Caring for a COPD patient

  1. 0 Anyone know of a good website regarding caring for patients with different diagnoses? I'm specifically looking at patients with COPD. I had a situation at work a few weeks ago, regarding a patient with COPD, who ended up on a vent. His sats were good, in the mid 90's. He was on a 100% non-rebreather, as he couldn't tolerate the Bipap.

    He didn't have any mental status changes for me, although he was lethargic for my entire 12 hour shift. When nights came in and assessed him at around 2000, he was pretty much unresponsive. I was in frequent contact with the MD throughout the day, but more regarding cardiac issues, although he was aware he was lethargic. He was following commands for me though.

    Anyways, while I didn't necessarily do anything wrong, I didn't push for an ABG or anything. He would have ended up on the vent either way, but family was very upset, feeling I didn't listen to their concerns.

    Basically I am just wanting to do a little re-education for myself, to brush up on things, so in the future I can handle any situations with COPD patients differently.

    Or any words of wisdom anyone has, that they care to share

    BTW... I don't mean I don't know anything about it, I just want to brush up!!
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  3. Visit  Simply Complicated profile page

    About Simply Complicated

    Simply Complicated has '5' year(s) of experience and specializes in 'Med/Surg, Neuro, ICU, travel RN, Psych'. From 'New York'; 37 Years Old; Joined Mar '10; Posts: 1,152; Likes: 622.

    19 Comments so far...

  4. Visit  Fribblet profile page
    0
    What were his sats on room air?

    I'm no expert on COPD, but being a 100% non-rebreather is a no-no I would think. Too much oxygen will suppress the drive to breathe.

    How advanced was his COPD? Was he on home oxygen?
  5. Visit  DebblesRN profile page
    2
    100 % NRB will increase the CO2 levels, which will increase work of breathing, and kill the respiratory drive.

    RN.com has a course on COPD. It cost 10 dollars and is 2 CEUs, BUT you can review the course material for free, the test cost ten dollars, so at least you can read the class. Here's the link.

    Title Page

    I'll see if I can round you up some other links.
    Crux1024 and labcat01 like this.
  6. Visit  DebblesRN profile page
    1
    labcat01 likes this.
  7. Visit  hburatti85 profile page
    0
    I actually covered this in class recently with oxygen adminstration and too much oxygen in a COPD pt can elevate the CO2 levels because the body has adjusted to working at a lower level of oxygen. I have to agree with the previous poster and use the above links, or if you have the ability to do so refer to your med-surg or fundamentals texts.
  8. Visit  Simply Complicated profile page
    1
    Quote from Fribblet
    What were his sats on room air?

    I'm no expert on COPD, but being a 100% non-rebreather is a no-no I would think. Too much oxygen will suppress the drive to breathe.

    How advanced was his COPD? Was he on home oxygen?

    We never did sats on RA. This was in the ICU. He was transferred to us from the tele floor for breathing and cardiac issues. He was originally found with CP and a sat of like 75% on NC. No O2 at home though. He was ordered to be on the Bipap/ NRB by Pulmonology. He did end up dying within a couple weeks. He had so many co-morbidities, he was really really sick.

    I've just gotten different reasoning from different people on putting COPD pt's on higher levels of O2, which is why I want to brush up a little. In hindsight, I can see where I could have handled things a bit different with this case, although at the time I thought I was doing the right thing. I'm new in the ICU as it is, so I am just trying to get take as much of a learning experience as I can from this situation.


    Thanks for the links ladies. I will check those out!
    Last edit by Simply Complicated on Jul 14, '10
    SuesquatchRN likes this.
  9. Visit  Simply Complicated profile page
    0
    Quote from hburatti85
    I actually covered this in class recently with oxygen adminstration and too much oxygen in a COPD pt can elevate the CO2 levels because the body has adjusted to working at a lower level of oxygen. I have to agree with the previous poster and use the above links, or if you have the ability to do so refer to your med-surg or fundamentals texts.

    Thats what I've always been aware of, or had learned. It just gets me a tad confused, because then you have docs that order these things on the patients. So I just want to read up a bit. Thanks!!
  10. Visit  tewdles profile page
    6
    Quote from nursemandalyn
    We never did sats on RA. This was in the ICU. He was transferred to us from the tele floor for breathing and cardiac issues. He was originally found with CP and a sat of like 75% on NC. No O2 at home though. He was ordered to be on the Bipap/ NRB by Pulmonology. He did end up dying within a couple weeks. He had so many co-morbidities, he was really really sick.

    I've just gotten different reasoning from different people on putting COPD pt's on higher levels of O2, which is why I want to brush up a little. In hindsight, I can see where I could have handled things a bit different with this case, although at the time I thought I was doing the right thing. I'm new in the ICU as it is, so I am just trying to get take as much of a learning experience as I can from this situation.


