LTC facility - O2 delivery for respiratory distress

[WCCRN]

I'm looking for some constructive input on a situation that recently happened at work.

I'm currently at a long term care facility that -to put it nicely- seems to often be lacking necessary supplies and equipment. I was called upon by a co-worker for help because her resident was in respiratory distress. She told me that when she went in to give meds, the resident was more lethargic than normal and had labored mouth breathing (uncharacteristic for resident). O2 sat was 65%. She threw on an Albuterol nebulizer (ordered for resident PRN for SOB) and then found me for help on her way to call physician & squad resident out. On my way to the room, I also learned from her that the resident had some cardiac history, but no respiratory history such as COPD or anything.

When I entered the room, I sat the resident up in high fowlers as they were laying nearly flat. O2 sat at this point was fluctuating between 77 & 80%. I tried to find a simple face mask, thinking the nasal cannula probably wasn't being the most beneficial since they were breathing through their mouth. We didn't have any. Other than the nasal cannulas, all I could find with our respiratory supplies was a non-rebreather mask. Then I realized our O2 concentrators' max LPM is 6 and I had in my head that 10 LPM was a minimum for non-rebreathers to prevent CO2 buildup. With the nebulizer complete, O2 now hanging out in mid to high 70's and respirs still labored, I decided the non-rebreather was the best thing I had available. The reservoir inflated on the 6 liters and remained inflated once I put in on the resident. I was thankful the squad was there very shortly after, as I felt a little helpless.

So my main question here, is did I act appropriately? In this situation, should I have just left the nasal cannula in place since I couldn't provide at least 10 LPM for the NRB mask? If I had the appropriate supplies, what would have been the optimal O2 delivery system for this situation? This part of nursing is new to me... I've been doing strictly wound care for four years.

[Buckeye.nurse]

I feel for you. Emergency situations are stressful enough without the added stress of scrambling to find needed equipment. It sounds like you did the best you could for the patient with the available equipment.

I suggest bringing your concerns to your management. Present the situation, the items you needed which weren't available. Then suggest an emergency grab bag for situations like this. In it should be an oxygen head which goes up to 15 liters/min flow, suction equipment, a simple face mask, a non-rebreather, an ambu-bag...and anything else you can think of which would be helpful in these situations. Our facility uses a sturdy bright red tackle box. Then you just need to grab the kit and run to the room.

[AnnieOaklyRN, BSN, RN, EMT-P]

Hi,

1) at 6 LPM, you were either giving equal to or less than atmospheric oxygen to the patient, while adding to CO2 retention. Next time listen to your gut and use the appropriate device for the amount of oxygen you have.

2) where I live I was told that nursing homes were not allowed to provide more than 6 LPM of oxygen, although I am unsure how true this was. I went to various nursing homes several times to find patients on a non-rebreather at 6 LPM which is essentially suffocating them.

3) You did the right thing sitting the patient upright which helps with breathing mechanics, calling for a physician, and arranging for transport.

4) ALWAYS listen to lung sounds before you give someone medications for their breathing, just as you would obtain a BP if you were going to give a BP medication. If this patient is in CHF a nebulizer could make her worse or if she wasn't having bronchospasm you are giving an elderly person a medication that is going to increase there cardiac workload.

Annie

[canoehead, BSN, RN]

An alternative was to use the NRB at 6lpm, but snip off the nose piece so it was no longer a sealed mask. That would be the equivalent of giving blowby, and solve the problem of mouthbreathing. I agree that nasal cannula wasn't going to do the trick.

[amoLucia]

Could you have converted the pt's concentrator over to a big green O2 canister? Facilities usually keep them on BACKUP EMERGENCY standby availability.

You would then have been able to use the non-rebreather with O2 delivery cranked up.

[Wuzzie]

An alternative was to use the NRB at 6lpm, but snip off the nose piece so it was no longer a sealed mask. That would be the equivalent of giving blowby, and solve the problem of mouthbreathing. I agree that nasal cannula wasn't going to do the trick.

I had forgotten that trick. To clarify I think what Canoe means is to remove the "flapper" valves (the circular pieces of rubber on either side if the top of the mask). They just pull off. By doing this you have created a partial re-breather. Minimum flow for this is 6lpm and it should only be used, in your situation, as a bridge to getting the appropriate O2 delivery system for the patient.