Nurse-initiated interventions

[flyingchange]

Hi all, student nurse here. Some background on my question:

We were in a Sim lab yesterday and Sim Man was post-op from MVC-related femur fracture, on 2L/min O2 via NC.

He developed SOB and desatted to around 85%, HR 180, can't remember BP. We were told he had pink frothy sputum. While one of the students went to phone the doc, we kept him at 2L, sat him up in the bed, and tried to keep him calm. Sim Man said it hurt too much to breathe so someone gave him PRN MS.

Student came back with the order to turn O2 to 10L/min. Sats back up to 95%. Some comfort care provided, end scenario.

Our instructor said in general we reacted appropriately, but suggested that we should have turned up the O2 to 10L and switched the nasal prongs to a non-rebreather mask while we waited for orders, and should have considered holding the MS until Dr decided on plan of action.

I didn't think we could put O2 above 10L/min without orders? She said we should just do it and let the Dr sign off on it later. That seems kind of unwise...? What if the doc didn't want to sign off on it? I would like to get your opinions.

If this situation was occurring on your floor, how would you respond and why? Would you call the rapid response team? How about asking for a stat Ativan for his distress?

Many thanks :)

[Altra, BSN, RN]

Hello student nurse :)

Suddenly desatting to 85% is an emergency and needs immediate intervention. A non-rebreather is appropriate. After all, if the patient suddenly became apneic altogether, you would certainly bag the patient without orders, right?

PS - what do you think could have developed in this s/p MVA patient with the femur fx that produced the SOB?

[flyingchange]

Thank you Altra! I hadn't considered the immediate intervention aspect. Her recommendations confused me because I thought that only 2L of O2 was within nursing scope to initiate. I will remember that about the mask.

In regards to Sim Man, we suspected PE, which was confirmed by a V/Q scan and our next scenario involved me hanging heparin and fighting with the Alaris pump for 5 minutes...lol :)

[gonzo1, ASN, RN]

It is never inappropriate to give a desatted pt oxygen, no matter how many litres, now if they have COPD you might need to find out what their normal sat is first.

[April, RN, BSN, RN]

If this were happening to my patient, I would have put him on a non-rebreather. Any doctor would expect that we do this if sats were 85% on nasal cannula. Gotta keep your patient breathing. I'd expect the doctor to at least order a STAT chest X-ray, and EKG, and labs like ABG, CBC, D-dimer, coags.

As for the PRN morphine or ativan... these medications can further impair the respiratory status and can mask symptoms, making it difficult to accurately assess what is causing this patient's pain and respiratory distress. I'd want the patient to be able to describe the type and intensity of the pain to help determine what is causing the pain. However, if the patient is in excruciating pain like it sounds like yours was, I'd probably end up giving the morphine, too.

[MunoRN, RN]

You should never avoid an intervention that is a standard of care solely because you don't have a specific order, standards of care hold some weight as well.

Even so, most O2 orders are not written as a specific rate, but as "O2 to keep sats > x%", in which case you already may have an order to increase the rate if the goal is >90.

[Belle Epoque]

OP, you would have to check with facility policy. Since 02 is considered a med, in many areas nurses can only administer up to 2L w/o md order. I would certainly not be comfortable bumping someone up to 10L w/o an order. I am surprised your prof said do it anyway and get the order later? Sure we do this all the time for various things but not considered best practice and can be a breach of facility policy.

As for holding the MS, why would you do that? Patient was clearly in pain, hello, femur fx! and that would explain why he was so tachy, and SOB. Pink, frothy sputum.. classic PE.

If he had an order for Ativan I certainly would have given it.

As previous poster said anticipate new orders for stat CXR and get ready to draw for labs, maybe page RT.

Didn't sound like a rapid response... yet, but could quickly have turned into one w/o your proper intervention.

[OCNRN63, RN]

O2 @ 10liters/nc would be inappropriate. Most of it would be blasting out of the patient's nose. The patient needs a NRB mask.. I would have put a NRB on the pt., and yes, I would have done it without an order if necessary. In fact, I have done so in the past in a crisis situation. ABCs. I don't think there's a doc who would fault you for this. Without enough oxygen, the head is dead. I think the doc would rather that not happen.

If there was an order for MS, I'd have given it. It would have reduced the pt's pain, helped him breathe more effectively and helped improve his oxygenation. I probably would have not give the ativan at the same time unless the patient was extremely restless; I would have been concerned about overly sedating the patient.

[meandragonbrett]

Morphine would be an appropriate intervention in pulmonary edema to reduce your preload. Other appropriate interventions could include diuresis, nitrates, etc.

MANY facilities have standing orders for an emergency situation for things such as Nitro for Chest Pain, ABG and O2 for Resp Distress, 12 lead for tachycardia and chest pain, etc. You would implement those emergency standing orders while somebody else calls the LIP and updates them on the changes.

[MissERN]

Absolutely time for a rapid response! Sat dropping to 85% and heart rate of 180 on a post op femur fracture...I'm definitely thinking PE, and I'm definitely giving more oxygen! In a situation such as this by the time you get an order for more oxygen it may be to late. This patient needs high flow oxygen immediately! Sounds like a great learning experience!

[RedhairedNurse, BSN, RN]

Thank you Altra! I hadn't considered the immediate intervention aspect. Her recommendations confused me because I thought that only 2L of O2 was within nursing scope to initiate. I will remember that about the mask.

In regards to Sim Man, we suspected PE, which was confirmed by a V/Q scan and our next scenario involved me hanging heparin and fighting with the Alaris pump for 5 minutes...lol :)

Did you draw some baseline coags before starting that hep drip?

[Ccp65_61]

It is ok to administer more than a few liters of oxygen until one can get a better handle of the situation. Using the mask is always a good move. I would have held up on the administering any type of meds that could suppress respiration until the MD could better diagnose. We use to always put up5L if using prong or 10L with non-rebreather mask.