    Thanks for the links ladies. I will check those out!
    poor old guy...he should have probably never been in the hospital in the first place...

    shoulda been home with his family...comfortable and safe...

    sigh, musings from an old hospice nurse
  11. Visit  hburatti85 profile page
    0
    I know sometimes Dr.'s order things without taking in all the considerations the patient has. (and that's speaking at a personal level with my dad)
  12. Visit  SaltyNurse profile page
    4
    The dec. in LOC has more to do with the fact that he was on the nonrebreather mask than that his level of oxygen was too high. Even if he was on a O2 mask with vents, with the severity of air-trapping that you get with end stage COPD, the only thing that would have helped prevent that would be if he stayed on the BiPAP. And even then, depending on the severity, that is just putting off the inevitable. I've been down this road with these patients before. They refuse the BiPAP until they neurologically deteriorate, and then their CO2 is so high that they can't fight you when you put the BiPAP back on. Then as their CO2 improves, they wake up fuss about the mask, refuse it, go night-night, then comes the mask again. Yeah, fun cycle there. A good take home lesson is don't use nonrebreathers with these patients. I can't believe the physician was aware that it was in use and did nothing. Well, yes I guess I can believe it, but that never should have gone down that way. Second take home message- when in doubt, just get the ABG. Do what you need to do to get that order. In the grand scheme of things, does it necessarily change outcomes? Not necessarily, but it's the appropriate way to do things. With these patients at some point, you're going to hit a wall. You can force the BiPAP, you can tube 'em, but at some point you'll have to keep cranking the pressure either way just to maintain reasonable gases. The next thing you know, you've got a spontaneous pneumo from a ruptured bleb, and the game is pretty much over. Yeah, you can try the ol' chest tube bit, but really by that point, you're flogging a dying horse.

    COPD is evil.
  13. Visit  Simply Complicated profile page
    0
    [quote=SaltyNurse;4415985]The dec. in LOC has more to do with the fact that he was on the nonrebreather mask than that his level of oxygen was too high. Even if he was on a O2 mask with vents, with the severity of air-trapping that you get with end stage COPD, the only thing that would have helped prevent that would be if he stayed on the BiPAP. And even In the grand scheme of things, does it necessarily change outcomes? Not necessarily, but it's the appropriate way to do things. With these patients at some point, you're going to hit a wall. You can force the BiPAP, you can tube 'em, but at some point you'll have to keep cranking the pressure either way just to maintain reasonable gases. The next thing you know, you've got a spontaneous pneumo from a ruptured bleb, and the game is pretty much over. Yeah, you can try the ol' chest tube bit, but really by that point, you're flogging a dying horse.





    Thank you, this was very helpful! My problem was, he didn't actually have any neuro changes for me. During my 12 hour shift, he stayed pretty much the same. Which I guess I got so focused on that, I didn't see the bigger picture. Their was a lot of issues with the family, which I'm sure you know can detract with patient care. I was also focused on the cardiac issues, the drips he had going, etc. Which is why I say at the time, I thought I was doing things right. But I should have listened to the family a little closer, when they were telling me his neuro status, changed or not was not his norm. But they were throwing so many things at me, plus I'm still learning the ICU setting...

    In hindsight, I can definetely see the whole picture. I learned that it can be easy to get tunnel vision as well!
  14. Visit  LouisVRN profile page
    0
    Having never worked ICU I can't give you much advice on the patient care aspect. However I have learned to ALWAYS listen to families, they can detect subtle changes in their loved one long before I might suspect something being amiss. We also have a number patients/families can call (basically a patient/family driven CRT) if they don't feel their concerns are being addressed. While I work nights, I can honestly say, I've never heard it use whether this is because families are not sure it is available is something to consider.
  15. Visit  Simply Complicated profile page
    0
    Quote from LouisVRN
    Having never worked ICU I can't give you much advice on the patient care aspect. However I have learned to ALWAYS listen to families, they can detect subtle changes in their loved one long before I might suspect something being amiss. We also have a number patients/families can call (basically a patient/family driven CRT) if they don't feel their concerns are being addressed. While I work nights, I can honestly say, I've never heard it use whether this is because families are not sure it is available is something to consider.

    I do try to listen to families. I have in the past caught problems because of listening to family concerns. This has taught me though, that even when the families are being a pain in the butt, to try and overlook it and listen closely.

    This particular family was very demanding, questioning every little detail. I had 4 phone calls in a 15 minute period by different family members. I had asked them to designate one person, to no avail. One of the daughters is a nurse in this healthcare system, although at a different hospital. Although it was only 1 daughter there throughout the day, she was calling the RN with every little thing. For the most part the family concerns were not really addressed until 15 minutes before my shift change, as their was only 1 family member there from 8am. Although I will admit I was getting frusturated with their family dynamics and probably let that affect me more than it should have

    They burned out every nurse who cared for this patient. They refused to let any nurse care for him who hadn't been in the ICU for 5 years or more. Most of the nurses were refusing to take him again because the family ran them so ragged. When he passed, it was a whole nother ordeal. Security almost had to be called.

    This experience has definetily taught me how to handle the family dynamics better. It is different when in ICU. I fell sorta like I went from big fish in a little pond, to little fish in a big pond. It's hard when you feel like you loose that steady footing. On M/S I was great. I feel so unsure of myself at times in ICU. But that is all a learning process!!

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