Nurse-initiated interventions

[flyingchange]

Hi all, student nurse here. Some background on my question:

We were in a Sim lab yesterday and Sim Man was post-op from MVC-related femur fracture, on 2L/min O2 via NC.

He developed SOB and desatted to around 85%, HR 180, can't remember BP. We were told he had pink frothy sputum. While one of the students went to phone the doc, we kept him at 2L, sat him up in the bed, and tried to keep him calm. Sim Man said it hurt too much to breathe so someone gave him PRN MS.

Student came back with the order to turn O2 to 10L/min. Sats back up to 95%. Some comfort care provided, end scenario.

Our instructor said in general we reacted appropriately, but suggested that we should have turned up the O2 to 10L and switched the nasal prongs to a non-rebreather mask while we waited for orders, and should have considered holding the MS until Dr decided on plan of action.

I didn't think we could put O2 above 10L/min without orders? She said we should just do it and let the Dr sign off on it later. That seems kind of unwise...? What if the doc didn't want to sign off on it? I would like to get your opinions.

If this situation was occurring on your floor, how would you respond and why? Would you call the rapid response team? How about asking for a stat Ativan for his distress?

Many thanks :)

[GoodNP]

I mostly agree with you instructor, although I would have gone to NRB. Even though I've heard people say MSO4 is part of ACLS, I still would not give without MD order.

One last thing, even though your simulation ended with a dx of PE, after a femur fracture remember to also consider fat embolus.

[ObtundedRN, BSN, RN]

If you were making the decision to permanently turn up the O2 and leave it, then yes you should get an order. But if you need to turn up the O2 because your patient is in distress, then for the sake of keeping your patient alive, you turn it up, and then call the doctor to let them know the problem. And you're calling the MD to let them know their is a problem and that your patient needs more O2, not calling just to get an order for the O2.

Some people are afraid to turn up O2 for COPD patients because they think they may knock out their drive to breath. It takes much longer then a few minutes of high flow O2 to cause this. And without enough O2, they are dead. If we knock out their drive to breath, we have machines that can breath for them.

Anyone who says that you shouldn't turn up the O2 for a patient in resp. distress without an order is a total fool, and shouldn't be allowed near a patient. Or at least don't let them near me if I'm ever a patient...

[K+MgSO4, BSN]

what is your hospital criteria for a rapid response? A HR of 180 sounds about right for a rapid response.

Also do you need an order for an EKG?? WHAT I take them all the time because I think something is up with a pt or before starting massive electrolyte repalcement

[GM2RN]

I mostly agree with you instructor, although I would have gone to NRB. Even though I've heard people say MSO4 is part of ACLS, I still would not give without MD order.

One last thing, even though your simulation ended with a dx of PE, after a femur fracture remember to also consider fat embolus.

The instructor did advise to use a NRB, and they already had a PRN order for morphine.

[systoly]

Airway, Breathing, Circulation

Time is critical, so you turn up the O2. A mask, because it's the appropriate delivery method for high volume delivery. It's more effective and a nasal cannula will cause discomfort if not damage at high volume. No MS or loraz, because of previously stated reasons and also because hypoxia could be masked.

[April, RN, BSN, RN]

Also do you need an order for an EKG?? WHAT I take them all the time because I think something is up with a pt or before starting massive electrolyte repalcement

This depends on your facility. There is actually a recent thread on orders for EKGs. Some facilities require an actual order. Others have standing orders or protocols that cover EKGs when a patient's condition warrants one. In my last post where I said I'd expect the doctor to order an EKG, I just meant that the doctor is definitely going to want one. I'd do one and have it ready for the doctor instead of actually waiting to be told to do one.

[flyingchange]

THANK YOU for all of your responses! This has been *extremely* helpful. I am glad I asked!!

We don't have a facility policy at the moment because it was an in-school lab experience. We generally go for best practices, "facility policy TBD".

RedhairedNurse, we were not told about the lab results because it was a simulation, and the next scenario was designed to see if I could hang IV meds properly. I will remember that when I am on the floor. Thank you for pointing it out!

To all who suggested the tests that might be run on this patient, thank you. It helped me see the bigger picture.

Also I appreciate the co-morbidity suggestions, such as fat embolus. Wow, there is so much to consider. You nurses are amazing. One day I hope to answer a student's question with that much knowledge. I am quite sure that if I ran into an actual patient in distress, I would run screaming into the night. :bowingpur:bowingpur

Thanks again, this has been tremendously helpful :)

[mcknis]

To the op you did well and the patient survived so all is well, especially since this was a school lab! Without the knowledge if post femur fx I would be thinking pulmonary edema but definitely turning up the o2 would be per protocol and ACLS,PALS, and any other cert is going to have this as a priority. After all ABCs take precedence.