Oxygen Question

[Hoosiernurse, ADN, RN]

At the risk of sounding like a dork, I have a question. I was taking care of an elderly man in a nursing home who recently developed a respiratory infection. He does not have COPD. His lungs sounded crackly, and his sats dropped to 76, so the doctor ordered supplementary oxygen, titrate to keep sats above 88%. At 3.5 liters he did well, satting at about 91-93%. However, he had a dip to 86% for awhile and the nurse during the day upped the oxygen to 4 liters. When I checked his sats that evening, he was at about 95%, more alert, doing well with his breathing treatments, etc, still on the 4 liters.

So this morning, I reported to the oncoming nurse that the patient was on 4 liters and satting at 95%. She asked me why I hadn't dropped the oxygen back down to 3.5 if he was satting at 95%. I sort of stared a her like a deer in headlights (after being up all night, I do that) and I said,"Because I didn't drop the oxygen" I couldn't think of anything else to say. It bugged me all the way home. I know if he had COPD I would need to closely watch to keep from giving too much oxygen, but this guy is having some respiratory troubles due to a respiratory infection brought on by bedrest. It didn't seem to me to be wrong to let him sat between 93-95%.

I know the order said a minimum sat of 88%, but does that mean we have to keep it as near there as possible?

Don't beat me up...no one knows everything. At least I'm smart enough to ask and learn. :)

Cara

[BriRN]

I don't think anything was wrong with you having the pt on 4 L if his sats were 95%... I could be wrong though..

[Hoosiernurse, ADN, RN]

I guess my thinking was I'd leave him where he was for the time being, and they could reevaluate him in the morning, since he had been having some issues with having his sats drop below 88% on 3.5. It just didn't seem to be that pressing of a thing that I get him back down to 3.5 from 4 right away. He was on the 4L for 12 hours or so. Obviously if his sats are consistently that high for awhile, then it's time to titrate it down and ween him off...as he was on room air previously before his respiratory infection. I don't know. The morning nurse just seemed really miffed at me that I hadn't dropped his oxygen back down, so I decided to find out if I was missing something. Like most nurses that enjoy finding fault, she didn't enlighten me.

[OnwardEver]

Because the patient doesn't appear to have COPD I agree, I don't think it's so much about the risk of knocking out respiratory drive as it is about the day nurse wanting to know if you tried to titrate down to see if the patient responded well and was able to keep his sats up with less help from the oxygen. I just did a Google search to see what the literature has to say about oxygen therapy in oxygen-naive patients but there isn't much that isn't specifically about COPD. Generally, I don't think it's a great idea to maintain higher flow rates of oxygen over the long term (and here we're talking days and weeks); you want to wean down to discourage the body from developing a dependence/tolerance of sorts. While you could have done a trial with 3.5 liters or less overnight, I don't believe not doing it would have caused any harm (and here we're speaking hypothetically/generally as there's no way to know for certain if this would actually be the case without access to the big picture and all the information about this specific case).

Having worked night shift for years, I would also venture to guess that the day nurse's disposition has to do with the classic dynamic present between day and night shift (and I'm not trying to start a flame war between day and night shift folks but sharing something I believe has held true in my own personal experience): nurses coming on days assume night shift does nothing and this entitles them to feel superior and ask questions like "Why didn't you drop the oxygen back down to 3.5 liters if he was satting at 95%?"

Next time you're on with a similar situation on nights, and given the opportunity and time, you can titrate down as ordered by the physician and see how your patient tolerates it and you'll have an answer for the smarty pants day nurse. :)

[scoochy]

Perhaps you could have titrated it in the evening. However, once you did that and say he did well, I would have let him be for the night so as to get a restful sleep. Early mornings in a nursing facility can be harried, to say the least. You would not have been able to closely monitor him if you titrated it @ 6 or 6:30 a.m. The day shift nurse could have done an assessment on him after report was completed, and titrate 02 based on her assessment.

[Esme12, ASN, BSN, RN]

I guess my thinking was I'd leave him where he was for the time being, and they could reevaluate him in the morning, since he had been having some issues with having his sats drop below 88% on 3.5. It just didn't seem to be that pressing of a thing that I get him back down to 3.5 from 4 right away. He was on the 4L for 12 hours or so. Obviously if his sats are consistently that high for awhile, then it's time to titrate it down and ween him off...as he was on room air previously before his respiratory infection. I don't know. The morning nurse just seemed really miffed at me that I hadn't dropped his oxygen back down, so I decided to find out if I was missing something. Like most nurses that enjoy finding fault, she didn't enlighten me.

