i feel so guilty..should i have done more?

nyteshade, BSN · Oct 22, 2009

Please don't be offended, but I get the feeling you don't understand why your pt was retaining O2...If you give a COPD pt more than 3 liters of O2, they will become unresponsive. Their respiratory system will shut down, because having too much CO2 is their stimulus to breathe, vs. a normal person whose stimulus to breathe is too little O2. So a COPDer will stop breathing with too much O2, b/c the body doesn't detect the need to breathe.

Yes, the pt will be tachy when they are SOB, anyone would be tachy if they couldn't breathe. It's anxiety. I know you work a cardiac floor, and do cardiac geared assessments, but you need to step outside of that and look at the whole picture of each pt.

Virgo_RN, BSN, RN · Oct 22, 2009

What would putting her on tele have accomplished? The problem was with her lungs.

BTW, do you mean she was retaining CO2?

I agree with the above. Sounds like she was pushed into respiratory acidosis.

SandBetweenMyToes, BSN, RN · Oct 22, 2009

Unfortunately, Nyteshade is correct. With COPD, you have to be very careful with the O2 because they rely on the higher CO2 to initiate a breath. You bring those sats up, and they stop breathing. This is basic nursing. Conversely, the MD shares some responsibility because you did in fact make him/her aware of the fact you were implementing a non-rebreather. Had he/she been on the ball, they would have asked more questions, and stopped you. Sorry...hopefully the patient is alright and you have learned a very valuable lesson.

ellakate · Oct 22, 2009

This lady was pretty sick when you got her. Telemetry would not have made it better. An onsite physician assessment would have helped. This is a very good point of nursing, because you will not know what could have happened. But we have all learned.

Gracias!

erin01 · Oct 22, 2009

WOW i now feel worse =( she looked so bad when i got her that i just wanted to help her breath!!!!!!!!!!! I even called respiratory and they came up and said she is not wheezing a tx would not help but i would keep her on the non rebreather. UGGggggggg!!!!!!!!!!! I feel horrible.........what did i do............................i want to quit!!!!!! I remember someone saying in nursing school about retaining o2 but i just looked at her struggling and just could not put it together. What kind of nurse am i???????? oh my god

Be_Moore · Oct 22, 2009

The more than 3L is not exactly true..I've taken care of COPD patients who are on continuous home O2 @ 4L who come in with a perfect gas. The amount of O2 they are on will vary per patient on how much CO2 they retain.

On the other hand, yeah she needed BiPAP if you were having trouble maintaining sats and your respiratory therapist should have realized that. You can't keep COPD patients on NRB masks. If they need NRB for more than a couple hours to catch up, they need BiPAP.

cloister · Oct 22, 2009

Stop flogging yourself. I don't think you did anything wrong here.

With respect to the previous posters, I have to disagree with them. Your patient was a COPD'er admitted with a sat of 84% on 5 liters per NC. Generally speaking, we try to keep these folks in the 88-92% sat range. I think you were correct in what you did to try to elevate her sats to a decent level (90%). Clearly, your patient was hypoxemic and in respiratory distress. Unfortunately, her COPD makes it a dicey thing to correct because of the CO2 narcosis these folks go into when you shove a mask on them.

I had a patient like that on a rapid response once. I nailed the diagnosis almost from the door, and sure enough, the CO2 on Bipap was 120. So, we took the bipap off and the patient woke up, and I'm thinking I'm pretty cool until the sats drop to approximately 75%. Back on with more O2, which was clearly indicated, and back to narco-land we go. End result? This guy had a nasty pneumonia that knocked out what little alveolar space he had, and we couldn't win. We called a code, tubed him, and brought him to ICU.

Sounds like your physician was behind the 8 ball here. You weren't getting results from the lasix, and he orders more. Not much you can do in these situations except keep calling the MD, stressing the respiratory distress of your patient, and having your intubation tray handy. I've had quite a few patients turn south and need intubation, all while the MD I was calling was insisting that the patient was fine and was not having respiratory issues. It frustrates the hell out of you, but hey, it happens. It still happens to me as a charge nurse in the SICU, and yeah, I usually feel bad afterwards, because I second guess myself and wonder what else I could have done. Frankly, it sounds like you did what you could as a nurse, and your physician wasn't as aggressive as he maybe should have been. Funny how these things seem to happen more in the middle of the night........

Again, stop flogging yourself and move on. The patient was alive when you left, and his getting worse is a function of his disease process, as opposed to a reflection of your nursing care. Don't quit! You'll have other moments like this, but it does get easier with time. Frankly, I think you did the best you could under the circumstances.

IHeartPeds87 · Oct 22, 2009

I am not a nurse (yet!) but this is my two cents on the topic.

Don't keep berating yourself. It was an accident. Feeling guilty is not a solution.

What is the solution? Vow to do better. Read up on why you made the error that you did.....refresh your knowledge on respiratory issues.

