new grad here, I recently had a pt with pulmonary fibrosis, not doing so well, and family just agreed for pt to go to hospice. He was going to transfer to hospice the next morning and not yet on comfort measure. Last ABG showed that he's hypoxic, he was on BiPAP 99% throughout the day until the afternoon they switched him to 100% non-rebreather to prepare him for transferring to hospice because hospice doesn't take BiPAP.
At beginning of my shift (7pm), family and friends were all in the room, talking with him, saying goodbye, pt was still AAO x4.. 1 hour into the shift, just as I went in to the room again to made my round, I noticed he start to get restless, very confused, trying to take off his non-rebreather.. I know it's due to the lack of oxygen, but I can't really do anything such as putting him back on BiPAP or call an RRT, so what I did at the time was place the mask back on him, talked to him, was about to go get morphine IV asap for him that's what has been keeping him comfortable, and then call the doc. before I walked out, he had an episode 10 second seizure, body stiffening, tremor, staring to the left.
I stayed in the room, had someone to call the charge, we gave him ativan x 1, morphine x1. called MD, gave another ativan x1. and started him on morphine drip and comfort measure.
before the drip, his RR was 36, restless, seem uncomfortable. after on the drip, he's RR was 26 on 1mg, eyes closed/resting besides using accessory muscle to breath. He's non-responsive now. after one hour, I titrated to 1.5mg, and RR = 22-24, still using accessory muscle breathing.
at this point, I talked to my charge, I don't know if up the dose would help more or would it depress his respiratory even more and cause him to have to work harder breathing? at the same time, I don't want to overdose him.. this is my first pt on comfort measure, I don't really what to expect..
I had also asked my other co-worker too, and asked if we should keep their breathing between 12-20? or as long as patient seem comfortable..
our conclusion, pt seems comfortable, family also think patient seems comfortable, so leave it as it.
when giving report, morning RN came and saw the pt, she said - no no no, pt's not comfortable, when they are on morphine drip, you titrate it until they no longer using accessory muscle breathing, and appear as if they are just breathing normally..
I'm confused.. what should I have done here?
also, throughout the care, I feel really bad because I don't know what to say to the family. I let them know that i was there for them if they had any questions or anything I can help. I explained everything I do with the family, made sure tissue, water, and blankets are available for those that are visiting/staying. kept the room quiet and neat, called the priest per family request to say the last word..
I left work that day feeling like I could have done better..
I guess the feeling of I didn't know what to say so I really didn't say much to comfort the family made me feel really bad.. I felt I did everything i could "tasks" wise but didn't offer them emotional support.. how can I do better next time?
Mar 8, '13
i agree, that your heart was clearly in the right place.
as a longtime hospice nurse, i am with the a.m. nurse who said pt wasn't comfortable...
or, he didn't achieve his maximum level of comfort.
it doesn't matter whether he has used accessory muscles as his baseline.
morphine is to be given until a resp rate of 12-14 is achieved, with no accessory muscles being used is ideal...
not always achievable but sometimes it is.
also, for resp pts, a circulating fan (pointed at their face) is a Godsend to many of these pt.
please, do not worry about hastening death or suppressing resp drive.
as long as your intent is to alleviate suffering, then you haven't done anything wrong/illegal.
please be persistent and consistent with the morphine and ativan.
there is nothing worse than a suffocating death.
eta: many nurses remain reluctant in giving mso4, having same fears as you with resp depression and/or hastening death.
because of that, you will often see they have noted "pt resting comfortably"....and that is just not the case.
there really is an art in assessing pain.
PLEASE do not hesitate in titrating up.
morphine is one of the best agents out there for dyspnea.
and, there is no ceiling to amount given.
again, you will get a lot of different opinions but not all of them are truly in the pt's best interest.
i do appreciate your efforts and concerns.
Last edit by leslie :-D on Mar 8, '13