Protocol and Nursing Judgement with comfort care patient.

[burnoutward, BSN, RN]

This is two parts bear with me...

I understand that we must all make decisions when it comes to protocol and nursing judgment, but I had a recent situation that made my gut feel very uneasy and I need some opinions. I have always been told nursing judgment is the way to go. If a patient is sating low, slap some 02 @ 2L Nasal Canula on the patient. If patient struggling to breathe past mucous, you can suction in oral cavity. If doing anything more call the physician for orders.

I recently was told that apart of comfort measures you can deep suction (ET) without an order as nursing judgment. I really am not comfortable doing this but I see other nursing doing it and it is freaking me out! I have even seen one do it with just clean technique.

The other measure was 02 it was put on for family hand then a veni mask with humidity with oxygen was added by RT so she wouldn't be dried out. And now nurses have been taking it off and on due to the fact there is no doctors order vs nursing judgment. Because they do not want to get sued.

After watching all this mess, I tried finding the protocol/procedure manual and could not find it anywhere last night. I feel frustrated because people are making a fuss about her 02 levels although I don't understand why we are still fighting with it because they aren't even being maintained even with oxygen. She is dying and shouldn't the goal be to make it peaceful and comfortable?

Any advice?

[GingerSue]

I was taught that deep suctioning is sterile technique

[RNperdiem, RN]

Bring it up when the respiratory therapist comes around. They can deep suction patients, and might have some ideas. O2 mask or not makes little difference in the very end. Is the patient gasping for air or anxious with air hunger are issues in comfort care to address rather than the O2 sat number.

[burnoutward, BSN, RN]

The patient is comatose and we are the ones suctioning not RT.

[TraumaGirl1018]

we ET and NT suctions patients as needed in our ICU...i was under the impression that it was a nursing measure. Ive never seen an order written for either...:uhoh21:

[clee1]

we ET and NT suctions patients as needed in our ICU...i was under the impression that it was a nursing measure. Ive never seen an order written for either...:uhoh21:

That is how it is in our ICU, too.

[Blee O'Myacin, BSN, RN]

Does your facility have a written policy or a standard order set for "comfort care"? In all the places I've worked, there have been specific protocols where the doc has the option to order O2 or not, but the suctioning is left up to nursing judgment. If the patient is distressed by the secretions, then I suction the patient. It's called comfort care, so I make the person comfortable (there's my intellectual rationale). If the patient is comatose and not bothered by the secretions, I keep the patient clean, dry and comfortable and that's it. If death is imminent, I stay with the family and reassure them that the noises are normal and answer any other questions they have.

I hope this helps!

Blee (who, by hospital policy, never had to wait for respiratory to suction a patient in the ICU or ER- they are busy enough running around doing treatments for the entire hospital!!)

[burnoutward, BSN, RN]

Does your facility have a written policy or a standard order set for "comfort care"? In all the places I've worked, there have been specific protocols where the doc has the option to order O2 or not, but the suctioning is left up to nursing judgment. If the patient is distressed by the secretions, then I suction the patient. It's called comfort care, so I make the person comfortable (there's my intellectual rationale). If the patient is comatose and not bothered by the secretions, I keep the patient clean, dry and comfortable and that's it. If death is imminent, I stay with the family and reassure them that the noises are normal and answer any other questions they have.

I hope this helps!

Blee (who, by hospital policy, never had to wait for respiratory to suction a patient in the ICU or ER- they are busy enough running around doing treatments for the entire hospital!!)

Thank you so much!

I am going to look for that today when I go into work because I have gotten so many different answers from different nurses and it is particularly frustrating since she is a DNR and with Hospice. My frustration is all the different answers. Where I worked at before we couldn't even use O2 without getting a order (though we usually started it at 2L and then called the physician for an order) here you can run at 2L. We also couldn't do ET suctioning without an order, we could use Yaunkers since it wasn't evasive.

Yes it is nursing judgment but I am not getting written up because of it.