Pt with severe COPD scheduled for surgery to repair a fracture was on the floor. Sats all over the place; mostly 90's with venti but pt wouldn't leave it on & drop to 50-70's. Back on nasal cannula, pt would leave it on & stay mostly in the 80's. Big mouth breather. Monitored by ICU with tele & continuous pulse ox.
When I checked on the pt after a call from ICU re sats dropping again, pt looked like a fish out of water, unable to match slower breaths with me, sats staying in low 80's, accessory muscle use, RR 22-26....
I suggested to the pt's nurse maybe give a little morphine (I assumed it may have been ordered for pain control d/t fracture) & felt like I was smacked in the face when his nurse with 20+years experience stated "What?! You want to give granny who can't breathe respiratory depression?"
Specializes in Nurse Leader specializing in Labor & Delivery.
What made you want to give this patient pain medication, was it her breathing or did she complain of pain? Did they rule out a PE?
HPRN
She was not using it as pain medication. She was using it to decrease oxygen metabolism, which then reduces oxygen demand in the patient, improving dyspnea.
Thanks again for everybody's response. No, I wasn't thinking about pain although this was a hip fx & no doubt caused significant pain. Just sort of always stuck in my head from school that morphine dilates vessels
Well, off to work again now; will see if this pt made it back to to the floor post-op.
In my experience, the patient would have been started on nebs (continuous if necessary) and then BiPAP. I don't think the practice of medicine, in my facility, would treat such a seemingly distressed patient as mildly as morphine with such a clinical description as the one you gave.
But, if a patient is not tolerating a mask or even a nasal cannula, they are going to hate the BIPAP mask. This patient will need pharmacological intervention before attempting BIPAP.
Without knowing more history I would be very hesitant to do a continuous neb. Severe COPD usually comes with severe cardiac problems.
In reference to an earlier post:
Depending on who does the ABGS at your facility, the results could take up to an hour. Don't wait to intervene. Also, the numbers may not fit the clinical presentation. The A-a gradient might go unnoticed and a "normal" looking ABG might be interpreted. You might get a frustrating "wait and see" response from a physician based on an ABG. It is sometimes better to emphasize the "look, listen and feel" components of your assessment rather than relying on just reporting numbers.
Thanks again for everybody's response. No, I wasn't thinking about pain although this was a hip fx & no doubt caused significant pain. Just sort of always stuck in my head from school that morphine dilates vessels
Well, off to work again now; will see if this pt made it back to to the floor post-op.[/QUOTE]
Please let us know. I'd bet the farm the pt is in the ICU on a vent or BiPap when you get back.
I don't know many surgeons who'd even perform surgery on a patient in that condition.
Thanks again for everybody's response. No, I wasn't thinking about pain although this was a hip fx & no doubt caused significant pain. Just sort of always stuck in my head from school that morphine dilates vessels
Well, off to work again now; will see if this pt made it back to to the floor post-op.[/QUOTE]
Please let us know. I'd bet the farm the pt is in the ICU on a vent or BiPap when you get back.
I don't know many surgeons who'd even perform surgery on a patient in that condition.
Prepared to be amazed. Pt came back to the floor post-op & did very well taking everything into consideration. I was not her nurse, but started an IV for her on eve shift & her breathing was like night & day. Nasal cannula 3-4L & sats in upper 80's. Through the night, cannula was moved to her mouth as she slept (mouth breather) & sats were 90's. Only one call from ICU monitoring her continuous pulse ox & it seemed that was due more to cold hands & difficulty picking up a good reading. Little bit hypotensive end of evening shift & will be getting transfused this am, but all in all, doing outstanding.
klone, MSN, RN
14,857 Posts
She was not using it as pain medication. She was using it to decrease oxygen metabolism, which then reduces oxygen demand in the patient, improving dyspnea.