rapid response on new admit

[PaigeRN90]

Hi everybody..I am a new grad on a med tele floor. I recently (on my last day of orientation actually) had a new admit around 1am, a "frequent flyer" who came in with a diagnosis of pneumonia and respiratory failure. She was not admitted with any ABGs drawn and was not admitted on telemetry (not everyone on our floor has telemetry). She came with her home bipap machine which RT set up-her vital signs were fine, O2 sats were good. Around 5am I went to hang vancomycin and she was sleeping on an off. I went back about 20 minutes later to do something else (cannot remember what now) and the patient was in extreme respiratory distress, obviously fighting to breathe so I go an O2 sat on her and called a rapid response. Her O2 sat was 15% and she started turning blue and became unresponsive. We got a nonrebreather on her in time so she did not code (thank god) and by the time the rapid team got there her sats were bouncing around from 70s-90s. We did an EKG, ABGs, etc. and she was in extreme respiratory acidosis so she was transferred to ICU immediately. Long story short...I'm wondering what I can do in the future to better help patients like this? I just worry that had I not gone in to check that patient 20 minutes after I hung that antibiotic, she could have easily died since she was not on any monitors and was not able to yell for help (she had her call light but she was the most mobile woman because she was over 450lb+). Any advice would be great...I honestly cannot keep thinking about how glad I am that I went back in that room, but I want to make sure that I don't just get lucky next time!

[iluvivt, BSN, RN]

I would have called MD for an ABG order and requested telemetry. Did she have a cardiac history at all? Was she given any medication that may suppress her respiratory effort? Hindsight is 20/20 but is is good that you are thinking about these things because that is is how to grow your knowledge base and skills. I would have also checked on her after her CPAP or BIPAP was set up to make certain it was set up correctly and leave cont O2 sat in place. If you could not get the orders you thought you needed one option is to know she is at a high risk for respiratory distress and failure and watch her like a hawk. Also use your chain of command if you think you need another nurse to assess or to get orders you need. Honestly she sounds like she should have been placed in ICU from the start. I believe that patients are at a higher risk just after admission from the ED since often the clinical picture has not fully emerged and many are still unstable. I even have had patients die on me as we were moving them from the gurney to a med-sug bed and also when we took a look at them said,"what are you kidding me they need to be in an ICU".

[MunoRN, RN]

Pt's on BiPAP, particularly those admitted for Resp failure need to be on continuous pulse ox. You'll find a fair amount of variation in monitoring standards from facility to facility, but it's my impression that this one is pretty standard.

[turnforthenurse, MSN, NP]

Pt's on BiPAP, particularly those admitted for Resp failure need to be on continuous pulse ox. You'll find a fair amount of variation in monitoring standards from facility to facility, but it's my impression that this one is pretty standard.

Even if you didn't have orders for a continuous pulse ox, I would have stuck one on the patient. I also would have called the MD for orders for tele and an ABG. Where I work, any patient with respiratory failure and is on BiPAP has at tele orders and an ABG.

[Sun0408, ASN, RN]

Check you policy, like others have already stated a contentious pulse ox would have been warranted in this case or any case a pt is on Cpap or Bipap. Even without an order, I would have placed one and called for an order. Resp distress would = a ABG from the start...

[gb8852]

At my hospital when a patient is using a cpap/bipap we do not use continuous pulse ox unless there is an order written.