Giving O2 without an order??

[strawberryfields]

Last night I had a patient sitting up in his bed at 0300 when I was checking up on everyone. At this time he is usually sleeping so I asked him if everything was okay and he said he couldn't breathe. I grabbed the pulse ox and it was at 75% he had no orders for oxygen but I went ahead and got him 2L of O2 NC. and raised the head of the bed. His oxygen went to 85% on 2L so I raised it to 3L and stayed by his side watching the pulse ox assessing his lung sounds, conciousness etc. It got to 95% and half an hour later I was able to move it to 2L and his oxygen stayed at 93% and he caught his breath and said he felt much better. I asked my supervisor and she told me to document everything and endorse to the AM nurse to call the Dr. in the morning.

I documented about 2L and moving to 3L all of the readings I got from the pulse ox and assessment of lungs and altertness/conciousness AND the fact that I am going to follow up with the dr. in the morning to get an order for PRN O2

My question is was it okay that I gave oxygen at 2L and then 3L when needed without a doctors orders? Is it okay that I documented that I gave oxygen and would follow up with the doctor to get an order? Because i made it clear I didn't have an order for this in my progress notes ... worried :| But I felt I did the right thing..

[Been there,done that, ASN, RN]

Treating the shortness of breath is one thing...

that falls within common sense and your facility's protocol.

The CAUSE of the desaturation needed to be addressed by a physician...who cares what time it was.

[Altra, BSN, RN]

I'll repeat what I have said before here at AN ...

If you are ever taking care of me, and find me in respiratory distress ... unless we all agree that it's my day to die please, PLEASE crank up that O2.

I completely agree with the above posters that after obtaining vital signs and applying O2 ... that was the time to call the physician, not hours later.

[Cat_RN, ASN, BSN, RN]

No, it was not ok that you documented giving o2 without an order, especially saying that the on-coming shift would 'get the order' for you. That is like shooting yourself in the foot! If you did not feel the pt's condition warranted a call to the MD, you at least should have written the order for PRN o2- and 'may titrate to 3L as needed to maintain sats'. Yes, the oxygen was the correct intervention initially, but none of that matters in the legal world if you don't have an order. I would have written one.

I probably also would have called the doctor too for CXR orders, labs, or whatever else they wanted, because obviously there is something going on with the pt. I don't care that it's late, nursing is 24/7. 75% is low for someone who usually sats normally. Pt condition changed on your shift, and as a dayshifter I would have been furious that the night shift gave to me a potentially unstable pt that had nothing done for him thus far. That would not fly in my facility. Why wait for patients to get worse, just so we don't have to 'wake up' doctors?

[Anna Flaxis, BSN, RN]

I agree with the others. This was a change in patient condition that should have been reported to the MD right away.

As far as giving O2 without an order, if it can be reasonably assumed that any prudent nurse would have done the same under those conditions, I think you're okay. But keep in mind that it could also be argued that any prudent nurse would have called the doctor!

As far as CO2 retention, if someone is in acute respiratory distress, I'm giving them the O2, at whatever flow rate they need. CO2 narcosis takes time to develop, longer than respiratory failure because you didn't give oxygen! Once stabilized on oxygen, if it is determined they are a retainer, the flow rate can be decreased to maintain a lower saturation, or if still experiencing increased work of breathing, they can be put on bipap.

I'm also wondering why the duoneb wasn't tried? This could certainly have been an episode of bronchospasm, which would only be helped by the duoneb. Did the patient have a history of asthma or COPD?

[strawberryfields]

Thanks everyone for your replies:) yes I did give the duoneb first the patient told me it was helping a little but his o2 was still 78-79 so I got the oxygen. I'm a new nurse so I am learning. What is awful is that where I work everyone seems like they are afraid to call the md ... I was ready and willing but they advised me not to call this late. We have a dr that gives us times you can call him and if you call him outside of that time frame he yells at you. You all are right and this is my license if he wants to yell at me so be it .. On call dr is no joke. One of the nurses I work with had a really high blood sugar reading and it said call the md and I was like are you going to call ? And he said, "why make my night more difficult ... When the dr is just going to tell me to tweak the insulin?" it was 410 and the order said 400+ call md. This is something I want to bring up to my facility in the next meeting.

[Esme12, ASN, BSN, RN]

You can be sued for liability and lose your license for not calling him. You just get yelled at for calling him. For 34 years I have chosen the get yelled at option every time. That's what they get paid for.

Do I care that they are disturbed? NO!

[strawberryfields]

Now you have me worried :/ sued for liability and lose my license even though we have an order now and the dr has seen him and he's fine?

[hiddencatRN, BSN, RN]

I really do not think the worry here should be that you gave oxygen. My concern reading this is that you have a patient who normally is sleeping well, find him sitting bolt upright in bed, and with a sat of 75%. Yes, you treated with Oxygen and the pt improved, but WHY did the patient have such a sudden change? Everywhere I have worked (And I admit, i have only worked in Hospitals, it sounds like you are in a long term care kind of place, since you know the pt fairly well) that would be an immediate call to the MD, not a follow up in the morning. I realize your supervisor told you to follow up in the morning, so in that sense you would not need to worry, but why on earth- with a very sudden change in Airway and respiration, would you not call that physician immediately.

Agreed. In many hospitals that would warrant a call to the rapid response team.

Now that the patient is stable with an o2 at 95% and responsive+ totally concious was there a need to call the doctor at 3 in the morning ... I didn't think so.

So the patient's ok NOW, but what if whatever caused the SOB reoccurs, but this time more acutely? The patient is STABILIZED, not stable, and finding out why there was an episode of SOB that woke the patient and required oxygen is not a "follow up later" situation.

Particularly in an area like rehabilitation, where folks can develop clots and emboli....SOB is not something to take lightly.

[Nascar nurse, ASN, RN]

Now you have me worried :/ sued for liability and lose my license even though we have an order now and the dr has seen him and he's fine?

Oh, take a deep breath. Can you get sued/lose your license - sure you could. Is it likely to happen based on this particular occurrence - highly unlikely.

The advice you have been given is very good. Just learn from it and move on from here. You just got an opportunity to become a better nurse because you asked a question and are receptive to the answers you have been given. (Some of the newbies have a horrible time accepting a mistake).

Best of luck to you

[cjcsoon2bnp, MSN, RN, NP]

I agree with the statements of the other users on this issue. Good job trying to keep the patient safe but the follow up with the MD needed to be immediately.

In this situation, I would have first completed my assessment of the patient (V/S, lung sounds and the whole bit) and because the pulse ox was that low I would have put the patient on O2 via NC immediately. In the mean time, I (or the RN supervisor) would have grabbed the PRN neb. treatment that is ordered and administered that to see how that affects the patient's dyspnea. I would page/call the MD as the neb. treatment is finishing for orders and further instructions. Once the MD and I have come up with a plan, I would then document what happened and how we plan to continue to monitor the patient.

What does everyone else think of that plan?

!Chris

[MN-Nurse, ASN, RN]

I worked at one of the crappiest of craptastic nursing homes and even they had standing orders for O2 PRN to keep sats >92%.

[Been there,done that, ASN, RN]

I worked at one of the crappiest of craptastic nursing homes and even they had standing orders for O2 PRN to keep sats >92%.

Craptastic! Thanks so much for the new description to apply to our wonderful field of nursing!

Crap on.. my friends.