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!
Morphine is the answer. But you tried to express that there may have been some other factors which were not evidence based which precluded your feeling morphine was what your pt needed. That happens to EVERYONE once in a while. But for this circumstance Roxanol with re-assessment was appropriate. When the rate decreased with, say 10-20mg SL, you may have chosen to direct the family to use q 2 hours (or whatever worked).
Another stratagy I have is to think, "if this was me what would I need?"
Live and Learn kuddos for caring and asking. Your next pt will be happy.
I don't want to criticize but I agree with all of the above. In my mind a respiratory rate that fast = air hunger... I wouldn't want to die feeling like I was starving for air.....next time give the meds...liberally and often. When a patient is actively dying I don't really worry about giving too many meds, my only focus is to keep them comfortable and anxiety free which means roxinol or oxyfast and ativan intensol as often as they need it.
Don't beat yourself up over this one though, use it to learn for the next one.
I am in med/surg, not hospice, but I do have an interest in hospice down the road. I'd like to add that I occasionally have alert and oriented med/surg patients with respirations in the 30's who deny pain. They just have shallow and rapid respirations. I get my fair share of COPD patients...and...with me being a relatively new nurse, whenever I assess anything that appears to me to be out of the norm on a pt, I always have a more experienced nurse come in to check the pt for my peace of mind.
I had a pt a few months a go who was lethargic with respirations in the 40's. I called the pulmonologist because I was sure she needed to be transferred to ICU. He ordered stat ABGs and a CT to rule out a PE. Long story short, she never was transferred to ICU and went home looking like a completely different woman the following week.
I personally feel that you were much too critical of the OP. Tachypnea is not always an indication of discomfort.
No tachypnea isn't always an indicator of pain but in a dying person who is otherwise unresponsive it's either pain or anxiety, either way you don't want to leave someone in that state from the hospice perspective. We want them comfortable, it doesn't really matter why they are tachypneic when they are in the dying process we just don't want them to stay that way, it's much kinder to give them something to ease their breathing.
I am in med/surg, not hospice, but I do have an interest in hospice down the road. I'd like to add that I occasionally have alert and oriented med/surg patients with respirations in the 30's who deny pain. They just have shallow and rapid respirations. I get my fair share of COPD patients...and...with me being a relatively new nurse, whenever I assess anything that appears to me to be out of the norm on a pt, I always have a more experienced nurse come in to check the pt for my peace of mind.
I had a pt a few months a go who was lethargic with respirations in the 40's. I called the pulmonologist because I was sure she needed to be transferred to ICU. He ordered stat ABGs and a CT to rule out a PE. Long story short, she never was transferred to ICU and went home looking like a completely different woman the following week.
I personally feel that you were much too critical of the OP. Tachypnea is not always an indication of discomfort.
Tachypnea in a post-surgical patient is not the same as an actively dying patient with RR in the 50s.
i am in med/surg, not hospice, but i do have an interest in hospice down the road. i'd like to add that i occasionally have alert and oriented med/surg patients with respirations in the 30's who deny pain. they just have shallow and rapid respirations. i get my fair share of copd patients...and...with me being a relatively new nurse, whenever i assess anything that appears to me to be out of the norm on a pt, i always have a more experienced nurse come in to check the pt for my peace of mind.
w/med-surg, there can be many variable processes occurring.
even fever will increase rr.
it may not be "pain" as we visualize it, but it is still a stressor and needs addressing.
i had a pt a few months a go who was lethargic with respirations in the 40's. i called the pulmonologist because i was sure she needed to be transferred to icu. he ordered stat abgs and a ct to rule out a pe. long story short, she never was transferred to icu and went home looking like a completely different woman the following week.
i personally feel that you were much too critical of the op. tachypnea is not always an indication of discomfort.
unless tachypnea is someone's baseline, it is uncomfortable.
you were correct in calling the pulm doc.
and pt was managed on the med/surg floor.
but she was still 'managed' with whatever meds/txs she got.
as for this hospice pt, als destroys your body piece by piece, function by function.
furthermore it is the als pt's worst fear, that when their diaphragm/lungs fail them, they will suffocate to death.
a rr in the 50's is a clear indicator of resp insufficiency.
given that we are trained to treat the whole pt (body, mind, spirit), and the op being a hosp nurse x 6 yrs, i just cannot understand how/why this happened.
she truly failed that pt and there's no getting around it.
nor will i try to sugarcoat it.
as another poster stated, hospice is very different than any other specialty.
and it commands a whole lot more consideration in how we approach and treat the pt.
please learn much more about hospice before you decide to pursue it.
Specializes in psych, addictions, hospice, education.
I'd like to suggest that we let the OP rest on this topic. I believe she understands things now and to continue as things are going isn't likely to help her understand better....
I'd like to suggest that we let the OP rest on this topic. I believe she understands things now and to continue as things are going isn't likely to help her understand better....
Whispera, the OP hasn't been back to allnurses since starting this thread. I believe she already knew what would be said when she posted
May I add one thing? Perhaps the OP was seeing kussmaul's respirations. If the pt had a reason to be very acidotic, ie renal failure, resps become deep, fast and "machine-like".
When I've seen it, it seems to be pretty resistant to opiates ... we keep pushing it anyway but it takes a lot of morphine to make a difference.
I would have given Roxanol, and possibly Ativan also. But please, hospice colleagues, let's remember Lorraine has six years experience, obviously cares, and unlike the rest of us, ACTUALLY KNEW THE PATIENT. Was there something happening in that home that we're not aware of?
There is nothing worse than calling into the office (or hearing the day after a 2 am crisis) .... "what do you mean you didn't...? " or "Don't you think you should have...?"
Of course none of us get it right all the time. Good for Lorraine for soliciting opinions.
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pammyf
21 Posts
Morphine is the answer. But you tried to express that there may have been some other factors which were not evidence based which precluded your feeling morphine was what your pt needed. That happens to EVERYONE once in a while. But for this circumstance Roxanol with re-assessment was appropriate. When the rate decreased with, say 10-20mg SL, you may have chosen to direct the family to use q 2 hours (or whatever worked).
Another stratagy I have is to think, "if this was me what would I need?"
Live and Learn kuddos for caring and asking. Your next pt will be happy.