What did I see???

[nerdtonurse?, BSN, RN]

Okay, had a pt that was a DNR (thank GOD!) the other night. Lungs full of fluid, agonal resp, obviously dying (NPO, PEG, ESRF, CHF, COPD, DM, MRSA, pretty much all the rest of the alphabet as well). I did my initial assessments, did the 2100 med pass (he only had an IV antibiotic, which he'd had for the prior two days, no prob), and went back by and stuck my head in pt. X's room before I tried to chart ---

It looked like he had thrown up Pepto-Bismol, but it was a darker pink. It's just pouring out of his mouth. It was bloody froth. I hit the button and yelled for help, started suctioning, etc. His O2 sats went down in the 40's, never came up, and he passed a few hours later (the doc made him comfort care, so we didn't have to do anything invasive, thank goodness). I guess it was coming from pulmonary edema, but I'd never seen that "Pepto" effect before. So....what the heck was that, and if the person hadn't been a DNR, would anything we did have helped? We're on a tele / ICU stepdown floor, and had the person not been a DNR, I'd have yelled for the US to call the ICU and get security to open all the doors between, 'cause we'd be coming NOW. But for that next time, what would would you guys recommend as the first initial interventions (after thinking "HOLY ****"). Thanks!

[babynurselsa, RN]

That IS pulmonary edema. Think pink frothy sputum.

IV Lasix, bipap, or intubation this would have given some peep to try and force some of the fluid out of the lungs. Pressors also possibly.

[Virgo_RN, BSN, RN]

Classic flash pulmonary edema.

Even a DNR can get IV Lasix and Bipap. This might have pulled him through it. But since he was made comfort care, this is why these things weren't done. DNR just means Do Not Resuscitate, meaning no CPR/defibrillation/intubation. Lasix and Bipap are none of those, so they would be permissable for a DNR.

[ghillbert, MSN, NP]

Definitely - drowning would be a horrible way to go!

[joeyzstj, LPN]

If the patient was a full code, I probably would have went ahead and prepared to intubate. The initial thing that you should do if the patient is a full code is simply revert back to protecting the airway as in you ACLS training (ABC's). Suctioning and possibly bagging with an ambu would be a good choice as well. Most of the time it takes Respiratory some time to go grab a bipap, set it up and get it on the patient. If you patient had sats in the 40's I probably would have someone call the doc while I prepared for intubation after providing 100% Fio2 and suctioning.

[nerdtonurse?, BSN, RN]

Thanks everyone. I know I'll see this sort of thing again, and I'll remember. I did call the doc to get an order for lasix, just as a comfort care thing, but he was in complete kidney failure, and we got nothing. I was very glad he was a DNR.

Thanks again.

[PalmoRN]

Wow!

I'm a new RN and reading the post/question and replies was a big help to me also...

I know in class that they teach us about the classic "pink frothy" but I've never actually seen it.

[jennifer79RN]

Thank you for this post. I, too have never seen the "pink frothy" sputum, however I did have a patient go into flash pulmonary edema one night and was able to reverse the process by administering IV lasix and putting pt on bipap. I agree with a PP who mentioned that being a DNR means we just don't do CPR,etc. I have had many new nurses (I'm still pretty new myself) who don't fully understand that we treat up to the point of CPR/intubation. I have seen many times where our interventions on a patient who is a DNR saved the person from coding and ultimatly passing away. Although, the hospital I work for keeps going back and forth between bipap being allowed for a pt who is a DNR.

Jennifer