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

harrird · Sep 19, 2012

Excellent thread. OP some additional information would be useful in these situations. Pt Age, COPD, CHF, why was her crit down to begin with? Hemocult? It was stated that the patient already had antibiotics x2 I believe. Did she have cultures drawn first? Why wasn't a type and cross drawn at that time? I agree with others this lady definitely needs additional access. Do what you have to do to make that happen. Get some help! ABG's are also a priority in determining if she needs ETT placement or BiPAP. Kudos to you for having the drive to improve your skill set by asking for information here.

brainkandy87 · Sep 19, 2012

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?

I use the term "throwing" loosely. Absolutely if you don't see a vein you can access in a couple of attempts, it's IO time. I'm not implying you should stick and stick and stick. IO is definitely a viable option if you need an immediate line and don't have anything else that can be easily accessed.

whichone'spink, BSN, RN · Sep 19, 2012

I'm curious as to why her H&H was low to begin with. Does it have something to do with her COPD? Did she have a history of G.I. bleeding? I've taken care of patients with COPD who had crappy blood counts, but not so bad that they needed transfusions. So I'm just curious what her H&H was in the crapper.

wildlaurel · Sep 19, 2012

I agree with several of the other posts, call RT - get them to assess the patient. If the patient had a hx of COPD - you have to be careful about over oxygenating. Go to the EDP and say, "I'm really concerned about this patient and need you to come assess her again." A central line would have been called for if she was septic or had poor vascular access. I'm not so sure you could have gotten anything beyond a 22 in someone like that - she was probably vasoconstricted if her H&H was that low...so don't beat yourself up about that. Nursing - all nursing, but especially ED nursing - is a team sport! You're not a marathon runner out there by yourself. You could also call your charge nurse and tell them you need help. I've been an ED nurse for 4 years now and I sometimes still call someone more experienced than me and say, "I need a nurse who's been doing this longer than me." Ativan would have calmed the pt some - she was probably oxygen starved and that is a scary feeling.

dirtyhippiegirl, BSN, RN · Sep 19, 2012

No ac, no foot, I'd go EJ before drilling!

Eeeeeh. I can see a preference for an EJ over an IO if you need blood work done STAT and/or are expecting to need blood work done STAT and can't art stick for whatever reason. But at the end of the day, an EJ still takes more skill/luck/decent veins than an IO -- as a burn nurse, I'd pick an IO over an EJ because I'm worried about fluid resus, and quick.

/also, sometimes you get a RT that is just as newbish and scared as you are.

//or just dumb

///one good RT is as good as ten decent docs, 'tho

Anna Flaxis, BSN, RN · Sep 19, 2012

I'm curious as to why her H&H was low to begin with. Does it have something to do with her COPD? Did she have a history of G.I. bleeding? I've taken care of patients with COPD who had crappy blood counts but not so bad that they needed transfusions. So I'm just curious what her H&H was in the crapper.[/quote']
Typically, people with COPD will have an elevated crit. People with chronic kidney disease will have a decreased crit due to decreased erythropoeisis.
I wish the OP would come back and give us more info! The picture I see, based on the original post, is someone in early compensated hemorrhagic shock. The pnuemonia is a confounding factor, but the fact that the nebs were ineffective in reducing the patient's dyspnea and anxiety tells me that the symptoms were more related to the low H&H than an obstructive cause. I wonder if the doc did a rectal exam to check for occult blood?

Esme12, ASN, BSN, RN · Sep 19, 2012

Ej's are awesome :)
No ac, no foot, I'd go EJ before drilling!

I am not sure that lying this anxious patient down, at this point, would be the most prudent action. Many facilities do not allow RN's to do EJ IV's.

sakura07 · Sep 19, 2012

-Activate code blue if pt express trouble breathing and loss of conscious

-Follows Airway Breathing Circulation

-Put patient HOB upright; instructs slow deep breath; since she has 2L NC you could bump it up to 6L. Your help would arrive soon with RT member.

TheSquire, DNP, APRN, NP · Sep 19, 2012

-Activate code blue if pt express trouble breathing and loss of conscious

As stated earlier in the thread, Rapid Response and Code Blue tends not to exist in the ED, which is a (usually) self-sufficient critical care unit. You just stick your head out of the room and yell for help.

Guest343211 · Sep 19, 2012

Typically, people with COPD will have an elevated crit. People with chronic kidney disease will have a decreased crit due to decreased erythropoeisis.
I wish the OP would come back and give us more info! The picture I see, based on the original post, is someone in early compensated hemorrhagic shock. The pnuemonia is a confounding factor, but the fact that the nebs were ineffective in reducing the patient's dyspnea and anxiety tells me that the symptoms were more related to the low H&H than an obstructive cause. I wonder if the doc did a rectal exam to check for occult blood?

