tachypnea symptom.

[oncalllorraine]

6 years as a hospice nurse, and i recently had a new situation tha36-5t i was not sure how to handle symptom control. this patient was actively dying, peaceful,unresponsive,pain-free,afebrile...yet, so tachypneic! his respiratory rate, though non-labored , was 36-52 rr./min. regular for over 12 hours before he finally passed. there seemed to be no associated distress-and i felt that using roxanol to slow him down did not seem appropriate, somehow. it was like he was 'finishing a race'-which of course he was...and i let him do it. any comments? his underlying disease was motor neuron (als)and he was not congested.getting occas.dosing of roxanol to assure comfort only. any ideas on cause or treatment options, or your own experiences -let me know. thank you!

[leslie :-D]

respiratory failure is almost always the final outcome with als.

and roxanol, ativan would have been most appropriate.

roxanol is always indicated for dyspnea.

i'm sorry your pt experienced that...

leslie

eta: Symptom Management of the Patient With Amyotrophic Lateral Sclerosis: A Guide for Hospice Nurses

http://www.medscape.com/viewarticle/578915

may need to register at medscape.

[ghillbert, MSN, NP]

I am not hospice. But if I had a patient who was imminently dying, with a RR up to 50bpm, you'd better believe I'd be giving morphine.

[leslie :-D]

it was like he was 'finishing a race'-which of course he was...and i let him do it. any comments?

and yes, i do have 1 final comment.

i think you let this pt down.

i'm upset, esp as a hospice nurse, you should have known better that tachypnea is a sign of distress.

that's all i'll say in terms of criticism.

leslie

[truern]

Just wondering how you knew a patient with a RR that high was peaceful and painfree if he was unresponsive??

[leslie :-D]

Just wondering how you knew a patient with a RR that high was peaceful and painfree if he was unresponsive??

what bothers me, is folks with als almost always anticipate and fear their forthcoming resp insufficiency.

leslie

[GrumpyRN63, ADN, RN]

I had this same circumstance w/ a pt yesterday. Unresponsive, eyes open, gaze fixed, working @ 50/min, I considered the pt to be quite distressed, switched her to Haldol 1 mg sl, doubled her mso4 to 20 mg q2hr, slapped an extra fentanyl patch on, upped her 02, anything I had in my orificenal to ease/manage the sx's. She passed about 6 hrs after my visit, I did the pronouncement, family said she was able to calm down moderately prior to her passing, whatever she was 'working through' might have been pain free (never had pain), but it certaintly wasn't peaceful , I couldn't let that continue until she ' worked it out', dyspnea is distress ie suffering, it requires tx, I wouldn't let an animal go thru that, JMTC

I also don't understand how someone could be breathing @ 36-50 and it be non-labored?

[americanTrain]

Always use Roxanol for pain/increased respirations.

Resp that are above 20 is indicative that something is wrong.

We are taught in nursing school to watch for abnormals.

I would have used Roxanol 20mg/ml ; 0.25ml - 0.5ml sl 1 q1 hr prn.

I second the comments of Lesie and Truern

[mc3, ASN, RN]

Sorry, but yikes! 36-52? Imagine how you'd feel if you were breathing that hard? Death isn't a race to the finish line. The rate alone would tell me it's labored breathing. As the others have said, Roxanol and Ativan should have been used. As much I hate it, this is how we learn from our mistakes...

mc3:nurse:

[Whispera, MSN, RN]

Sometimes the only way a dying patient can indicate pain (physical, emotional, spiritual) is through increased heart or respiration rate. I think the patient in question was in intense pain.

Warm hugs for your caring--next time you will know what to do!

[tencat]

Sorry, I have to agree with the others. I'd rather err on the side of too much medication for a patient than not enough, especially when they are actively dying and cannot communicate.

[rnboysmom]

Agree with the others although morphine is usually our first chice. Dyspnea, tachypnea, even mild is distressing to any patient, and should be considered a priority. We utilize roxanol 0.25 to 0.5ml every 15 minutes until symptoms resolve then calculate how much it took to get the patient comfortable and utilize a range PRN Q hour thereafter (ie, 4 X .5 doses= 40 mg ) would be 20-40 mg hourly as needed to control dyspnea. We try to get a "may repeat" for the 15 minute order as well.

We make the mistake of telling our families that hospice will make their loved ones death a peaceful experience---sometimes that is not true. We should, instead, tell them that we will do everything we can to make the experience as comfortable as we can possibly make it. I have been in the field, and on call for hundreds of deaths, and there are those VERY FEW that, despite everything you have available in your orificenal, aren't as comfortable as you would have wanted them to be. We are only human--what allows us to sleep well at night is the clear conscience of knowing that we did everything within our human powers to make them as comfortable as we could have possibly made them, to do less, is to have failed them and ourselves as hospcie nurses.