Can there be labored resparations (not agonal) with a pulse??

Been there,done that, ASN, RN · Nov 2, 2016

You would not start CPR on a patient with an effective pulse and effective respirations.What was the complete set of vital signs? I see a pulse of 60, what was the bp, what was the respiratory rate and pulse ox?

You should have the necessary equipment available, and applied a cardiac monitor and continuous pulse oximetry. Pretty sure you have an AED .. use it.

Cowboyardee · Nov 2, 2016

I don't mean any offense by this, but I'm a little confused by your post. I would expect an RN to know whether a patient could have a pulse and labored breathing at the same time, and (just being honest) I was a little suspicious that this might be a post by a patient's family member posing as an RN. I think I believe you enough to post a response, but I suggest you retake a BLS course along with perhaps speaking with an educator about dealing with deteriorating patients. Again, I mean no offense - it's just that the nature of the question is a little alarming if I'm understanding you correctly.

It is certainly possible for a patient to have a pulse with labored breathing. Breathing uses muscles; muscles are supplied with blood; the heart must beat to provide blood. If the patient was pulseless, I would expect the breathing to stop in short order.

You didn't say what caused the paramedics to initiate CPR, and I suspect not knowing is really your big problem here. Either the patient was no longer breathing effectively (agonal doesn't count), or no longer had a pulse, with or without a fatal heart rhythm on the monitor.

You have to recognize when you see a patient with ominous acute changes that the situation can decline rapidly. You already noted labored breathing and unarousable mental status - both bad signs. You should also have checked vital signs and assessed for signs of poor perfusion. If the patient was pale, clammy, diaphoretic, hypoxic, and/or severely hypotensive, those are further ominous signs. Given the situation, it is likely that the patient lost his pulse between the time when you checked it and when the paramedics checked it. The question is what were you doing in the meanwhile? If you're getting enough bad signs, you should really get the AED and have a CPR team assembled and ready to go and a nurse continually checking the patient's pulse until help arrives.

SmilingBluEyes · Nov 2, 2016

That you even ask this question, worries me; I am being earnest, not facetious. Seems to me, this stuff was covered in nursing school and for sure, in BLS-----yea, I am sure it was.

Good luck.

1CAnursepain · Nov 3, 2016

Thank you for commenting Been there done that,

A manual bp was attempted but the cuffs were not functioning. the respitory rate was 24 and the pulse ox read 82 so O2 was applied. while attempting to get further vital signs the parametics arrived. there was no cardiac monitor on the "crash cart" due to this being a Long term care facilty, so there was suction and O2. If there was an AED in the facility it was not obtained.

Been there,done that, ASN, RN · Nov 3, 2016

Thank you for commenting Been there done that,
A manual bp was attempted but the cuffs were not functioning. the respitory rate was 24 and the pulse ox read 82 so O2 was applied. while attempting to get further vital signs the parametics arrived. there was no cardiac monitor on the "crash cart" due to this being a Long term care facilty, so there was suction and O2. If there was an AED in the facility it was not obtained.

You're welcome.You were initiallly responding correctly,however were the cuffs not funtioning,or was her BP too low to register?

You need to know where all of your equipment is, how to use it and make sure it is functioning.

This scenario will happen again, be ready.

1CAnursepain · Nov 3, 2016

Thank you Cowboyardee for responding, I am an RN, (I have been for 17 years) This is not my first code by far. I'm sorry that I wasn't clear in my post. I feel that her heart stopped beating when the parametics attached the monitor to the patient. I understood that this was a deteriorating situation, which is why 911 was called. There were signs of perfusion, there was no cyonosis present in either the lips or the fingernails, the patient was slightly diaphoretic, not clammy her O2 was 82 so oxygen was applied.

1CAnursepain · Nov 3, 2016

You're right Beenthere,donethat. This was my 3rd day at this facility (i am a registry nurse) and usually I do check all the emergency equipment, but hadn't done it at this facility yet. Looking back her Bp might have been to low to register. I am of course going over each moment in my mind to see if there was anything I could have done differently or sooner to change the outcome.

1CAnursepain · Nov 3, 2016

Thank you for responding SmilingBluEyes. Yes, this was covered in Nursing school. I am asking because I am questioning my actions minute by minute to find out if my actions could have been done sooner or differently in order to see if the outcome could have been better. I was looking for support and confirmation from my fellow nursing professionals.