We need more information. The nebs may or may not help, based on what the agent was that was given in the nebs--but it seems like less of a "zebra" if you will, that she had a V/Q mismatch due to her pneumonia. Less areas in the lungs for optimal gas exchange. The shift in oxyhemoglobin of course could further complicate the situation. This is why I say this person needs a unit bed ASAP. There often isn't the time for honing in on the various factors and how they effect the individual in the ED.

The biggest thing one sees in respiratory distress is anxiety. And we all would benefit from more information. Without an exam and the appropriate data (eg., ABG) makes it difficult to tweak corrections. An ABG would tell us if there is a primary compensated or uncompensated respiratory acidosis. It may also give us some metabolic insight. I mean it's inferred that she needs tx for a primary respiratory distress-->O2, (? does she have any fluid accumulation backing up into her lungs? It's hard to get O2 through for exchange if there is fluid backing up into the lungs--you can up the O2 to kingdom come, and it's not going to get through, so, IF that were a factor, it would have to be dealt w/ even if they ended up intubating and artificially ventilating her.) OTOH, is she in need of some wisely titrated volume. If so, the blood--> more hgb along with the protein-based fluid may help balance her hemodynamics. Without looking at the patient and more data, it is hard to appropriately treat her.

Often pt's come in with mixed comborbid issue.

Hers seem to be:

1. respiratory related to poor ventilation/perfusion-->pneumonia--harder to get gas exchange due to decreased areas in the lungs, which are able to cause gas exchange.

2. increased metabolic demands--immunological--r/t acute infection

3. decreased O2 carrying capacity--> low H/H.

So, I agree Stargazer, to go further, we'd need more information.

Guest343211 · Sep 19, 2012

Also, I am wondering what the hold up was for administering blood. T&C, OK. But if you couldn't get another line in her-- 20g or > is better for blood transfusion b/c of hemolysis and clotting, wasn't there anyone else around that could help you do this? Although an 18-gauge needle is standard, a needle or catheter as small as 23-gauge can be used for transfusion if needed. It's just that the smaller the gauge, the slower the flow rate and the higher is the risk of clotting. You have to be careful to avoid excessive pressure leading to hemolysis when very narrow lines are used. But if she needs the blood, well, she needs the blood. You can dilute the red cells with saline (as it protocol in adults in many places) or ask the blood bank to split a unit, so that you are giving only half at a time if it will be running slowly. You also have to watch these transfusions more than what is protocol, b/c they tend to stop, and time is a factor. You just have to be careful, b/c this patient is a medical player with questionable issues going on related to her core system functions. She's not a surgery or trauma patient, so while she needs blood, you have to give it very carefully. It's a tricky balance--meeting volume needs for optimal hemodynamics while also not overloading the patient.

The other benefit of spliting the unit is to do what we have referred to as the blood and lasix then blood sandwich. Not knowing the women's cardiac and overall lung and kidney function, although she would benefit from the blood and perhabs the volume, you may have to intervene to tweak what goes in and what comes out. Protein based fluid (such as in blood products) will give her better intravascular volume, which can help decrease systemic vascular resistance; at the same time, excess fluid has to be judiciously moved out through gentle diuresis. Thus the use of the "sandwich."

Like I said, there is more time to look and deal with these things, specific to the patient and her core systems, once she is in a good intensive care unit. She's on the fragile side, so she needs to be in a place where all these things can be carefully and continuously assessed and tweaked.

Anna Flaxis, BSN, RN · Sep 19, 2012

Yes, we definitely need more information. Keep in mind that in the ED, the primary focus is on stabilization and moving the patient to the next appropriate level of care, whether that is discharge home, admission to the hospital, or death. Patients do not stay in the ED.

The original poster's question was what s/he could have done, as a lone nurse, to help the patient's breathing. For starters, s/he could have given the patient more oxygen. 4LPM via nasal cannula is nothing. It provides only 25-45% (depending on who you ask) oxygen concentration, in contrast to the 60-90% (again, depending on who you ask) that an NRB would provide, plus you'd have it at 15LPM. You could move up to NRB, then titrate back down as the symptoms are alleviated.

For the purposes of stabilization in the ED, a nonrebreather mask is the next appropriate step and a priority intervention for the emergency nurse. ABGs would definitely be helpful, but ABGs are not standing orders in my ED, and I wouldn't be surprised if that was also the case where the OP works. Even if they were, it would not be the priority intervention. Breathing comes before diagnostic tests.

To those who worry about CO2 retention, if the person needs oxygen, you give it. Hypoxia develops rapidly, while CO2 narcosis takes time.

I agree that if the patient's respiratory status was not improving, the physician needed to be notified and come re-evaluate the patient, and write new orders appropriate for the patient's condition, and the patient needed to be in the ICU as soon as possible. This is one of the frustrations of patient care in the ED at times, is when you're sitting on a patient waiting for a bed, knowing that you don't have the resources to provide the care they're in need of, and you're being pressured to take on another unstable patient that just came in via ambulance.