Question about demanding COPD patient

[oldiebutgoodie, RN]

Hi, all,

I'd like your input on the patient I had yesterday. She was an 82 year old woman with COPD who had been admitted due to increasing SOB. When admitted, she demanded frequent neb treatments as well as an inhaler at her bedside. She was tachycardic (probably from all the meds), and the MD said absolutely not, pick one: bedside inhaler or neb treatments from respiratory.

She chose the neb treatments from respiratory (very reluctantly, with lots of anger, drama, etc.) So, when I had her, she was demanding neb treatments about every hour and a half (treatments were for every 3 to 4 hours). She cried that she couldn't breathe, couldn't breathe, couldn't breathe, and was screaming out to the hall for me to get the respiratory therapist (who, of course, would not come due to MD order).

Meanwhile, her sats are 99% on 2L of O2, and I couldn't see any accessory breathing. When I listened to lungs they were diminished all over, and respiratory said as day went on, they were clear, no wheezing. She was not gasping for breath, and had plenty of energy to yell at us.

Only once did she sit up in tripod position due to her inability to breathe (sats 99% at this point).

So, what do you think? Is she just a PITA patient, or in actual distress? She did not have blood gasses done, so I can't give you that info. She was also very demanding about food, saying the food was always cold, but when we got her a tray, she wouldn't eat it because she said she couldn't breathe.

I just can't imagine she is just making all this up-- can neb treatments have some sort of dependency effect? Even though she was a pretty unpleasant person, it just seemed she put an awful lot of energy into this "can't breathe" thing for it to be made up.

What do you all think?

Thanks,

Oldiebutgoodie

[Tweety, BSN, RN]

It's one of those subjective things. If a patient says they can't breathe, we need to take it seriously. You did a good assessment. Did you notify the MD? Maybe she needs her nebs increased from q4 to q2? Maybe she needs the nebs changed to another kind of med? Maybe she needs something for anxiety?

You did a thorough assessment of the objective signs. These patients can be a challenge for sure. Once all options have been ruled out through ABGs, r/o PE, chest x-rays (which I'm sure she already had), etc. you have to consider things like anxiety and attention seeking and maybe come up with some strategies to deal with that.

These patients are a challenge for sure.

[fultzymom]

I work in LTC facility on the skilled unit. We have a patient who always comes here for therapy after a stay in the hospital before going home. She does the same thing. Goes into COPD exacerbation and can't breathe. But she is yelling for help and telling you to get someone here fast or get her back to the hospital. Unfortunately, with COPD et the fact that when home she still smokes, things are not going to get any better for her. However, it is our job to do the best we can so we try. Her neb treatments are ordered Q2HR et she has an inhaler et still wants more. Last time she ended up doing this, we finally got the DOC to order some Ativan for anxiety et some Roxanol for dyspnea. She used the Roxanol et it seemed to help her. The dose was high enough to help her but low enough that she was not too sedated to work with therapy. Finally we got something to help her, then she refused further therapy and once AGAIN, went home. I am sure we will see her again sometime in the future.

[oldiebutgoodie, RN]

Tweety, those were good ideas about anxiety meds. I feel bad that I didn't have more time to advocate for the patient (as obnoxious as she was :-( ) because it was one of those 6-patient days with tons of tests, meds, etc. I barely kept my head above water.

Thanks for the feedback.

Oldiebutgoodie

[babynurselsa, RN]

I would also suggest something for the anxiety. Pts with COPD typically have a very anxious, less than pleasant demeanor. Part of it is the chronic hypoxia, and sensation of SOB. Even on their best day they are still going to feel this way. Their lungs and oxygenation function are not anywhere near normal.

[oldiebutgoodie, RN]

I would also suggest something for the anxiety. Pts with COPD typically have a very anxious, less than pleasant demeanor. Part of it is the chronic hypoxia, and sensation of SOB. Even on their best day they are still going to feel this way. Their lungs and oxygenation function are not anywhere near normal.

What causes the sensation of SOB? If her sats are good and there are no objective signs of hypoxia? CO2 buildup?

I'm really curious.

Thanks,

oldiebutgoodie

[Nurse Valium]

Pts with COPD typically have a very anxious, less than pleasant demeanor. Part of it is the chronic hypoxia, and sensation of SOB.

Very interesting to read this here today - I just had a coworker share with me two days ago her theory that since COPD patients have no control over the basic necessity of oxygen exchange that they overcompensate their 'control' in other areas.

[morte, LPN, LVN]

what is her H+H? if it is low, a pulse ox of 99%, doesnt mean, hmmm what ever explitive you might want to throw in there,lol

once saw a patient with a pulse ox of 100%, in air hunger......she was on her second unit of blood...

[oldiebutgoodie, RN]

what is her H+H? if it is low, a pulse ox of 99%, doesnt mean, hmmm what ever explitive you might want to throw in there,lol

once saw a patient with a pulse ox of 100%, in air hunger......she was on her second unit of blood...

Good point! As I recall, it was okay, but again, it was a crazy day...

[babynurselsa, RN]

Part of it I believe is that they have impaired lung funtion. Their "normal"

pao2 is going to be lower than a person with healthy lungs, along with an "normally" increased paco2. They have damaged tissue that is not going to oxygenate. In the later stages the slightest exertion is going to wind them. Think about how SOB you feel after a sprint, brushing thier hair can make them feel this way. Being SOB makes you feel anxious.

Along with all of this they have typically had episodes where they have gotten into a bind with severe dyspnea, I think this always stays in the back of their heads and they are worried about getting like this again and not getting help in time. It is scary not feeling like you can get your breath.

[nservice]

This behavior is what I call a typical COPDer. Your guess is as good as mine as to why they act this way. They are used to having their meds when they want them at home. I do believe, as previously posted, that some of it is anxiety and some stems from control issues. One thing for sure is patients like this can run you to death during a shift. The only thing you can do is keep calling the doctor with the patient's complaints and your assessment findings. Try to get something for anxiety..and give the patient one too!!

[NurseyBaby'05, BSN, RN]

I'm with Tweety and the others re: meds for anxiety. I would also take a few minutes when the pt is calm and give her a good explaination about anxiety exacerbating feelings of SOB. Tachycardia is probably also not helping to decrease that feeling. Is she getting Albuterol or Xopenex? Xopenex has much lower incidences of tachycardia associated with it than Albuterol. As for this pt's other damending behavior, the staff needs to set limits on what is acceptable. She also needs to know you're not there to do private duty for her. Also, I'm assuming she's on some kind of steroids too. These can exacerbate anxiety as well. Maybe it's time to take a look at all of her meds to help this poor woman get on an even keel.