first incident report

[law3576]

I had to write my first incident report yesterday and I'm pretty upset about it. Please let me know if I was in the wrong.

My pt. was transferred to my floor from the ICU. ( oncology/med) floor. SHe was on 8 liters of 02 and was satting at 84%. During the day she was on 8 l and satting at 96%. She was on a high flow nasal cannula and I bumped up the 02 to 11 Liters. she then was satting at 92%. The doc came in the morning and saw that she was on 11Liters and was upset and wrote an order that an incident report needed to be filled out. I was the RN so of course I had to fill it out. Meanwhile this was at 0900. I had already worked my 12 hour night shift. I don't understand this. Where is nursing judgement? There was a respiratory therapist on the floor and I asked her to go and look and make sure everthing was okay and she said it was..

I am really upset by having to do this. I graudated in June so Im still very very new with my career. Anyone have any suggestions? Also on his orders was an order to do a chest x ray and also ABG' levels be drawn. She was in the ICU earlier for respiratory arrest. no history of COPD either. That is all there is to the story..does this make sense to anyone?

[Medic2RN, BSN, RN, EMT-P]

11 liters is too high of a setting for a nasal cannula! I'm surprised the RT didn't correct it.

[law3576]

it was a high flow nasal cannula. not a regular one.

[RoyalNurse]

It sounds like the doc was upset that he wasn't called about the decrease in O2 sat on a higher level of O2, especially because the patient just came back from ICU for respiratory arrest. Is that what you were asking?

Why was her sat going down?

Something I learned: Respiratory therapists have an invaluable job, but they don't replace a nurse. If you ask a therapist to go in the room and make sure everything's ok, they will look at the O2 device, settings, connections, and how the patient is saturating/breathing on the current O2 therapy. Very few will assess the patient for potential complications (increasing crackles, or a patient needing more O2 after an ICU admission), and I've only had one tell me I needed to call a doctor (patient's ETT cuff was above his larynx).

[PICURN74, ASN, RN]

I am a little confused too, I am hoping that not knowing there was a change in the patients condition was what upset the doc. I have never seen a MD order an IR, at my facility IRs are not punitive but a chance to prevent future incidents, also we don't mention them in pt's chart but that is between you and your legal department. I have seen pts on HFNC on more than 11L flow but it is a pretty significant requirment and with the hx of resp failure I would have been a little concerned they were going to need to be intubated. Our RTs are amazing and are often my first call when my kid looks funny but I find you have to be specific in what you ask, for instance I specify my kid is changing tell me what you think about them versus can you check my equipment (sometimes I ask them both in the same shift)

[lashawn04]

I agree w/ the previous post. I'm a new grad too, graduated in July, and we was told never to mention incident report in the patient's chart. Since the doc wrote that order, it will be a part of the patient's medical record. After seeing that order I (personally) would have sought the advice of my charge nurse to see specifically what the doc wanted in regards to that IR order. Don't feel bad about filling one out, I just had to fill one out too.

[Spatialized]

Why the doc wanted a incident report is beyond me. But when a patient is satting 80% or so on 8L I start looking to see what else is going on and trying to manage that. There has to be a reason that their sats are that low. A chest Xray and an ABG would have been a good idea when you had to bump the o2 up and she was still only satting 92%.

More importantly though, how did the patient look? Numbers are great, but was the patient in distress? Using accessory muscles to breathe? Tachypneic? Cyanotic? Altered mental status? Sometimes we get so fixated on the numbers that we forget to look at the patient. I'm not saying to ignore the number by all means, but it should be part of your assessment of the patient. Not the whole thing.

I use RTs all the time. Usually I will say, "Hey, somethings going on, I'm out of ideas, can you take a look at this patient and maybe recommend something?"

You did fine. You saw the issue and corrected as able. The doc was just trying to assert themselves. My only advice would have been to try to figure out why the sats were so low.

Tom