I am a fairly new nurse and was wondering for advice from some seasoned nurses....
I work in a post surgical unit and often my pts are medicated with Norco or morphine/fentanyl. I wonder how to tell sometimes if someone is just tired or if they are lethargic and needs an ABG. If someone is lethargic is it likely that the O2 sats are low (cause I know it isn't always the case correct)?
I guess I'm asking what factors do you use to decide about getting an ABG or not getting one. (in my hospital we are allowed to just get a STAT ABG if we feel it is needed)
An EtCO2 reading will be quicker, cheaper and far less painful. If the CO2 is elevated then you would have a reasonable rationale for an ABG. Plus are we talking about a lethargic patient or an obtunded patient? For me these are two entirely different assessments (although I am conceding that an obtunded patient was most likey lethargic prior to becoming well...obtunded).
If you know the CO2 is elevated wouldn't it be wiser to attempt to find a reason, correct it or provide support and then check an ABG to see if the treatment or support is working? I've seen too many want an ABG for a patient breathing at a rate of 4 and will not even bag until the RRT gets back with the ABG results confirming the patient is barely breathing. Don't get overly reliant on numbers if clinical assessment points to intervention before sticking an artery. In days of past we use to get an ABG on every patient coming through the ED for respiratory distress to "justify" intubation regardless of the clinical signs. Too many times it was learned the hard way just how much distress the patient was in when they coded while waiting for an ABG to see if BiPAP or a tube was needed.
Agree about the EtCO2 but how many facilities will use these? Not too many of the hospitals in my area are using them in the units or in step-down. I always like a VBG if I don't have an arterial line but I'm gonna be honest, if my gut says grab an ABG , I'm going for it.
Well do your general assessment (HR, O2, RR, BP, Glucose) check whites of the eyes for blue tint, Lips, Nail beds Capillary refill..
ABG's take too long..... think about it... you have to order the stat ABG... they have to draw it... it take several minutes for the results... you just gave up 15 mins of this persons life to find out from the ABG... yup he is in respiratory distress I now have proof....
Remember ABC's Airway first, not ABG first...... Testing confirms care your giving is correct or Identifies areas that need to be changed... a ABG wont help the patient get more air or Narcan ... the ABG only helps to Identify the problem ...
If the eyes are closed and wont open
Sternum rubs baby... that's my thing if that dont wake them up... increase the O2 and call for an Emergency response team... if your hospital has it... if not check with Tele unit (if on tele) for changes, get the charge nurse to double check your findings and if all else fails... CALL THE CODE ....
ERROR on the Side of Keeping the patient alive...
I would rather be a fool with a live patient.. than an Idiot with a dead one.
Keep them alive till 7:45.... (shift change) .... thats my motto
If you know the CO2 is elevated wouldn't it be wiser to attempt to find a reason, correct it or provide support and then check an ABG to see if the treatment or support is working? I've seen too many want an ABG for a patient breathing at a rate of 4 and will not even bag until the RRT gets back with the ABG results confirming the patient is barely breathing. Don't get overly reliant on numbers if clinical assessment points to intervention before sticking an artery. In days of past we use to get an ABG on every patient coming through the ED for respiratory distress to "justify" intubation regardless of the clinical signs. Too many times it was learned the hard way just how much distress the patient was in when they coded while waiting for an ABG to see if BiPAP or a tube was needed.
We're on the same page Grey Gull I just didn't get into the specific order of care. I was responding to the poster who was talking about patient's who are acidotic with normal sats. Of course you try to remedy the situation first.
A history of recent activity maybe helpful if obtainable. I went in for a procedure one morning after working 3p - 7a. When I was hard to arouse the nurse became very concerned (I'm glad and thankful), but my wife, knowing that I was exhausted, stopped any further intervention (again glad and thankful).
Have a personal experience w/ this. I had a pt that I felt was too sleepy. The house supervisor, RRT and ICU charge nurse happened to be on my floor so I pulled them into the room for a second opinion. Plus, this would have been the exact people to show up had I called a Rapid Response. She was arousable but lethargic. She hadn't been sleeping well at night. I think she reported she hadn't slept in 24+ hours.
Everyone concluded that her vitals were stable and she was probably just exhausted. I still had that "spidey sense" that something wasn't right. However, this was one of those rare occasions where I dismissed my hunch and relied on the other nurses years and years of experience.
I continued to keep an eye on her/monitoring VS and LOC. A while later the Pulmonologist came in for rounds. I was relieved to see him and quickly updated him on the above situation. I followed him to her room. She was even more lethargic. ABGs were done and her CO2 was sky high. She went to ICU and was placed on BiPap (later that night she was intubated).
I felt like a horrible nurse. I was kicking myself for NOT listening to that inside voice that told me "something is still wrong". I was not a new nurse. I should have known better. How could I be so stupid? The Pulmonary doc came back to our floor to continue rounding after transferring the pt to ICU. He saw that I was visibly upset (teary-eyed). He had a reputation of being an abrupt growling bear and could be intimidating. He instantly pulled me into the break room and sat me down. We had a long talk and gently reminded me that that inner voice is there for a reason. "Do STAT ABGs on any of my patients anytime you have that hunch". "Always listen to that voice."
The patient survived but it could have been a bad outcome.
GreyGull
517 Posts
If you know the CO2 is elevated wouldn't it be wiser to attempt to find a reason, correct it or provide support and then check an ABG to see if the treatment or support is working? I've seen too many want an ABG for a patient breathing at a rate of 4 and will not even bag until the RRT gets back with the ABG results confirming the patient is barely breathing. Don't get overly reliant on numbers if clinical assessment points to intervention before sticking an artery. In days of past we use to get an ABG on every patient coming through the ED for respiratory distress to "justify" intubation regardless of the clinical signs. Too many times it was learned the hard way just how much distress the patient was in when they coded while waiting for an ABG to see if BiPAP or a tube was needed.