The correct way to send a patient out to the hospital...

[lvnnars1]

just for clarification. regarding LTC facilities. ok, lets say you have a patient having SOB you check the O2 sat. and it's 84% you give 2 liters of o2 via NC and it's about 86% now, pt. is a code, patient is a&o X3 how would you go about sending this patient out? would you first get an order from the MD first to send the patient out, or do you use your nursing judgement and send out patient then call the doctor after the ambulance picks him up? do you call 911 at all? curious to see your answers.

[lvnnars1]

To the comments of not turning the O2 above 5 or 6 liters. Would you rather kill your patient from lack of O2? Yes, high flow O2 can cause them to lose their drive to breath. But it isn't an instant thing. Without the O2 they're dead. If they lose the drive to breath, that can be fix much easier then dead.

just for clarification, it's ok to turn up the o2 due to nursing judgement right? .. most o2 orders on the MAR say something like: O2 via NC 2 liters per minute prn .. but when giving more than 2lpm in that situation without an order (emergency) how do you write that in the nursing notes when there is no order to give O2 anywhere above 6lpm???

[lvnnars1]

As for the 911 lights/siren, in my area, no matter who is calling 911..the ambulance goes code 1 (lights and sirens). The caller, regardless of them being a nurse in a facility or a private citizen, cannot ask nor dictate how the ambulance comes.

where i work in CA, they sometimes ask something like "is this a non siren emergency?"

[JenniferSews]

Okay, I practice in Colorado where 90% is considered a normal O2 sat and 86% on a COPD patient wouldn't make me call 911 in itself. So let's for my sake adjust the O2 sat down.

First, I would assess the patient. Are they still AO3? Did they just finish therapy? Has their O2 tank been empty for hours? Then I'd look for a prn neb treatment and find out if they got their respiratory meds. Then I would listen to their lung sounds. Then I would put on a non rebreather mask and titrate O2 to what is considered acceptable for a copd pt in CO, 88%. While all this was going on someone would be calling the MD. If the issue didn't resolve after those interventions, or something else was obviously wrong after my assessment, I would send out the patient. Whether I dialed 911 or called a non-emergent transport ambulance would depend on whether the patient was stable and holding at those sats, whether they were responsive and the sats were dropping fast, and the overall condition of the patient, and the stated response time of non emergent ambulance. Often I can call and they will be there within 5 minutes without taking an ambulance away form the 911 system. If the patient is relatively stable, I leave the 911 for very sick patients. More than a few times I've dialed 911, had them come and assess, and then call non-emergent.

I have had patients have episodes of dyspnea with alarmingly low O2 sats that recovered in facility. In house we got a stat chest xray, started the patient on antibiotics based on the xray, and they continued on their plan of care without transport. I've had patients transferred because their sats and LOC were low because their O2 had been empty. Put on a mask in the ambulance they were fine and sent back to us with an angry call from the ER. Then I've had patients sent out who really needed to be in the hospital.

With the info you provided it's hard to make a clinical call. Of course, that's all based on practice and not theory.

[systoly]

I see what you did there...

What's funny 'bout that, is if it weren't for scholars, we'd still be convinced that bacterial growth was the product of spontaneous generation and your cannula might come straight to your nose from your roomie with the bacterial pneumonia without any pause for the thought of sterilization.

It is nice in this day in age to be able to take some things for granted. But that luxury didn't come without the work of those who continued to ask questions when the state of the world had been "determined" by others.

I am familiar with the works of Florence Nightengale.

[metal_m0nk, BSN, RN]

I am familiar with the works of Florence Nightengale.

Okay, now you're just being cheeky.

I hope.....

[ObtundedRN, BSN, RN]

just for clarification, it's ok to turn up the o2 due to nursing judgement right? .. most o2 orders on the MAR say something like: O2 via NC 2 liters per minute prn .. but when giving more than 2lpm in that situation without an order (emergency) how do you write that in the nursing notes when there is no order to give O2 anywhere above 6lpm???

If your patient has a PRN order for 2 liters of O2, then by all means start with that. But if it doesn't work, then continue to titrate up until it brings your O2 sats up to a safe level (if possible).

As for how to handle doing this without an order. When needed, give the higher then needed O2 and then call the MD or 911, whichever is appropriate to call first. If your patient is in severe resp. distress, then please give them the highest O2 you need and your equipment will allow (if you happen to be in a LTC that has a non rebreather and need that, use it) and then call 911. If your patient is having some mild dyspnea that isn't fixed by 2 liters, but say 4 or 6 will. Then give that and call the MD to tell him about the increased O2 need and get further orders.

The only time you may get in trouble is if you increase that O2 and don't tell anyone that your patient has increased O2 demands.

As for your nursing notes, I've never worked in LTC, so I may not be the best advice to ask. But you could probably say sometime to the effect of: Pt c/o dyspnea, O2 at 2 liters resulted in XYZ (not effective), O2 increased to X liters with XYZ result and MD notified, orders received. Or patient sent out with 911 emergently, etc.

If you need to give more O2 then you have orders for, then by all means do it, but let someone know and don't wait a long time to let them know.

[JenniferSews]

The only time you may get in trouble is if you increase that O2 and don't tell anyone that your patient has increased O2 demands.

For LTC, that is a very good point. If it's a chronic change that a pt normally good on 2L us needing 3L over time but you just adjust it without notifying a doc, that's a problem. We tried orders that read "titrate O2 to x-x% O2 saturation" but that was a problem when state came around. I have treated O2 like a nursing judgement in acute situations and no one has ever expressed concern. I think most people would like a nurse to turn up the O2 a bit and get a patient either through a moment of dyspnea or and acute episode before 911 arrives than stand their with their arms tied while the patient deteriorates to a code.

[systoly]

Okay, now you're just being cheeky.

I hope.....

I never do resist. The truth is, however, I'll be doing a lot of reading up about the subject matter discussed in this thread.