It is interesting to see this post. I am in A&P and actually have an exam on the respiratory system 2morrow. I was having a hard time understanding the whole hyper/hypo ventilation thing in regards to CO2 levels and ph. I was bored of studying and came on here to waste a little time. Funny how important these classes are, huh?

Just goes to show you...you can never know the material well enough.

nyteshade, BSN · Oct 22, 2009

You are NOT a bad nurse! I have responded to some of your previous posts, and see a trend. Have you looked into other specialties? Less acute? Maybe jumping into step down tele is too much. When I was a travel nurse, I made sure my contracts included no floating to tele. (I don't enjoy fast-enviroments, I work in MDS, so I'm not knocking you). Why not general med-surge, or even rehab? I love rehab...it's a bit more physically demanding, but (dare I say it?!) stable. It's a great opportunity to really see a pt recover as a whole. Just food for thought..

In regards to what the other posters said, my explaination was in a nut shell. Everyone is different. I thank them for pointing that out.

Medic/Nurse, BSN, RN · Oct 22, 2009

I think this may be an excellent teaching case. I have a few questions.

erin01 - the very fact that you are questioning yourself and reviewing the care provided, your actions and the doctors inaction - speaks volumes. First, STOP beating yourself up - I understand the guilt issue and I'll guarantee that most of the experienced folks on here have had patients that serve to teach us more than we could ever learn in school.

This is a tough one to admit. In the process of getting "good" at what I do - some of those entrusted to me have paid my "tuition" with their lives. This is not to say that I ever killed anyone - but, there have been things that I did not recognize, treat as aggressively or as quickly as perhaps someone else may have or even that I may have given different circumstances. Even "doing it by the book" does not guarantee a good outcome and some patient presentations are odd, subtle or determined to be a more obvious problem - all the while one "problem" masked another.

We get patients that are sicker and on more medications for more complex conditions than I ever dreamed possible and it is getting worse. Patients are demanding and families unreasonable. Anyone that has even gotten a critically ill patient and the patient be unable to talk or the ever helpful family detail "their history is in their chart - look it up" "they take a round blue pill, 2 small white ones that are football shaped, a yellowish capsule and red capsule and a brownish one with white letters" "their allergies are on file" and then offer that they are "soiled" and need to be changed "right now" when you left the bedside less than 15 minutes earlier - is frustrating. Often this frustration and difficulty is translated into a patient not getting the best of care due to a lack of info or focus.

* I may have made "mistakes" - but, I have never made the same one twice.

* The art of advocacy for your patients is a difficult (often seeming impossible with certain doc's) one. Learning just how far to go is tough. I think it is really hard for newer nurses in some environments (those without "leadership" or those with mobbing or hostility - and most all of us have some element in our workplaces that "restrict" our actions") to speak up about a patient due to being made fun of or being "wrong" and feared to be thought of as incompetent.

Regardless, I will try and help with the clinical explanation. No blame is gonna be here though - it is what it is. As long as you come away from this better than when you went into it - nothing that you did is to be carried as guilt or blame. The sum of all the patients we take care of is what makes great nurses. There is not a single nurse that starts out as a great one - but we all give our patients the best we have. And that makes us great one patient at a time.

?????'s

When you put the patient on the non-rebreather mask - what time did you do it? what was the flow rate of the oxygen? did you call respiratory or consult with your charge that you had a patient "looking bad"?

Did you document the contact with the MD? Did the lasix work? Admitted from the ER - was she given lasix, what did her labs look like/did they do ABG's in the ED? home meds with lasix?

I get the concerns about the tele - but, it is just a monitoring tool. AT first glance, I'd say this is a chronic COPD patients with poor reserves and it does not take too much to push these patients into respiratory failure. Even without doing ANYTHING this patient may have been tiring out from the increased work of breathing and be headed toward a vent or critical care respiratory interventions depending on what she had left. These patients care be really sick and decompensate quickly.

And the fabled "hypoxic drive" is real but, depriving a hypoxic patient oxygen in the short term just guarantees a hypoxic patient and all that goes with that. Sure, these patients live in a mildly hypoxic state and adapt - but the point is they have very little reserves. Difficult patients to manage in some cases - sounds like your patient was sick.

:angel:

HmarieD · Oct 22, 2009

Reminds me of a situation a loooong time ago... working on med-surg, had a lady in resp distress, RR in the 40's... I called the doc, got orders similar to what OP got... didn't help. I wanted this lady OFF my floor and in the ICU. Kept calling the doc (middle of the night of course) and at one point he ordered an Ativan. I don't know what possessed me, but I yelled at him "If you don't get real and get this lady to the unit every nurse on this floor is going to need an Ativan and this lady is going to be dead!"

Long pause... and then an order to transfer to ICU. She was on a vent within the hour. Doc approached me during early morn rounds, thought I was in for a big ole butt chewing, but he actually thanked me and told me I probably saved his patient AND his a**. Very satisfying.

Moral of the story - don't be afraid to push. Ever.