Oh for heavens sake ......she obviously has absolutely nothing better to do other than make disparaging remarks toward other people.... I wish some people would just knock it off already .

Without the presence of a pre-existing reason like COPD, CO2 retainer, there is no reason to turn the 02 down......"the order said a minimum sat of 88%" the key word here is minimum ....... sounds to me like the MD 1) didn't want to be called back if a normal 02 sat could not be obtained and 2) had no expectation that the 02 sat would improve. If the MD had wanted the sat no more than 88% the order would be something to the effect.....Titrate 02 to maintain 02 sat > 88 or

It's a nasal cannula for heavens sake.....A nasal cannula is used to deliver low concentrations of oxygen. It can deliver from 24% to 40% oxygen at a flow rate of 0.26-1.58 gal (1-6 L) per minute. A simple mask is used to deliver moderate to high concentrations of oxygen. It can deliver from 40% to 60% oxygen at a flow rate of 2.64-3.17 gal (10-12 L) per minute. A partial rebreather mask is used to deliver high concentrations of oxygen. It can deliver 70% to 90% oxygen at a flow of1.58-3.96 gal (6-15 L) per minute. A non-rebreather mask is used to deliver high flow oxygen. It can deliver 90% to 100% oxygen at a flow of 3.96 gal (15 L) per minute. A variable flow rate mask has interchangeable adaptors that may be set to deliver oxygen at 24%, 28%, 31%, 35%, 40%, or 50%.

I would interpret the order you have as that I can titrate the 02 to get it at least above 88% and that the MD doesn't expect this patient to do very well. But if I did get a decent 02 sat on a reasonable amount of 02 I can leave it and let the poor man rest.

You did just fine......I would tell that nurse that you intrepret your order your way on your shift and I'll intrepret it my way on my shift.

Good job....

[brownbook]

No one can improve on Esme's brilliant reply.

I would need a magnifying glass to have the flow meter on exactly 3.5 versus 4. Unless there is new improved flow meters with LED displays? I seldom even know exactly how many liters per minute I have my flow meter set on.

If my post op patient needs a little extra oxygen via nasal cannula I just crank it up and kind of glance that it is somewhere between 2ish and 4ish.

I wouldn't argue with or try to correct that nurse vis a vis Esme's information. She sounds like an idiot. Just try to not laugh in her face as she dings you with more of her catty comments or observations.

[wooh, BSN, RN]

In LTC? I'd have probably left the guy overnight. It's better to wean when the patient is awake anyway. Respirations while sleeping get more shallow, sats will drop transiently, and you'd likely have had to up it back if you did wean any.

I'm all for letting people rest.

Now in the hospital, I'd be a bit more aggressive if it looks like a discharge home is imminent and it depends on getting off the O2. But even then, if it's going to take a few days to wean anyway, I'm not going to push it at night like I would during the day.

[miss_vtRN]

Honestly, I've found that nighttime is often a tough time to start titrating O2 down. A patient might be find on 3 L during the day when they are alert but at night can drop quite a bit and require more O2 to maintain sats. (lying down, partial tongue obstruction, mild sleep apnea, etc).

Since he had an episode of needing more O2 during the previous day, I would probably not feel comfortable tweaking with his O2 overnight. Let the poor man rest! It's easier to titrate and monitor sats during they day, without waking him up and risk interrupting his sleep. Day nurses sometimes forget how important SLEEP is in the healing/recovery process, and part of the night nurse's job is to make sure patient can safely accomplish a good nights sleep, sometimes no small task! I know, I've worked both shifts...

[jujuseah, RN]

0.5l is like erm nothing. she is making a mountain out of a mole-hill.. well we do like to trial patients to lower dosage but hey 0.5, she is messing your morale! cheer up. as long as your patient is alert and conscious at the end of your shift, hey good job! you kept him alive.

[pixie120]

SO...the correct answer is, at report "THis is what I did, and...you can,on your next 8 hours, do what you want to do". End of story.

[systoly]

Leaving it at 4LPM was fine. But consider responding like this, "I didn't feel it was indicated, however, you seem to disagree and I'd like to know your rationale".