how much o2 is too much?

Good Morning, Gil · Sep 18, 2012

It does sound like this patient was going to die anyway, but DNR does not mean do not treat. You still do everything that you would for any other patient except you do not code them or intubate. Even though you think this patient is dying, ready to die, they are not comfort/palliative care until the physician and/or family/POA makes them comfort care.

You called the doctor, and did what you could with standing orders. How long before the doctor called you back? In that situation, he/she needs to call immediately, and if not, then you call again. This patient needed a NRB until the physician called you back. You do what you have to do.

amoLucia · Sep 18, 2012

The woman was actively dying and in reality, no amount of oxygen would probably help her. I always check lower extremities for mottling as my indicator of impending expiration. You make no mention of her struggling to breathe. You did what you could do within the orders you had. It was just her time.

MassagetoRN · Sep 18, 2012

You followed standing orders and you also alerted the doctor to the patients condition. Oxygen is a medication. I swear, nurses are darned if you do and darned if you don't.

It sounds as if you are carrying some guilt or other emotion over losing a patient. You did your best, and the fact that they are DNR tells me that they were terminal already. Plus DNR status keeps you from implementing any ACLS protocols, including medications, ie. oxygen.

You did well.....

Been there,done that, ASN, RN · Sep 18, 2012

More details, please. If the patient was a DNR, yet death was expected .... is a confusing scenario.

In the hospital setting, treating the oxygen saturation level may require additional interventions , beyond O2 administration.

However, this depends on the DNR parameters.

Don't focus on oxygen concentration, if the patent is actively dying, no amount of oxygen will affect the outcome.

unsaint77 · Sep 19, 2012

I work at a nursing home, hence the calling oncall doc and waiting for return call. It took about 15 min for the doc to call back. It is true that I wasn't as freaked out since the death was expected.

Probably not related to her impending death, but her legs were mottled and dusky blue when I first met her two days before.

I didn't think of the NRB. We proabably have one in the crash cart.

My biggest question is this.. If she was not expected to expire and her sat dropped to 68, would you have raised the O2 beyond the 4L as the protocol says? At what level of O2 is usually dangerously risking losing one's own ability to breath? Or does that even apply in an emergency, unexpected situation?

Should I have at least change the NC to mask? Perhaps I should have.

Thanks for all your input.

akulahawkRN, ADN, RN, EMT-P · Sep 19, 2012

I highly doubt that you hastened her death. It sounds like this patient was ready to go, and nothing that you could have done with the oxygen would've made any difference. In the non-COPD patient, you can provide up to 100% oxygen and you will not suppress the patient's own ability to breathe. Those patients are still on the normal CO2 drive to breathe.

As far as the mottled legs are concerned that were dusky blue, to me that is a sign of very poor circulation. It was probably very much related to this patient actively dying. In any event, given the DNR/DNI and the patient's situation, there is probably very little that you could have done. You did the best you could given the circumstances, and even if you provided a high concentration of oxygen at a high flow rate, you would not have probably changed the outcome.

From what little I have read so far, it sounds like you took over the shift, did an assessment, increased the oxygen to the maximum allowed by standing order, and notified the physician, and the patient took their natural course of things and expired before the provider could call back.

I am but a student nurse, but that does not mean that I am not inexperienced in some of these things.

I think you did fine, and given my previous education and training and experience, I would've done the maximum allowed by protocol/standing order. If I needed to go beyond the standing order, I would've called for additional orders just like you did. There is only so much that we can do to nudge the patient towards life, sometimes we can give a little bit of a push, but if the patient does not want to respond, that is all we can do.

Don't beat yourself up over what you did, I think you did exactly what you should have. I hope others agree with me.

Esme12, ASN, BSN, RN · Sep 19, 2012

:hug:.....She was dying.....you didn't hurt her. You followed orders......increased the O2 and called the MD, and she passed away. It was just her time.

joanna73, BSN, RN · Sep 19, 2012

I work in a nursing home also. When someone is actively dying, their vitals, including O2 sats may or may not be unstable. Providing oxygen keeps them comfortable, doesn't prolong their life. As long as you followed protocol and provided comfort care (which you did), that's what counts. It was their time.

amoLucia · Sep 19, 2012

To OP - sometimes using a mask makes things worse.

Some pts FIGHT it as they feel suffocating. I have just laid (lain)(layed) a mask near the chin/chest/neck area without using the elastic. This seems to be a better approach for a open mouth breather.

You did fine.

sapphire18 · Sep 19, 2012

To answer your question, if a pt was not actively dying and satting 68%, 4L NC would not be enough. 68% = 100% NRB. Since the pt WAS dying and no other interventions were ordered, you did fine:)