Collaborating with HCP: Initial Orders – COPD Nursing Care in ER

by Rhonda Lawes, PhD, RN

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    00:00 So let's look at what the health care provider wrote as initial admission orders for the patient.

    00:07 So we know they've already been admitted to ER.

    00:09 Now first, arterial blood gases stat, repeat in 1 hour and 4 hours.

    00:16 You're gonna do your blood gases, you're gonna draw an arterial sample and you're gonna do those immediately. Stat means right now.

    00:24 That is a huge priority word when you see the word stat.

    00:27 Now, you're gonna note the time that you draw those stat because you're gonna repeat it in 1 hour and 4 hours.

    00:33 So you're gonna have to add that to your list to make sure you don't miss that.

    00:36 Some people set timers on their watches but it depends on how many patients you have, how many timers you have, but you're gonna have to figure out what's the best system for you to not forget time the lab work and medications.

    00:49 Now, the next order's a little longer.

    00:51 Titrate oxygen on nasal cannula, one liter, q15 means every.

    00:58 The q is medical shorthand for every 15 minutes to maintain a pulse ox between 90 and 93%.

    01:06 Now, the next part says if unable, change oxygen to Venturi mask.

    01:13 Okay, wait, so I'm titrating oxygen and if that doesn't work, I'm going to change oxygen to a Venturi mask.

    01:20 Oh, that's just a different delivery method.

    01:23 Nasal cannula is a little prongs that have a tubing that go around your ears and down under your neck.

    01:28 Venturi mask involves a mask and a special way to adjust the oxygen.

    01:33 So I've got that. A Venturi mask is gonna deliver more precise oxygen to the patient.

    01:39 So titrate oxygen on Venturi mask every 15 minutes between 6-15 liters to maintain a sat between 90 and 93.

    01:49 So I know the target identified by the health care provider for Mrs. Taylor's sat is between 90 and 93.

    01:56 You gotta try and make the nasal cannula work as long as possible.

    01:59 If it doesn't, then I'm gonna change to a Venturi mask, still with the goal of maintaining that sat between 90 and 93.

    02:07 Now, you and I, I wouldn't be feeling great with a sat at 93 but I don't have COPD.

    02:13 That's why they're willing to tolerate a sat of 93 for this patient because of the diagnosis of COPD.

    02:19 Maintain continuous oxygen saturation.

    02:23 That's gonna be with a pulse ox.

    02:25 So we do the ABG that gives us precise data about what's going on right from the blood and we're gonna do a pulse ox to kinda give us a running estimate of what the saturation is from a monitor on the patient's finger.

    02:38 12-lead ECG is gonna let me look at the heart from all different angles.

    02:42 Why? Well, COPD increase risk for cor pulmonale.

    02:47 We wanna make sure their heart is still functioning well because those are obviously interconnected.

    02:52 The breathing treatment with 2.5 mg of albuterol in 3 mL every 1-4 hours as needed.

    03:01 Okay, so I can give that every hour if I need to, to get things under control.

    03:07 So when you see breathing treatment with 2.5 mg of underlying with that medication is, that's albuterol.

    03:15 That's a what type of medication? Right. It's a short-acting beta2 adrenergic agonist.

    03:26 So albuterol will hit those beta2 receptors on your lungs, bronchodilate, and that's why they would be getting that from Mrs. Taylor.

    03:35 Now, we've got the amount that we're gonna give, 2.5 mg in 3 mL and how often we can give it.

    03:42 So I'm already storing away in my mind.

    03:44 This is one of the weapons I have to help deal with this.

    03:48 I've got breathing treatments and I can give them every hour.

    03:50 Now, I know it's gonna make her heart rate go up so I'm gonna also keep an eye on that but I'm gonna track closely what time she receives these treatments so I know how long it is before she can have another one.

    04:02 Now, methylprednisolone, 60 mg every 12 hours and I wanna give it IV.

    04:08 So what do you know about methylprednisolone? Good. That's a corticosteroid.

    04:15 So we're trying to knock out the inflammatory process of what's going on in her airways.

    04:20 So 60 mg every 12 hours.