Cowboyardee · Nov 3, 2016

Thank you Cowboyardee for responding, I am an RN, (I have been for 17 years) This is not my first code by far. I'm sorry that I wasn't clear in my post. I feel that her heart stopped beating when the parametics attached the monitor to the patient. I understood that this was a deteriorating situation, which is why 911 was called. There were signs of perfusion, there was no cyonosis present in either the lips or the fingernails, the patient was slightly diaphoretic, not clammy her O2 was 82 so oxygen was applied.

Once again, I'm not trying to brow beat you here. You had a patient who was very sick, identified as sick, and coded - these things happen and are not always preventable. As to whether there was anything you could have done better, understood more fully, or recognized earlier - there may be a few things.

1) As noted above, a blood pressure cuff that inflates, dials up, and doesn't inappropriately lose air is working. If you don't hear a beat while auscultating or see spikes in the needle while deflating, that's often a sign of very low blood pressure. Do you know how to palpate a blood pressure using a cuff? You can feel a pulse while inflating a cuff, note the pressure where the pulse drops off as you pass it, and then note where it starts again on the way back down - that spot is the systolic pressure (when reported, a palpated blood pressure is often listed as, say, '60 over palp' - that is, a systolic of 60, with diastolic pressure undetermined). This is often useful for when someone's blood pressure is too low to effectively auscultate. If a doppler is handy, you can also sometimes assess a low blood pressure using that.

2) I believe just about any LTC has an AED. I think the regulations for LTCs vary by state, but I have a hard time believing that ANY state doesn't regulate that a nursing facility keep and maintain an AED. Familiarize yourself with it, check its battery status, and know where it is.

3) There's no real way of knowing exactly when your patient lost his pulse if no one was continuously checking. Closely watching respirations can give you some clue - but really all you know for sure is that the patient had a pulse when you checked him and didn't when the paramedic checked. It's possible that an AED would have helped you identify more quickly exactly when CPR needed to be started, but if the patient was in a PEA rhythm, even the AED would not have identified that. Given the respiratory distress, it is somewhat likely that the patient became bradycardic before losing his pulse, but I'm merely taking an educated guess here, because in truth we don't know the cause of the patient's distress or if hypoxia was the main driver of the patient's code. The big thing is to identify those situations where a patient is in serious trouble (you did, here) and then continuously monitor them using your resources in the best way possible until the cavalry arrives (you didn't quite). The only sure way to know would have been to repeatedly or continually check for a pulse.

4) Again, with no offense intended, a part of my concern here is just that you don't quite seem to understand what kind of things happen when a patient's condition is declining rapidly. Being unfamiliar with blood pressure difficulties in crashing patients, not knowing whether a patient could be breathing and pulseless at the same time, not identifying the need for an AED - those kinds of things suggest that you might benefit from more intensive education than we're able to provide on a web forum. I applaud you for seeking out a second opinion and advice in the first place. Maybe consider taking ACLS even if it's not required by your facility so that you can better learn what kind of things are happening when one of your patients crump.

Guest219794 · Nov 3, 2016

I am also confused by the question.

At 1200 you assessed the pt, who had experienced profound change of LOC and hypoxia. Given that you obtained a peripheral pulse, she had adequate cardiac output. You applied O2, but have not mentioned how she responded.

At 1205, paramedics arrived applied a monitor to the patient, then started CPR. The monitor is nearly irrelevant in this case. CPR does not depend on the monitor. If there is no pulse, CPR is started regardless of the monitor pattern. If there is a pulse, CPR is not started regardless of the monitor reading. Compressions are started when there is evidence of lack of perfusion.

While I do not understand why you are asking the question, I'll take a shot at answering it.

Do not do CPR on somebody with a palpable pulse.

If they have no signs of perfusion, start CPR. Breathing is a reasonable sign of perfusion.

If they are critical, monitor them. In your case, look at them.

Assuming the PT was breathing when EMS showed up, it is reasonable to assume they had adequate cardiac output, and CPR was not indicated.

I think I am not alone in understanding your question. It sounds like you are rattled because EMS questioned your actions. Since you didn't give much information on the PT condition in the 5 minutes between your assessment and EMS arrival, it's hard to know. FWIW- if they based their decision to initiate compressions based on the monitor reading, they were not doing their job.

Wuzzie · Nov 4, 2016

Did you mean to title your post "Can there be labored respirations (not agonal) WITHOUT a pulse??"

That seems to be more congruent with your subsequent posts.