Nursing judgment

[steve40]

I am not sure why this is bothering me so much but maybe other fellow nurses can give me another perspective on the situation. I am a part time night shift nurse and in charge of 2 floors with over 100 patients during my shift. I recently encountered a patient with end-stage COPD which was being monitored for increased falls/pain. I assessed this patient at approximately 12:45 am to find him with low oxygen saturations as low as 59%..granted this was with his nasal canula blowing oxygen into his eyes instead of nares :) I administered the oxygen at 3.5 L/min and shortly there after his oxygen sat increased to low 90's. He was repsonsive and replied " no" when I inquired to as whether or not he was experiencing any pain/discomfort. all other vital signs were stable. Later in the shift at approximately 430 am a CNA requested I come evaluate this patient. I discovered him with a large amount of brownish emesis of like pudding consistency, O2 Sats upper 60's and unresponsive. No repsonse to verbal stimuli, sternal rub etc. I cleared his mouth and oral cavity area as best as I could, raised the head of the bed..increased his O2 slightly...obtained all other vital signs etc. This patient was also a DNR code. I truly felt that this patient was basically dying in front of my eyes. I callled the on call MD and updated him on the situation to which he said it basically came down to the family's wishes...comfort vs. send in to ER for evaluation etc. I notifed a family member almost immediately after contacting the MD and explained the situation and offered either comfort measures or direct transport to the ER. She wasn't sure but called back about 45 mins later indicating she preferred him to be sent to the ER. Well, as it turns out the patient was admitted apparantly with primary diagnosis of pneumonia. abmormal labs. etc. Obviously this could have been as a result of aspiration. I guess my question is...should I have acted differently? Another co-worker, (RN) said; "you have to act for the patient". obviously he was unable to give me his designation at that time. so, was I wrong in not just taking initiative in sending the patient rather than first consulting a family Member and/or the MD...which I did. Just curious to get other nurses opinions on this situation.

Thanks,

Steve RN

[ounsrey]

I believe you did the right thing and handled it the way I would have. You called the doctor and informed him of the pts change in condition and followed his orders. Just curious was the patient with hospice care?

[jadelpn, LPN, EMT-B]

You absolutely did the right thing. There is not a thing I would have done differently.

And to the RN who stated "you have to act for the patient?" Patient is a DNR, it does not mean Do Not Treat!!

We see all the time when patient's become unresponsive and family makes decisions for care that perhaps we

would not. But it is not about us. You did what the doctor told you to do, and followed the family's wishes. It is

not for us to decide. Awesome--this RN gonna put her license on the line when the patient codes, patient is a DNR and

family is all up in your grill about it?????

[steve40]

This patient was not currently on hospice care but both him and the family have been undecided I believe for many months as to admitting him to comfort or hospice care.

[classicdame, MSN, EdD]

You were the patient advocate and that is a good thing.

[Been there,done that, ASN, RN]

This was a damned if you do.. damned if you don't situation.

Develop the policy within your facility...the patient and family's direction regarding treatment is clearly defined and documented.

So no other nurse, patient or family has to go through this again.

[steve40]

Thanks everyone! I really appreciate your feed back and support:)

[That Guy, BSN, RN, EMT-B]

The last time I saw emesis like the the pt was alive for about another 20 seconds so good job. I wouldnt have changed anything.

[Nurse SMS, MSN, RN]

The patient was a DNR. In my opinion you acted prudently with obvious desire to do as the family and patient would want.