Patient in Respiratory Distress

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Last night I received a patient from the ED who was diagnosed with pneumonia. She was initially on Bi-Pap 12/5/50% in the ED. They took her off for a little while to 6L NC, but she did not tolerate it well. She was put back on bipap and they tried 6L NC again about 2 hours later. She was doing okay so the ER nurse sent the patient up on 6L NC. We got her to bed then about 5 minutes later she became tachypneic - RR 48, had audible rales, was still sat'ing 96% on the 6L but had extremely labored breathing. We placed her back on the bipap. Her BP was also 173/101 with a history of hypertension. The patient told us she takes Lopressor 5mg BID and Clonidine 0.1mg BID also.

My preceptor and I quick glanced at her orders and saw only Lopressor 2.5mg q6H and nothing to help her diurese. We called the doc, told her what happened with the patient and the doc was really angry that we put her back on bipap. She wanted her on a 100% non-rebreather or a facemask. I'm still new so I'm still learning about the different levels of respiratory devices. I do know that you never want to leave a patient hanging out on 100% non-rebreather. Our thought was to put her on bipap since that's what she was on ALL day in the ED. Apparently she had an ABG done in the ED that showed no issue with her CO2 level, which I guess is why the doc didn't want her on the bipap. I had to twist an arm and a leg for her to order a one time dose of IV Lasix and to order the patient's regularly prescribed Clonidine. The doc couldn't understand why we were concerned about her breathing when "clearly the pneumonia is contributing to it." When a patient is telling me she can't breath, has audible rales and is breathing 48 times a minute, that's not okay.

About 3 hours after we got her settled, back on the bipap and gave her the lasix, lopressor and clonidine, the patient was resting much more comfortably and sounded much better. I felt like I was trying to advocate for the patient and to prevent the situation from turning into something much, much worse. I felt so deflated after I left and was really upset that the doc was so angry with me. I guess I'm just wondering - would you have done something different? If so, what? I'm trying to learn from this situation so that I can better handle a situation like this in the future.

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more than anything, it sounds like she needed that 1x dose of lasix.

once she's diuresed, everything else will fall into place.

i think you did an amazing job.:bow:

leslie

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Specializes in Pediatric Psychiatry, Home Health VNA.

I think you handled it perfectly. It's a hard line to draw in the sand between advocating for your patients and stepping on the doctors' toes. Many times you can't do one without doing the other too, and that's okay. Your patient comes first and when you finished the shift your patient was oxygenating well, safe, and comfortable, and that's all that matters. If your patient had been hyperventilating throughout the ER visit she was probably blowing off the CO2 and that could contribute to the normal ABG level, not to mention being on bipap for hours may have corrected it as well. One good ABG level doesn't mean her gasses won't go down the tubes on 6L later on. Be confident in your skills. Your patient was not tolerating the NC, was tachypneic and had abnormal breath sounds. Your assessment backs your action, so the doctor can have a holy cow for all I care, you did the right thing.

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Specializes in Med/Surge, Private Duty Peds.

:yeah::yeah: Job wel done and I know your patient knows ho good of a job you did.

Sometimes we as nurses have to stpe on the doc's foot to get things done for our patients.

Seems your assessment skills rpoved to be right on track.

Don't let the doc's attitude get to you. After all You observed the pt and YOU knew something was right and YOU did something!

Again job well done and the skin will get tougher !

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Specializes in Telemetry, ICU, Psych.

I think that I would have reacted the same way that you did. Not only were you advocating for the patient, but you were doing the job that the doc should have done.

What I've learned working in that ICU is that calling a respiratory therapist and consulting them helps. In the ICU where the docs lean on RT's a great deal, they rarely question suggestions from them. Also, it helps to have RT at bedside if the patient needs to be rapidly intubated.

I think that you did a good job.

CrazyPremed

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I would have done the same thing. You DID do a great job!

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Yeah it sounds like you did the right thing to me too! Im a new grad and if something doesnt look right and my preceptor isn't with me, respiratory is my next "yell for help" haha, they're a VERY invaluable tool. To add, I had a similar situation not long ago. A pt's lungs filled up quickly and she was in some resp distress with sats in the 80s. Doc ordered solumedrol and lasix. It is a scary situation though, especially for someone new

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Thank you to everyone who responded and has assured me that I was indeed thinking along the right track to keep the patient safe.

Just an interesting update on the patient:

The next day during day shift, the patient was called as a heart code, went down for an emergent cardiac cath, ended up being intubated while down there, and is now resting in an ICU bed. I do not know any other details, but really hope she is in better hands than the doc I had to deal with over the phone.

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Sometimes you have to step on the provider's toes. Don't take it personally when they get frustrated and upset with you. Advocate for your patient because you are the one that is there looking at them. You'll also find that some providers don't do well wtih you asking "can i give him 20mg of Lasix?" instead you need to make the provider think it was their idea and say "Well, I was thinking that some IV lasix might help pull some of the fluid off her lungs and ease her breathing a bit. What do you think about that?"

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Specializes in Post Anesthesia.

So once the doc had correctly identified the source of the problem it was supposed to be all fixed?! Just because the doc is behaving like an idiot dosen't mean the nurses have to. Fighting inept or unresponsive doctors in order to get appropriate care for our patients is, in my opinion, the hardest part of nursing. Hard as it may be, our patients are depending on us to fight for them. We are sometimes thier only hope of getting the needed care. Good Job. Sounds like you handled a difficult situation very well.

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Specializes in ICU, Telemetry.

I think you did the best you could at the time. Did the pt have a hx of emphysema or lung disfunction (other than the pneumonia)? How old? The only thing I would have done different, and maybe you did this, was call respiratory -- and if the person was really junky, I'd have asked for 60 of Lasix, assuming they had reasonable kidney function; it would have also helped get the BP down.

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You did a good job. Always good to advocate for the pt. I would have called the Rapid Response Team right away. Do you have RRT at your hospital?

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