First Rapid Response

xtxrn, ASN, RN · Oct 11, 2011

Sometimes things just have to play out because there isn't anything concrete to "fix"... doctors like to 'fix' things....nurses (well, hate to generalize-but for discussion, I'm going to go out on a limb) like to 'take care' of things....

:)

katielam616 · Oct 11, 2011

it was all very stressful. but i feel like i advocated for her as my pt and went with my instincts. i know everything will come with time.

xtxrn, ASN, RN · Oct 11, 2011

Sounds like you did fine :up:

katielam616 · Oct 11, 2011

itll get easier right?

xtxrn, ASN, RN · Oct 11, 2011

Yep... but there are always patients that throw a wrench into things, and don't follow the 'book" description of problems. That's when the "gut" reaction kicks in.... It's never easy to see a patient get worse- but if you can get them to the next level of care as well as possible, sometimes that's a really good day :)

LouisVRN, RN · Oct 11, 2011

Does it get easier yes and no. Depending on your doctor trying to explain how your gut is telling you something is wrong without proof is always diffciult but getting to trust your gut becomes a lot easier

MomRN0913 · Oct 11, 2011

OK, I think you did everything right, went with your gut, and you should be proud. I think I was really really nervous on my first RRT.

But I read the first few sentences and said "Pneumo, where's the chest x-ray"

I'm not saying you should have sad this.....I've been in the field for almost 6 years and in ICU....

But how did a doctor not say this much earlier when she was SOB?

07302003, ASN, RN · Oct 11, 2011

Congratulations! As a new nurse, it's SO important to be able to trust your gut - when you get the "oh no, he/she is going south" feeling again you can act on it more confidently. You should be really proud, USE that intuition. It's the part of assessment that starts at the door, looking at the patient.

Two tidbits to keep in mind the next time you get that feeling:

1) Mental status changes and craziness like you saw are often a sign of respiratory distress, they could be retaining CO2, they could be working too hard to breathe, they could be compensating because of the extra O2 you're giving them... only the ABG and chest x-ray will give a clear-er picture of what's up.

2) If a patient has higher O2 needs over a shift and ends up on a non-rebreather mask it is generally a BAD thing... I like to think of it as the last step before ICU and intubation (unless they are hospice, or DNI). Keep a close eye on those patients....

3) If a patient is going south, it always helps to grab a nurse whose advice you trust, look at the patient with him / her, and brainstorm what may be going on and how worried you should be. It will help focus your communication with the doctor. Experienced nurses do this too!

Congratulations again!

katielam616 · Oct 11, 2011

the doctor originally thought that the reason she was not responding as well was because of the xanax and morphine seeing as she did improve with the non rebreather. in all fairness to him she did look ok with the numbers but i thought she looked bad otherwise since i had seen her earlier in the day i knew it wasnt normal.

the second time i called him i asked if he wanted a portable chest and he became irritated with me lol. the other nurses i was working with were surprised he didnt order anything. they said if it had been any other doc she would have been placed on the unit the FIRST time. it took another doctor for them to place her.

Esme12, ASN, BSN, RN · Oct 11, 2011

it'll get easier right?

:hug:yes it does.....

i agree with 07302003......whenever there is an increased need for supplemental o2 to remain at baseline accompanied with increasing confusion and agitation is an ominous sign. the valuable lesson learned here is that little voice inside your head saying....."i don't feel good about this" that sense that some thing's terribly wrong is usually right and i always figured i'd rather over react than regret i did nothing.

shame on that doctor who acted badly. although i have always felt they start snapping when they realize they've missed the mark on something... :lol2: . sob in the presence of chest trauma with increasing anxiety that leads to confusion screams hemo or pneumothorax with or without flail chest....the fool. :cool:

while many chest injuries will require no specific therapy, they may be indicators of more significant underlying trauma. multiple rib fractures will often be associated with an underlying pulmonary contusion, which may not be immediately apparent on an initial chest x-ray.

fractures of the lower ribs may be associated with diaphragmatic tears and spleen or liver injuries. injuries to upper ribs are less commonly associated with injuries to adjacent great vessels. this is especially true of a first rib fracture, which requires a significant amount of force to break and indicates a major energy transfer.

a fracture of the first rib should prompt a careful search for other injuries. note also that the rib cage and sternum provide a significant amount of stability to the thoracic spine. severe disruption of this 'fourth column' may convert what would otherwise be a stable thoracic spine fracture into an unstable one.

flail chest

a flail chest occurs when a segment of the thoracic cage is separated from the rest of the chest wall. this is usually defined as at least two fractures per rib (producing a free segment), in at least two ribs. a segment of the chest wall that is flail is unable to contribute to lung expansion. large flail segments will involve a much greater proportion of the chest wall and may extend bilaterally or involve the sternum. in these cases the disruption of normal pulmonary mechanics may be large enough to require mechanical ventilation.

http://www.trauma.org/archive/thoracic/chestflail.html

in your clinical assessment in respiratory distress i would include observation of the chest expansion, is it equal?, and whether or not it is equal as well as auscultating the breath sounds. is there any crepitus signifying an air leak......

subcutaneous emphysema, sometimes abbreviated sce or se and also called tissue emphysema, or sub q air, occurs when gas or air is present in the subcutaneous layer of the skin. subcutaneous refers to the tissue beneath the cutis of the skin, and emphysema refers to trapped air. since the air generally comes from the ches cavity, subcutaneous emphysema usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along the fascia. subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching rice krispies; this sensation of air under the skin is known as subcutaneous crepitation.

chest trauma, a major cause of subcutaneous emphysema, can cause air to enter the skin of the chest wall from the neck or lung. when the pleural membranes are punctured, as occurs in penetrating trauma of the chest, air may travel from the lung to the muscles and subcutaneous tissue of the chest wall. when the alveoli of the lung are ruptured, as occurs in pulmonary laceration, air may travel beneath the visceral pleura (the membrane lining the lung), to the hilum of the lung, up to the trachea, to the neck and then to the chest wall. the condition may also occur when a fractured rib punctures a lung; in fact, 27% of patients who have rib fractures also have subcutaneous emphysema. rib fractures may tear the parietal pleura, the membrane lining the inside of chest wall, allowing air to escape into the subcutaneous tissues.

subcutaneous emphysema is a frequently found in pneumothorax (air outside of the lung in the chest cavity) and may also result from air in the mediastinum, pneumopericardium (air in the pericardial cavity around the heart). a tension pneumothorax, in which air builds up in the pleural cavity and exerts pressure on the organs within the chest, makes it more likely that air will enter the subcutaneous tissues through pleura torn by a broken rib. when subcutaneous emphysema results from pneumothorax, air may enter tissues including those of the face, neck, chest, armpits, or abdomen.

http://en.wikipedia.org/wiki/subcutaneous_emphysema (again not a wikipedia fan but a great explanation)

now remember that "something's wrong" feeling at use it to your advantage. it does get easier....:redpinkhe

well done!!!!! :yeah:

DookieMeisterRN · Oct 11, 2011

You did just fine! There is no 'right' way to handle a rapid response especially you're 1st one. You saw a dramatic change in condition and followed protocol but most importantly you stayed with your pt.

Sorry that doctor was a jackwagon to you but you can't control when you're pts decide to crash, he'll get over it.

RRT: the T stands for "team".