Sorry another ques. Was this write up justified?

[mondkmondk]

I came in to work one day and got report from the day shift nurse that a resident's wife thought he wasn't acting right and wanted to know if he should go to the hospital. The day shift nurse assessed him and couldn't find anything really wrong so she just reassured the wife that since he'd just had a stroke, that his symptoms were synonomous with that diagnosis.

So here I come to do my assessments. After checking his vitals, his respirations were 32/min. but his O2 sat was 99%. We got him up for supper and he did really well (I documented all this carefully). After putting him to bed, I went to check on him b/c wife said she would call at bedtime. I noticed he was having 20-30 sec. periods of apnea and wasn't responsive. I was unable to get a B/P on him and his pulse was nearly non-existent. I checked his chart and he was a full code, so I immediately called the ambulance, gathered up the crash cart and placed him on O2. We transferred him to our local hospital (rural) and they then transferred him to a bigger city hospital.

My DON wrote me up for not recognizing the early symptoms of respiratory distress, as evidenced by the resp. rate of 32 initially. She said I should have called the doc right then and there and placed him on oxygen. My only argument was that his sat was 99%. Does this write up sound valid?

Blessings, Michelle

[noc4senuf]

With the only sign that was off being a resp rate of 32. I wouldn't have immed called but, kept a close eye on him. What was his normal rate? Some do run higher than others.

[Emergency RN]

Sorry, but IMHO, Yes.

No offense, but one should consider what his O2 sat would have been if he was breathing normally. In effect, his sat was normal only because it was rate compensated. Once the pt became too exhausted to continue to breath at that fast rate (in other words, he was working his tail off to do it) his respiratory system just collapsed. You likely found him already with agonal respiration and pulse. Instead of just placement on O2, the patient should have been actively ventilated with 100% O2 via BVM (ambu).

In essence, shortness of breath, even mild to moderately, should be paid very close attention to. O2 saturation is only a number. One always needs to look at the patient overall; are there retractions, is he tripod posturing, what did his lungs sound like, etc. ie. overall respiratory effort or the work of breathing. In this case, the moderately higher resp rate was the harbinger to impending respiratory arrest.

[noc4senuf]

It all comes down to what is his norm. We currently have a resident that the norm for heart rate is around 36.

[cimplyc60]

Michelle,

I would have opted to give you a verbal warning and provide additional education to insure that this didn't happen again. Yes, the patient was exhibiting signs of respiratory distress but it sounds like both nurses could use additional education in this area. As managers, we have to make ure that we are not setting nurses up for failure and it is our continued responsibility to provide additional training where needed. Good question.

[mamamerlee, LPN]

I would definitely question a resp rate of 32, esp if his normal was 20 or less. And I would not have orally fed a patient with a resp rate of 32 - - increased chance of aspiration. Try to not worry about this too much - - you've just had an education.

[tencat]

Ummm.....maybe a write up was a bit harsh, but you were in the wrong. Are you a new nurse? I think it depends on your level of experience, any other occurrences that have happened before with you (I'm not saying there are any, I'm just saying that if there are, that would be taken into consideration). If you are new with no issues, then a write up was a bit harsh, I think. If you have experience, then probably you should have recognized that 32/min respirations is really not 'normal' for most people, and if it were different for him, then it should have been addressed.

[phoenixrn]

If a patient is breathing that rapidly, wouldn't they be blowing off too much CO2, and possibly becoming alkalotic? Or perhaps, could they be acidotic and blowing off extra CO2 as a result? That was my train of thought... I'm a new nurse.

[Da_Milk_of_Amnesia, MSN]

Treat the patient not the monitor.

[Emergency RN]

it all comes down to what is his norm. we currently have a resident that the norm for heart rate is around 36.

well, yes and no.

despite someone being totally asymptomatic with a heart rate of 36 (classic normal being 60-120 beats per minute), one has to especially careful not to be too dismissive. though he may be perfectly functional with no distress at a hr of 36, it has to be remembered that there is very little in terms of leeway or reserve; eg. he may easily pass out say, with a hr of 30. that is, since his hr is already so low, each decreased beat is functionally a much larger chunk of his cardiac output.

example: a rate drop of six beats from 86 to 80 is a loss of about 7%. however, that same six beats less from 36 to 30 would lose about 17%. since cardiac output is heart rate x stroke volume, a decrease of 6 beats alone in someone with an already very slow heart rate generally means a much larger negative impact on cardiac output.

the point is, if patients reside next to a physiologic cliff, it's quite easy for them to fall off. imho, a patient such as this always bears closer watch, despite (or especially because of) his historic abnormal normal.

[P_RN, ADN, RN]

OK this isn't about my heart rate, BUT I run a respiratory rate of between 8 and 10. Consistently for my entire life. NO one has ever made a comment and NO one has ever documented it correctly. Have you noticed all vital sign respirations are 20 on everyone, always? Well not my pulmonologist-he always comments.

At least you were willing to do a respiratory assessment and mini health assessment rather than jump up and grab the phone and call the doctor. You know what his next question will be? What are his sats, what is his hgb/hct etc.? He can have 100% sats AND have a hct of 21-BAD. Those whole 7 gms of hgb are totally saturated.

If your writeup were purely punative, where is the validation of writing it. Someone have it out for you? At the most it would have been an anecdotal note in my opinion.

[Darknights]

I am an Australian RN. In my state, NSW, we are currently introducing a new obs chart so every facility whether acute or long term care is using the same documentation. It is colour coded with coloured regions indicating when an observation falls within an area that will require a clinical review within 30 minutes, or critical - requiring a medical emergency team. The people who developed the DETECT programme considered that respiration is usually the key and earliest predictor for a patient's deterioration, yet usually the one observation that is poorly done.

A when to worry early warning sign requiring review within 30 minutes are resps 5-9 or 31-40. A late sign requiring immediate MET intervention are resps 40.

If a patient's normal obs lie within the coloured regions and it is acceptable to the medical team then this must be documented on the front of the chart.

Unfortunately the new chart is being introduced due to the ongoing failure of nurses to identify and manage deteriorating patients.