I have a case study question, I need some advise

[huota]

Mrs Rossi is an 89-year old woman with end-stage COPD. She currently resides in a nursing home in a large metropolitan city. Her husband died many years ago, and her children live far away. She often sits forward in her wheelchair leaning over the bed tray because this is the position in which she can breathe most easily. Usually she wears oxygen, 2 L via nasal cannula.

One day you (student nurse) notice Mrs. Rossi lying flat on her back in bed. Her lips are blue and she says, "help... I'm suffocating... I feel like I can't get any air". You see the nasal cannula has slipped away from her nose and is dangling from the side of the bed. Based on her chart, Mrs. Rossi's drugs are albuterol/atrovent via nebulizer bid; morphine 2 mg every 6 hrs, prn, for pain; lorazepam 5 mg every 12 hr, prn, for anxiety. There is a nurse button in the room.

1. What interventions will you do as the nursing student and how will you prioritize them and why?

2. What information will you communicate to the nurse and physician caring for Mrs. Rossi?

My question is as a student nurse what should I do?

I know if I was a nurse I would put the nasal cannula back in her nose, lift the head of the bed up, give her medications as ordered from the physician.

But as a student nurse what should I do??

Thank you for any advise.

[RN403, BSN, RN]

Besides giving medications the interventions you stated would be correct. Not saying as a student you cannot give medications, however, in this critical situation the nurse might want to take a handle on things his or herself.

As a student nurse you can still place the nasal cannula back in her nose as that is where it should be anyway and you can lift the HOB. You could then hit the nurse call light after intervening to the best of your ability and stay with the patient until the nurse gets there. Once the nurse gets there you might be able to get a pulse oximeter and vital sign machine (dinamap) to further assist the nurse with monitoring the patient as interventions are performed.

The key thing as a student is to call for help and get the appropriate personnel (nurse, clinical instructor, etc) in the room to assist the patient.

[BecomingNursey]

I would personally, put HOB up, place nasal cannula back on pt., hit nurse call button, apply pulse oximetry and take a set of vitals while waiting for the primary nurse.

I'm not telling you it's going to be easy, I'm telling you it's going to be worth it.

Author: Art Williams

[MendedHeart]

You could also place her in the Tripod position as mentioned in the first segment of the scenario, especially with her advanced COPD. Have her breath in through the nose and out through pursed lips

[NurseGirl525, ASN, RN]

I would set her up first. Put her in the position where she can best breathe properly. Then, I would put the nasal cannula back in and take her vital signs. I wouldn't just put the HOB up, I would put her in the position of leaning over. That is how end stage COPD people breathe. I would try and calm her by having her do pursed lip breathing also. If that didn't help I would look at her meds and see what to administer. As a student you can't just administer meds but as the nurse I would.

[Jenngirl34RN]

You need to make sure you list getting vitals before administering meds, particularly the morphine. You would not want to administer that unless her respiration rate is at or very close to her baseline. If it were me I would replace her cannula, raise HOB and giver her something to lean over, call the nurse, get vitals, administer meds if/when it is safe to do so.

[rob4546, ADN, BSN, MSN]

We had a similar scenario in my final semester of nursing school and we discussed applying high flow O2 for the patient (4-6 LPM NC). Before people start exclaiming "you can't give high flow O2 to a COPD patient, they will stop breathing", I might suggest that this fact is a medium to long term exposure to high flow O2. In the short term, ten minutes or so, it is therapeutic. The patient is hypoxic and resolving this is of great importance. Of course the position change, calling for help, vitals is also important.

Just my 2 cents.

[Mavrick, BSN, RN]

As a nursing student:

+ Remain calm, (you are useless if you wig-out)

+ elevate HOB, (patient most likely has a ventilation problem)

+ pull overbed table into position to assist pt with optimal positioning, (tripod position elevates ribs to increase ventilation)

+ press call button to summon help, (you need assistance sooner rather than later)

+ reapply nasal cannula checking to make sure it is attached to wall O2 and O2 is turned on, (less concerned about hypoxia than hypercarbia)

+ stay with patient to reassure and encourage patient to take deep breaths in through nose and out through pursed lips,

+ remain calm.

When help arrives, patient's nurse will assess and administer medications as needed.

Call facilities to have that damn bed fixed to lock out patient control of HOB. She should never have been flat!