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..
