Okay, looking at the remaining orders, what's left, what are the priorities out of what's left,
what's left to complete, and what needs follow up.
Again, that's a pretty big list, right?
We're still working on titrating oxygen, we finally made it on the last reading
to just into the bottom of that range that the physician ordered.
Has the 12-lead been done?
We know the chest x-ray has been done so we can cross that one off.
Breathing treatment has been given but I need to keep checking on
when is the next one that needs to be done, how is she doing?
Since she's coming in such distress, do I wanna give the next one at 1 hour?
That's gonna involve your nursing judgement
and that's why an RN will watch this closely to determine if that needs to be done.
Also by now, you should've given that methylprednisolone.
If you haven't, wanna make sure that you get that into the patient rather quickly.
Okay, now what time is it and what should you do?
Well, you've timed lab work for 1 hour after the initial draw so what type of lab work are --
that we need to do and repeat at 1 hour?
Right. Looking at the orders, you know ABGs need to be drawn again.
So what time are the ABGs due? Look at back at your notes.
What did you write down and make a notation to yourself about when those ABGs would be due?
Cool. The initial one was due at 9:45 so you need the next one to be drawn at 10:45.
Now we've got about 5 minutes before that's due.
We wanna try moving in that direction because you can always get pulled
with different priorities when you're taking care of multiple patients.
ER nurses rarely get the opportunity to take care of one patient at a time.
They have multiple patients unless it's a super severe trauma.
So this patient, you're balancing Mrs. Taylor's care with everyone else that is under your care.
So it's a good idea to get in the room a little bit early so you can draw that --
get set up and draw that lab work quickly and efficiently.
So you draw the ABGs.
Remember you wanna note the patient's level of supplemental oxygen
so we know that she's on 4 liters when you're analyzing the ABGs on the unit blood gas analyzer.
Now, most ERs and critical care units in hospitals of size have these devices right on site.
We call these point-of-care testing. So what is point-of-care testing?
Well, they are things like, doing at the bed side, we run the test.
The samples don't have to leave the unit and go to a lab and be interpreted
and then reported back to the unit.
Examples would be if you have an ABG analyzer on the unit.
Maybe a finger stick blood sugar.
You may call it a glucometer but if you do a finger stick blood sugar, that's also point-of-care testing.
So when you hear that terminology used, that's what it is.
Now this unit, you work on a unit where we can actually run Mrs. Taylor's ABGs
on the ABG analyzer right in our own ER.
ABGs only tell us what was going on, boom, right at the instant
that we draw them so you always wanna look at trends.
Now we did a repeated vital signs at 10:45. She's in sinus tach.
Has she been in sinus tach? She has.
She's running about 108 which is what she was running when she came into triage.
Her blood pressure is 160/90. It's a lower than it has been but not a significant drop.
Temperature, 37.2. It's up a little bit but we kind of expect that with what we've seen on the chest x-ray.
Now her sat has backed down at 89% on 4 liters nasal cannula
and her respiratory rate is still fairly high but not as high as it was.
Vital signs, lab work, you're always looking at trends
and comparing what's going on with your patient, how are they changing,
and how are they impacted by treatments that we apply to the patient.
Okay, so let's look at these ABGs. At 9:45 on 2 liters, look at where we are at.
We are in, remember, respiratory acidosis and our PaO2 was too low.
Now that we've drawn the ABGs, the pH is 7.34 still on the acidotic side.
CO2 is 50. Well, normal is 35-45 so it's still an elevated CO2.
A little bit lower than it was before but still elevated. Bicarb, 26, still within normal.
Now we kind of expect that because the kidneys and the metabolic system will try to help
but it takes longer for you to see those results or the impact on ABGs.
PaO2 is just barely up at 78. So is Mrs. Taylor still in respiratory acidosis?
Yes, cuz look at the pH and the elevated CO2, we know that she's still in respiratory acidosis.
We're making a tiniest bit of progress but really not making any significant progress.
You'd make sure that the physician or the health care provider sees these results
and you would give them a quick SBAR and update them on where the patient's status is,
what situation, background, assessment, and any recommendation.
Now looking at this, I want you to already be thinking about what should we probably do next?