Question about demanding COPD patient

[oldiebutgoodie]

Hi, all,

I'd like your input on the patient I had yesterday. She was an 82 year old woman with COPD who had been admitted due to increasing SOB. When admitted, she demanded frequent neb treatments as well as an inhaler at her bedside. She was tachycardic (probably from all the meds), and the MD said absolutely not, pick one: bedside inhaler or neb treatments from respiratory.

She chose the neb treatments from respiratory (very reluctantly, with lots of anger, drama, etc.) So, when I had her, she was demanding neb treatments about every hour and a half (treatments were for every 3 to 4 hours). She cried that she couldn't breathe, couldn't breathe, couldn't breathe, and was screaming out to the hall for me to get the respiratory therapist (who, of course, would not come due to MD order).

Meanwhile, her sats are 99% on 2L of O2, and I couldn't see any accessory breathing. When I listened to lungs they were diminished all over, and respiratory said as day went on, they were clear, no wheezing. She was not gasping for breath, and had plenty of energy to yell at us.

Only once did she sit up in tripod position due to her inability to breathe (sats 99% at this point).

So, what do you think? Is she just a PITA patient, or in actual distress? She did not have blood gasses done, so I can't give you that info. She was also very demanding about food, saying the food was always cold, but when we got her a tray, she wouldn't eat it because she said she couldn't breathe.

I just can't imagine she is just making all this up-- can neb treatments have some sort of dependency effect? Even though she was a pretty unpleasant person, it just seemed she put an awful lot of energy into this "can't breathe" thing for it to be made up.

What do you all think?

Thanks,

Oldiebutgoodie

[NRSKarenRN, BSN, RN]

my worse patient ever had copd....learned a lot from her re anxiety+ air hunger. for those that demand q2hr tx, one of the easiest things is to get a fan setup at bedside so the sensation of air cirulation is present on the skin.

even fanning the face with carboard/magazine will help during acute phase till can get a fan (good to assign to family if present).

sitting pt in high fowlers with pillow on overbed table to be able to rest arms on will help increase diphramatic angle too.

other things mentioned: check h+h , if low will shift o2 curve, change to xopenex if tachycardic and definately get antianxiety on board. iv steriods usually indicated too. strong scents: cleaning products, perfumes, gi gas can increase sense breathlessness too.

having experienced moderate breathlessness due to bronchitis 2 years ago with 99% sat, can full understand my copd pts....fan did the trick. found having hep lock fast nss flushed i get taste of alcohol in throat and odor up nose....now over 50 sensative to odors/ aromas worsened just like lung dr told me would happen... grrrrrrrr. it really hurst to have these symptoms dism issed as trivial.....eyes do get opened when your the one in that hospital bed.

sl morphine or nebulized morphine has been used too.

good ce article from nursing spectrum:

ce272b: assessing and managing dyspnea

[RNSuzq1, RN]

Hi Oldie,

My immediate thought while reading your post was - she needs something for anxiety. I see that all the other posters suggested this as well. I sadly lost my Mom to COPD a few years ago - she didn't yell at anyone, she was the type that didn't want to be a burden and needlessly suffered in silence.

Towards the end, my Mom said she felt like she was drowning, I could see the fear in her eyes. It's a scary, horrible way to go and heartbreaking to watch someone battling this awful disease. The least little thing makes them breathless - which only adds to their anxiety level, making it even harder to breath. Everything we take for granted - talking, eating, getting dressed, using the bathroom - makes them totally winded and wears them out. They need to save all their energy just to breath, so it's really important to cluster their care as much as possible and try to keep them calm and relaxed.

[oldiebutgoodie, RN]

These have all been great suggestions. Too bad with my current patient ratio I have not been able to spend more time with the patient to deal with her discomfort. (sigh).

Keep the suggestions coming, if you have more! I appreciate it!

Oldiebutgoodie

[Daytonite, BSN, RN]

i worked for a number of years on a stepdown unit where we had many copders who were regular customers. some very very typical in their behavior as described above. i think that a good deal of their behavior comes from the sensation they have that they are smothering. if you look at the pathology of their mechanics of breathing, you will find that their bronchus closes up and constricts very easily upon exhalation not wanting to let the air escape. this is why pursed lip breathing is taught. still, these patients have the overwhelming fear that they are suffocating. and, it is a powerful emotion. what i found over the years was to take some extra time with these patients. to spend (or at least seem to them that i was spending) more time with them. i would poke my head in the room every time i passed by, even if it was to say "hi, how ya doing". this, i think, gives them some relief that they are being watched. because of their behavior most of the staff will steer clear of them. they kind of get that. so, i would be very unafraid about introducing myself to them, telling them my name and urging them to call for me it they needed anything. then, when they do call for you, you just have to attend to what they want even if the requests are silly. i made conscious efforts not to let any irritation i had about their constant call light ringing show. i often would sit at the besides of these people doing my charting just to be company for them. your presence can be a powerful nursing tool. developing this trust is important because once that trust develops, most of these people settle down for you. once they feel comfortable that if they call for help you are going to be right there, some will start to act almost like normal people again. and, if you get to know them well enough you can even talk with them about this behavior. they will tell you about the feelings of suffocation and of the fear of dying and no one being able to hear their cries for help. it will bring tears to your eyes. the worst part was seeing them come in time and time again and seeing their conditions getting worse on each admisstion. eventually some of them get tubed or trached and put on ventilators.

i had one lady who was a real pita, as you say. by her last admission she knew many of us on the staff by name and she wasn't near the pita that she was a few years before since the place was more like home to her and she was extremely weak. she ended up being tubed and placed on a vent. she really looked scared then, but she seemed a lot calmer. she stroked and was kept on our stepdown unit as a dnr. she died peacefully on the vent. her heart just gave out. i always remember her because of what a fighter she was. isn't that all any of us wants? to live. well, i think that's a good deal of what is going on in the minds of these end stagers.

i've been a patient a few times recently. do you know how many times my nurse or the nurses aide came into my room? very few. i was alone in my room for hours at a time. i thought of how different i was as a working nurse. i was constantly on the go and constantly letting my patients know i was around and looking in on them.

[MURSE21]

It would have been interesting to see what stage of COPD she was in using the GOLD assessment. A simple spirometry may have been beneficial.