    04:22 Are you gonna immediately see a big difference in her breathing ability? No. Remember, it takes a while for those to really take effect so corticosteriods are important and we're giving it IV so that's like, a whopping dose, right? Straight into the blood stream. We're thinking about it from pharmacology.

    04:41 There's no need for absorption because she doesn't have to take a pill and wait for it to go through the rest of her body.

    04:46 It's going straight mainlined into her bloodstream.

    04:50 So there's some initial orders.

    04:52 These are pretty typical for somebody with COPD and why the health care provider might order each one of those.

    04:58 Now, a chest x-ray to rule out pneumonia.

    05:02 Well, with most COPD patients, we wanna make sure that their shortness of breath, we wanna look at the underlying cause.

    05:07 Is it just the COPD or is there something else going on? Now, what else do you remember from Mrs. Taylor's history that makes pneumonia a real possibility? Cool. I hope you said, well, because remember she had that respiratory infection.

    05:23 That's what the daughter told us. Awesome. So she might have pneumonia.

    05:28 Now, pneumothorax would mean air that had caused a lung to collapse.

    05:33 Pretty sure she doesn't have that from her assessment, how it looked different to us but the chest x-ray will rule that out for sure.

    05:40 Now, she might have pulmonary edema.

    05:42 Our guess is she doesn't because we listened to her lung sounds front and back and we know that pulmonary edema usually starts in the back and the bases if we're gonna auscultate it. But she could.

    05:54 We wanna rule it out. Or we're looking for a pleural effusion.

    05:58 So just because you have COPD, you could also have some other pulmonary problem going on and a chest x-ray will help us identify that.

    06:07 Now, lab work that you could expect would be a CBC, a complete blood count, and differential so we're gonna see red blood cells, white blood cells, platelets.

    06:16 We're gonna look at the H and H.

    06:18 When we say differential, we're gonna be able to see what the percentage breakdown is of the 5 different white cells on a CBC.

    06:26 Also look at electrolytes, glucose, and a sputum culture and sensitivity.

    06:32 Sputum, phlegm, it's my least favorite thing but it's a huge part of COPD.

    06:39 So why are we getting a sputum culture and sensitivity? Well, we know she had a respiratory infection, she has significant respiratory symptoms, she has COPD, and we're probably thinking with that infection, could be pneumonia and a sputum culture will help the health care provider order the most specific antibiotic.

    07:01 Why does that matter? Yeah, because antibiotic resistance stinks.

    07:05 So if they determine that they need to start around an IV, they will -- or start an antibiotic, they'll start an IV that's very broad spectrum.

    07:13 When they get the results back from that culture and sensitivity, that lab work will tell the nurses who are caring for Mrs. Taylor this is specifically the organism that is growing in her lungs if one is and these are the medications that will kill it.

    07:29 So the health care provider can look at that.

    07:32 When I say kill it, it means what it's sensitive to.

    07:34 The health care provider will look at those results and may change the broader spectrum antibiotic to a more narrow spectrum antibiotic.

    07:42 Why is that important? Because the more specific we can get on the type of antibiotic that's used, we reduce the risk of increasing microbial resistance making superbugs like VRE or MRSA.

    About the Lecture

    The lecture Collaborating with HCP: Initial Orders – COPD Nursing Care in ER by Rhonda Lawes, PhD, RN is from the course Respiratory Case Study: Nursing Care of COPD Patient.

    Included Quiz Questions

    1. The order takes the highest priority and needs to be done immediately.
    2. The order needs to be done with some urgency.
    3. The order needs to be done as soon as possible (ASAP).
    4. The order needs to be done within 30 minutes.
    1. Venturi mask
    2. Ventilator
    3. Nasal cannula
    4. Inhaler
    1. The client has chronic obstructive pulmonary disease (COPD) and requires a lower baseline oxygen saturation.
    2. The client is experiencing respiratory depression.
    3. The client has a low CO2 level.
    4. The client has influenza, and it is normal to have low O2 saturation with influenza.
    1. Short-acting beta 2 andrenergic antagonist
    2. Long-acting beta 2 bronchodilator
    3. Short-acting beta 1 agonist
    4. Long-acting beta 1 andrenergic agonist

    Author of lecture Collaborating with HCP: Initial Orders – COPD Nursing Care in ER

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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