumping all medic's in this macho, Dr wanna be, know it all catergory...it just is not the case. The job of EMS and LPN/RN are just different..like comparing apples and oranges...JMO!!
    RN in May...going back to school Jan 2008 for my NREMT-P!!
  13. by   UM Review RN
    Quote from lizz
    Question for the paramedics:

    Does the act of calling 911 and low O2 sats which, may or may not be reliable, override the patient's rights to refuse treatment if mentation is intact?

    From reading some of the posts, it seems that some of the paramedics think it does but, I was wondering if they could clarify their position and why.

    Does anyone know what the law says in this situation?

    :typing
    I know that when a patient needs air, they often become confused, but a few minutes before that confusion, they think they're fine. Hypoxic patients are sometimes resistive to care, so it's really hard to tell. We routinely do things to patients in an emergent situation (such as diabetic ketoacidosis, for instance) that they might not "want" but that are necessary, such as supplemental O2.

    Ask any ER nurse, it's pretty routine.

    I had one patient in CHF who reported "a little" shortness of breath and whose mentition was a/oX3 right up until her sats decreased to 63% and she remained "with it" for about 2 minutes at that sat.
    By then she was on a Venti or NRB, I forget which, and we were ready. She was quickly BiPap'd and she was unconscious for only a couple of hours and she had a complete return to a/o x3 status shortly after. No loss of brain cells there.

    The entire point of keeping a patient oxygenated is to help perfuse the vital organs. Let's not forget that the body shuts down the brain--therefore, mentition--LAST.

    My point here is that DG called EMS just before the patient's sats dropped to the point of losing mentition, and the EMS was trying to prevent the patient from going too far to be saved.

    Ever see a patient fight a mask or NRB?

    Patient might know her name and her location, but resists treatment because she needs air and the NRB makes her feel so claustrophobic that she has the sensation that it's causing her to smother, rather than understanding that it's giving her air.

    Most of my COPDers are extremely claustrophobic and some won't even let me close the curtain to assess them.

    Last night I had a patient whose heart rate dropped to 10--and stayed there. In the room, after waking patient up, patient's HR went up to 20, then 30. All the while, the monitor was correct, and the patient was a/o X3, and was satting in the high 90's, yet you can bet your bippy that I threw O2 @ 2L on her--because with a heart rate that low, her brain will not be perfusing for very long, and patient would not be able to maintain her mentition without supplemental oxygen.

    Many chest pain patients sat just fine on room air, yet we routinely supplement oxygen for the same reason--if there is even a hint of a problem with perfusion, oxygen is called for.

    It's even in ACLS protocols. Nowhere in ACLS protocol does it say "don't give supplemental O2 to CO2 retainers." Nowhere.


    In this case, I sincerely believe that the timing of the whole event was so critical, that both DG and the EMS responded appropriately. Had one or the other not done so when they did, there would be no argument. I think we all agree that the patient was beginning to crash, and what we're discussing here at this point would've become moot when the patient actually, visibly did crash.

    Apparently this patient finally crashed in the ER. But again, I have to echo the sentiments of other posters and say that the patient did not crash because someone gave supplemental O2; the patient finally crashed because the patient had something Very Big going on.

    So that, in the end, the question never should have been, "was the patient able to refuse O2"; the questions should have been "was the standard of care met" and "did the patient survive."

    OK, so some people would've given higher O2; others would not. Some think it was illegal to give the O2, others think it was unnecessary or detrimental, but regardless of the reasons for giving or not giving the O2, I guess some of us are just going to have to "agree to disagree."

    That being said, my questions at this point center around what happened next.

    I'm still curious about the patient. How about those BCs? What was the final Dx? How is the patient doing now? What did the patient's pulmo doc say about the supplemental O2?

    And by the way, I still think that was a great catch, DG. Maybe I missed it, but please don't let my high praise for your actions get lost in the sauce of the O2/no O2 discussion here: I believe that you did save this patient's life, and I for one, think you're an AWESOME nurse!
    Last edit by UM Review RN on Feb 1, '07

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