So I'm caring for my patient with COPD who came in with chest pain, ended up not having any cardiac compromise... pt has a history of anxiety, fibromyalgia, COPD, and ascites. Pt on 2L NC, satting anywhere from 90-96%, but says "I'm on 3L at home."
Pt has been on 2L NC whole 2-day stay, develops a spike in back pain and becomes anxious. The cardiac fellow just so happens to walk in at this time, and pt's oxygen is still fine, but mentions it to the doctor that 3L at home. Doctor says, "put them on 3L." I state, "they have COPD, and we are trying to keep their oxygen between 88-92%, and they've been on 2L their whole time here." Dr. "put on 3L anyway." "OK"
I come out of the pt's room, and the dr. says "Don't ever argue with/question a doctor in front of a patient. I'm a doctor, you're a nurse. If you want to be a doctor-go to medical school. Besides, they're on 3L at home." My response: "that doesn't mean they need to be on 3L."
I discussed this with the ICU/Pulmonary attending and he completely agreed with me, and said "she obviously doesn't know what she's doing and is rude!" However, I'm sure this lady is going to try to cause trouble for me as she intently stared at my badge and wrote down my name!
Part of being a nurse, especially in the ICU is being a patient advocate and speaking up about clinical issues for the patient. I didn't think this was out of line, but she sure did! Was she implying by her statement, that my suggestions were not characteristic of nursing?
She should have been kept at 3lmp-that's how she received insurance coverage! What you were making such a big deal about was stupid, I'm sorry. The difference in oxygen levels were 4%-
Anne
COPD patients can go into respiratory failure with too much oxygen. It overrides their drive to BREATHE.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
so i'm caring for my patient with copd who came in with chest pain, ended up not having any cardiac compromise... pt has a history of anxiety, fibromyalgia, copd, and ascites. pt on 2l nc, satting anywhere from 90-96%, but says "i'm on 3l at home."
pt has been on 2l nc whole 2-day stay, develops a spike in back pain and becomes anxious. the cardiac fellow just so happens to walk in at this time, and pt's oxygen is still fine, but mentions it to the doctor that 3l at home. doctor says, "put them on 3l." i state, "they have copd, and we are trying to keep their oxygen between 88-92%, and they've been on 2l their whole time here." dr. "put on 3l anyway." "ok"
i come out of the pt's room, and the dr. says "don't ever argue with/question a doctor in front of a patient. i'm a doctor, you're a nurse. if you want to be a doctor-go to medical school. besides, they're on 3l at home." my response: "that doesn't mean they need to be on 3l."
i discussed this with the icu/pulmonary attending and he completely agreed with me, and said "she obviously doesn't know what she's doing and is rude!" however, i'm sure this lady is going to try to cause trouble for me as she intently stared at my badge and wrote down my name!
part of being a nurse, especially in the icu is being a patient advocate and speaking up about clinical issues for the patient. i didn't think this was out of line, but she sure did! was she implying by her statement, that my suggestions were not characteristic of nursing?
i think the physician was out of line, not you! you are right -- part of being a critical care nurse is being a patient advocate. and part of being a patient advocate is questioning orders that you don't understand or that you disagree with. if it's done tactfully, i don't see a problem with questioning orders in front of the patient. after all, you aren't questioning anyone's competence, are you? you're just making sure that you understand the order and the rationale.
when i started out in icu in a teaching hospital a quarter of a century ago, my preceptor told me "part of your job as an icu nurse is to keep the residents from killing the patients." she was right. it may be residents who haven't learned as much as they think they have, hospitalists who are too tired to think straight or pulmonologists who have confused this patient with the one in the next room -- our job is to protect the patient!
COPD patients can go into respiratory failure with too much oxygen. It overrides their drive to BREATHE.
I seriously doubt you'll send a person into drive failure by merely increasing their FiO2 by 4% (and that's assuming they breathe through their nose!).
Of course, I seriously doubt there being any clinical indication for upping the O2 besides the need to have exert some control in patient decision making on the part of the perhaps less than useful consultant.
I had a neuro patient who was exhibiting changes and increasing difficulty keeping his airway open. I came out of the room, told the secretary to page the RT and neurosurgeon and intensivist. The intensivist happened to be sitting two doors down, said, "Oh, calm down B, don't page anybody, just suction the guy." I told the secretary to make those pages and for him to get his *** in the room. My pt was intubated and on his way to the OR about 15 minutes later. He ended up having a massive hemmorhage and resulting midline shift. NEVER tell me to calm down.
Specializes in CCRN-CMC-CSC: CTICU, MICU, SICU, TRAUMA.
I love that.
I had a neuro patient who was exhibiting changes and increasing difficulty keeping his airway open. I came out of the room, told the secretary to page the RT and neurosurgeon and intensivist. The intensivist happened to be sitting two doors down, said, "Oh, calm down B, don't page anybody, just suction the guy." I told the secretary to make those pages and for him to get his *** in the room. My pt was intubated and on his way to the OR about 15 minutes later. He ended up having a massive hemmorhage and resulting midline shift. NEVER tell me to calm down.
....And that's why you need a nurse to save your life... good work!
Since the pt wears 3l at home, maybe the Dr realized the pt was anxious about being on 2l in the hospital and wanted to be bumped up. Nothing like a little placebo affect from that insignificant rise in fio2. Just another perspective.
What was the patient's HGB? If HGB is low, the O2 Sat monitor reads the O2 in the HGB, and the patient very well may have been needing some extra O2. Decrease in HGB = decrease in the ammount of O2 circulating in the pt's system. There is also changes in blood gases that can precipitate increase or decrease in the rate of O2. I did not here those things mentioned. Besides, I would have still waited until outside the room to discuss this with the physician... Out of respect.. and as a common courtesy, according to the way I want to be treated. We are ALL part of the health care team.
This is how i look at it.... Im giving my pt a bath with the help of a PCT. The pt has a chest tube. The PCT says, "Dont you think you need to change that chest tube dressing?"... to which I politely reply, "Yes, I change my dressings after the pts bath so that the tape and gauze do not get saturated with the bath water."
That way, even though my "nursing practice" was "questioned" in front of my pt, I still handle the situation in a professional way without belittling and causing animosity between other parts of the healthcare team. arrogant doctors- cant work with them, cant work without them...
I seem to remember discharging a pt who was to be new to home o2 and that certain level of spo2 must be documented on a certain level of oxygen in order for the pt to be able to receive insurance coverage. And I believe that cutoff is 3L.
SaraO'Hara
551 Posts
COPD patients can go into respiratory failure with too much oxygen. It overrides their drive to BREATHE.