I feel so dumb... I got flustered - about a patient in respiratory distress

sserrn, BSN · Sep 17, 2012

Well, if she was satting fine and her airway was patent, I'd probably just teach pursed-lip breathing and try to calm her down. (I've never done it, but breathing in and out of a paper bag does work as well, I hear.)

if her sats were crap and or she was truly in respiratory distress, you could try a nonrebreather.

brainkandy87 · Sep 17, 2012

You page the MD and get your co-workers to help you. I don't care what they are doing. If someone is circling the drain, you go grab someone. If they feel inconvenienced, too bad. That patient's life is priority. I doubt they were all doing something more important than that. Never, EVER feel bad about pulling other nurses in to help when you've got a critical patient that's going down. You're absolutely right, you don't want people dying on your watch.

First of all, my priority would be getting a second line in her, an 18g at the very least. 22g angiocaths are for babies. I've never seen an adult that couldn't get at least a 20g somewhere in their body. You go for an EJ or use ultrasound to find a vein (this is why all ER nurses should be trained to use US). If nothing else, throw a 20g in their foot until a central line can be placed by the MD. When that pt crashes and all you have is a 22g, you're going to have one gigantic mess.

In your situation, I would've called RT to assess (and draw an ABG if not already done) and worked on getting a large bore IV in her while you had another nurse find the MD to come assess.

Probably, BSN · Sep 17, 2012

Does the E.D. have a dedicated respiratory therapists (RT)? They are an awesome resource. Get to know them and use them. If you don't like the RT that's on now, call someone else.

You wrote that her H & H were "in the toilet." I would have drawn a rainbow: a blue, lavender, gold, mint green, and a pink top. No order. Stick the tube(s) in your pocket and get an order. Was an ABG done? Are you all allowed to do arterial sticks? The RNs were responsible for arterial sticks at my former hospital. That said, if a person came up w/ peripheral IVs only, and we were having difficulty obtaining blood samples. We would stuck them "arterially" and obtained blood samples.

Also assessment, assessment, assessment! Skin color, lung sounds, heart rate, rhythm analysis, skin warm or dry, voiding or not, cap. refill, etc. With a strong assessment, the previous RN could have made a stronger case to the MD about this patient. Reads like she needed an MD sooner rather than later. I realize that you all perform focused assessments rather than head to toe, as we do in the ICU. However, when giving an MD pertinent info., they are more likely to see the pt. Even if that means dropping what they are doing at the time.

Respiratory patients: always obtain a baseline ABG, assess lung sounds, CXR, and notify RT of your pt. in respiratory distress. I know that BiPap is initiated in the E.D. After appropriate interventions and depending upon the situation. BiPap can prevent intubation in some situations.

DeLana_RN, BSN, RN · Sep 17, 2012

Do you have standing orders for MS? If not, get an order. Ativan works great as well (and helps with the anxiety that's making the respiratory distress worse). And have to agree with pp, get help if you need it! 4 months in a new area nurse is a very short time.

Best of luck, you will be more confident next time.

NightNurse876 · Sep 17, 2012

First is airway... then breathing... ventimask? non rebreather?.... no change...no hep. Document ()send labs this whole time.

bankssarn · Sep 17, 2012

I had a similar experience a couple of weeks ago. My patient was complaining of SOB. Since the day shift nurse had weaned her O2 to 2L, I bumped her back up to 4L. When that didn't make a difference, I applied the Venti-mask at 50%. She was still satting in the low 80's, so I applied a non-rebreather. Even then, her Sats were 83; she was anxious, tachycardic and diaphoretic. I immediatly paged the attending physician. Within a few minutes, the room was swarming with people. A CXR was done to r/o fluid overload (her lung sounds were wet), an ABG was drawn, a stat 12-lead was done, doc ordered IV Dig and a Bipap. Within minutes of starting the Bipap, she gave me the thumbs up. Her HR stabilized and her anxiety decreased drastically. We have awesome teamwork on my unit. Does your facility have the option to call a Rapid Response? Where I work, we can call a RR if a patient is declining, yet they're not yet at Code Blue status. A RR will get you a doc, ICU nurse and a RT. It's a wonderful intervention.

