Handled this situation wrong??

[givxnchy]

Hello everyone,

I was in clinicals this week and had an elderly patient with BPOC who came back from a hip surgery.

The thing is that the patient came back from his surgery terribly dysphagic. The evening I was there, his family gave him some yogourt and he choked on it. (like more than ever).

I was in the room, so I told him to spit everything he could and took his SpO2.

It was still in the normal ranges for him since he had BPOC (it was at 90 and we were targetting 88-92%) and his respiration was at 24/min but in the context I thought it was normal, I checked again 30min later and it was at 16/min, SpO2 still at 90.

When he was coughing, trying to spit the yogourt out he made a sound like he was gargling with the yogourt/secretions, trying to get it out.

When that was over I listened to his lungs and it sounded like a bad car engine, but I assumed it was normal since he had BPOC + he was recovering from a surgery + his SpO2 was in the normal ranges.

There was no other incident during the evening, but at midnight when I left I heard him doing the gargling noise again and it makes me wonder, should I have suctioned him?? (because they did at midnight)

I knew he had secretions from what I heard with my stethoscope, but his vitals were completely normal 30 min after he choked and he did not had any trouble breathing after that, but I am seriously wondering if what I did was appropriate or not enough?

[meanmaryjean, DNP, RN]

Peds nurse would like to know what BPOC is.

[CelticGoddess, BSN, RN]

Please don't fall into the trap that if someones O2 sats are good, they are fine. A person can present with normal O2 sats and be in some serious trouble.

I am also curious as to what BPOC stand for. (I am used to it being bedside point of care).

If he is having trouble swallowing, a speech consult might be in order. (It's policy where I work) It might be a one time thing but then again, it might be the start of swallow problems. And the last thing he needs is to develop an aspiration pna.

[givxnchy]

Yeah, a consult was already asked for this patient because his dysphagia was really serious. And the possibility of an aspiration pneumonia was brought up by the day shift. He was on antibiotics at the time of the events.

BPOC is actually how we call the chronic obstructive pulmonary disorder in my country. Naturally I didn't only took his sat and said okay everything's good, bye bye, but what made me think my patient was out of danger is that he had spit the spoon of yogourt that caused him to choke, he was not using any accessory muscles to breathe, his sat was okay, no cyanosis, respiratory rate a bit high but got down later and I heard secretions in his lungs but it's normal with an advanced case of chronic obstructive pulmonary disorder.

I was wondering what other thing I should have assessed at the moment? (I don't want to repeat the same mistake of course)

And the thing bothering me is that when I heard the gargle I thought it was my patient trying to spit the yogourt, because he only made that noise while coughing.

Im doing my clinical homework and I thought, what if this was secretions and I should have suctioned him at the moment? Even though he did not show any signs of embarassment until the time I walked past his room when I left.

Im trying to understand what I should have done differently

[TriciaJ, RN]

I might be off the mark but I wonder if yogurt was such a good idea for him. Dairy products can increase secretions.

[Libby1987]

I work home health so I would have sent him for CXR and treatment. He's already on abx so that is good but he obviously didn't clear his airways. I don't know that suctioning a conscious patient would be realistic other than oral suction. If I worked acute, I think I would have asked for RT.

One thing I wouldn't rely on in the home setting are WNL VS. That would have given me no reassurance that additional intervention wasn't needed. I see that a lot with our nurses, "Well, the VS were stable." Yeah but when you can see flames, the house is on fire, it doesn't matter that the smoke alarm isn't sounding.

[mmc51264, BSN, MSN, RN]

Peds nurse would like to know what BPOC is.

So would ortho nurse who gets a ton of geriatric hip pts with many cormorbidities. Sounds like pt aspirated.

[Chimio]

I work home health so I would have sent him for CXR and treatment. He's already on abx so that is good but he obviously didn't clear his airways. I don't know that suctioning a conscious patient would be realistic other than oral suction. If I worked acute, I think I would have asked for RT.

One thing I wouldn't rely on in the home setting are WNL VS. That would have given me no reassurance that additional intervention wasn't needed. I see that a lot with our nurses, "Well, the VS were stable." Yeah but when you can see flames, the house is on fire, it doesn't matter that the smoke alarm isn't sounding.

When you say RT is that for respiratory therapist? That would make a lot of sense. I think I'm going to review this situation with my clinical instructor tomorrow when I meet with her, to see as a student, all the interventions that I could have done beside of my assessment and immediate interventions.

[Libby1987]

When you say RT is that for respiratory therapist? That would make a lot of sense. I think I'm going to review this situation with my clinical instructor tomorrow when I meet with her, to see as a student, all the interventions that I could have done beside of my assessment and immediate interventions.

Yes, respiratory therapist.

Caveat, I don't know the obstacles to obtaining an RT consult in acute care, though I would know my way around them if I worked there.

[Chimio]

Yes, respiratory therapist.

Caveat, I don't know the obstacles to obtaining an RT consult in acute care, though I would know my way around them if I worked there.

There is always or two on call during the evening for all of the hospital for any kind of emergency.

[Cowboyardee]

You seem to be conflating a few things.

You should suction if the patient had audible secretions and is unable to clear them on his own, especially if the patient also has signs of dyspnea. When you hear the patient gurgling, ask him to cough. If he can't clear the secretions (weak cough, etc) but you can still hear them in or near the upper airway, suction away. If he has a strong cough and is able to bring up secretions, encourage him to do so. If the patient does not have continued audible secretions and no signs of acute dyspnea, it is still certainly possible that he might have aspirated, but you are unlikely to benefit from suctioning.

If you hear or see signs of dysphagia, the main thing you should do is make the patient NPO pending a swallow evaluation. Small amounts of aspirated food may cause pneumonia that will make the patient very sick in the long run, but it won't cause an immediate change to their vital signs or saturation. In this case, it was possible that the patient just needed more time to recover from anesthesia or being intubated before attempting to swallow, but withholding food upon signs of aspiration and calling a doctor would have been the correct steps to take.

[NurseGirl525, ASN, RN]

Did speech therapy clear him to eat yogurt? I'm confused as to who did his bedside swallow study? If you felt he needed one, why did you not report that?

Aspirational pneumonia is a huge thing. I'm thinking you are a student, but if you visibly saw your patient could not swallow, you should have taken the food away, reported it, and seen if a bedside swallow study was done.

More than anything, aspirational pneumonia should have been your biggest concern after determining they had an adequate airway.