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.
I'm sure this is very basic, but can anyone explain this to me?
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Genericaly speaking, like any other drug we want to wean the Pt to the lowest effective dose. Specifically with O2 we would be concerned with things like oxygen toxicity, absorbtion atelectasis, drying of the airways/secretions ect. The Pt's pathology may be the primary concern, think retainer.
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.
abundantjoy07, RN
740 Posts
I'm sure this is very basic, but can anyone explain this to me?