Dixielee, BSN, RN · Sep 17, 2012

You said she was profusing, but she was barely maintaining her sats with no activity, and you said her H&H was low, so regardless of what her vital signs say, she was just barely hanging on! You didn't give much medical hx, i.e. age, COPD, etc. I would have probably taken her from NC straight to 100% non rebreather. She was anxious because she was hypoxic. ABG's would have been a priority, also another line as large as you can get, preferable a central line.

Bipap would have been a fairly rapid next step. Did she sound wet? She may also need diuretic since you are going to be hanging several units of blood.

When you have a patient who is that sick, don't hesitate to ask for help. Get the doc in there, that is their job! At very least, go tell the doc what is going on.

I fortunately work in an ED where nurses have a lot of autonomy, we have 24/7 board certified ED docs, RT, etc. Everything I suggested would have already been implemented even if the doc was not in the room.

If your ED does not have protocols in place for basic life support orders, then do what you can to make that happen, or you are going to find yourself in this situation again.

Best of luck.

emtb2rn, BSN, RN, EMT-B · Sep 17, 2012

Bipap. Much better than tubing.

Murse901, MSN, RN · Sep 17, 2012

Page respiratory and get some help in there. You're in an ED full of people that should be able to assist you before your patient goes bad. Sounds like this patient may benefit from CPAP/BiPAP. Also, do you have any other resources for getting a line in? Sounds like she may have been very dehydrated on top of her other issues. If you were able to get orders to push fluids through that crappy 22G (depending on whether or not she's a CHF'er), you could rehydrate her and have better luck getting a larger line in. Maybe if you had an ultrasound available, you could get a line in that way. Or ask the MD to do an EJ.

The bottom line is - don't be scared to ask for help. That was my biggest downfall when I first started working in the ER, thinking that I had to do it all by myself. Ask for help early and often with those bad patients, and return the favor by being proactive and asking others if they need help with their bad folks.

We're in this all together to get a good outcome.

dirtyhippiegirl, BSN, RN · Sep 17, 2012

If nothing else, throw a 20g in their foot until a central line can be placed by the MD. When that pt crashes and all you have is a 22g, you're going to have one gigantic mess.

Feh! I know this is totally off-topic but, I work in burn and we do a lot of foot sticks/IVs. "Throwing" a 20g in a foot can be about as easy as throwing a 20g in a AC. When you really need it, it ain't there. Why not just do an IO instead?

Anna Flaxis, BSN, RN · Sep 17, 2012

My question is: If a patient is in respiratory distress, what do I do especially if the MD is nowhere to be found and my RN co-workers are busy with their patients? I’m new and I don’t want people to die on my watch.
Thankfully for this patient, she got an ICU room before her breathing got too bad. She was also perfusing fine and her O2 sats were reasonable if she wasn’t doing anything. I’m just scared for when I get a patient who is in respiratory failure and I have nobody to turn to. PLEASE HELP ME!!

You needed a doctor, an RT, and another nurse or a tech in the room with you. That you were alone with this critically ill patient who needed interventions beyond your scope of practice and level of training and experience is really at the crux of the matter.

Remember, airway, breathing, and circulation in that order. She had a patent airway, but was not ventilating (breathing) effectively because of the lack of red blood cells (circulation). Your priority interventions are to put her on NRB and get that blood transfusion going *yesterday*!

Do you guys have lab techs/phlebotomy services? If so, get a lab tech in there to get your type and cross. If not, get a tech or another nurse in there to help you get the sample and get it to the blood bank as quickly as possible. If you can get the sample with an IV start, great, but you've already got a patent IV, so hang a liter and keep that line open! Use what you've got! Getting some more fluid in her might help find a vein for better peripheral access, and it will help if the doctor decides to place a central line. Warm her up with some blankets to help those veins pop up. Gather your supplies for the blood transfusion; blood tubing, a pump, a mini bag of saline, any consent forms you need, so that you can start the transfusion the moment the blood is ready.

While you're doing these things, continue to monitor for s/s of deterioration and be ready for RSI.

Edited to add: Sats in the mid 90s on 4L NC, HOB at 90 degrees, anxiety and feeling of dyspnea, does not paint a picture of someone who is perfusing just fine! Do not be afraid to put the NRB on someone like this. If she is a retainer, you can fix that later. She needs more O2 now. It's no different from someone with a cardiac history who is in septic shock. You will still aggressively fluid resuscitate, and worry about fluid overload later.