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Discussion

what to do?

I had a pt(full code) who had a trach(had it for atleast 5yrs) he came into the hospital for one reason and they found out that he had a touch of pneumonia..also had long hx of copd..neway long story short he was very noncompliant with everything..refusing tests and treatments(md was aware of this behavior)..he had been in the hospital for 2 days then I had him for 3 nights straight..his o2 sat was in low to mid 80's when you would first put the sat monitor on him but with a few deep breaths it was in the low 90's..he refused oxygen/breathing tx. first night i had him i told the dr about this..and he pretty much wasnt concerned. The pt was alert/oriented etc..no real signs of distress..had did have some wheezing/and if he moved around alot..sob. I explained to the pt the benefit of o2 etc but he still refused..so apparently during the day he coded..and is in icu on a vent. I feel horrible like i should have done more..but I dont know what I could have done...I couldnt have forced the oxygen on the pt..he would have taken it off.The supervisor said I should have addressed his code status with the dr before this happened..but his condition had not changed from the first night I had him...(now if his condition declined rapidly in the middle of the night..of course I would have called the md)Im not going to call the dr at 4am and tell him this pt needs to be a DNR because I dont want to code this pt..I just feel bad that he coded on the day shift and I feel like a bad nurse..what should I have done...what would you have done?

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Since you tried to teach the patient about using O2 and since the patient had a hx of a chronic disease that required O2, essentially he was refusing treatment. There's nothing else you could've done, IMO. Although the next time you talk to a patient about O2 and they refuse, you could morph it into a code status discussion....

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Thanks for the reply/advice

Anyone with pneumonia and COPD, plus being bedridden can use an incentive spirometer, and teaching about air trapping. I paint a disgusting picture of all the crud and germs in a nice dark pungent spot, and the patient needs to get some fresh air and circulation moving around the infected area, or they can take antibiotics all they want, the crud will continue to multiply. Circulating abx to the infected area is what the patient does for themselves, we just get the antibiotics into his body.

You can't force the patient to do anything. You're not a bad nurse, so don't even think that. All you can do is instruct the patient as to why the certain intervention is necessary, explain (in gruesome detail sometimes) the consequences of not following the plan of care, and verify that the patient understands. If the patient still refuses, reiterate and document.

Some people will do their own thing regardless of the outcome. If I have done everything in my power to assist the person and they still refuse, then I do not feel bad when they actually suffer the consequences I forewarned. It was their decision and their gamble/risk!

I would have left a note for the MD saying "pt noncompliant w/ O2, sats low, please consider change in code status"

On my floor, we have "communication notebooks" where we leave these notes. The MD reads the notebook first thing in the am, and then they decide whether to write the requested orders.

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