Nursing Priorities – COPD Nursing Care in ER

00:01 Now we've included a sheet here.

00:02 Just a little note in your notes where you can organize the information.

00:06 This is just one example but when you're taking report quickly for somebody, you always want to write things down so you're clear, concise, objective evaluation before you ever receive the patient.

00:20 Now, Mrs. Taylor was diagnosed with COPD.

00:23 We know that 3 years ago and she states that it's much harder for her to breathe than usual.

00:28 Okay, that's definitely a sign of worsening symptoms.

00:32 It's really important, whatever a patient communicates to you, you need to listen closely because the patient's gonna give you clues they may not even be aware of.

00:40 Now, this one is really obvious.

00:43 We know she has COPD and she's telling us, "Yeah, I've got COPD but it's even harder for me to breathe than usual." That's why the triage nurse started her on 2 liters of oxygen per nasal cannula because that's what the triage protocol orders indicated with a sat.

00:58 So here were the key points.

01:00 Remember, she's got that history, she's had it for 3 years, she's telling us it's harder for her to breathe and so they started her on 2 liters of oxygen per the triage protocol.

01:11 So this is just another place where you make sure that you add in on O2 that she has nasal cannula at 2 liters.

01:18 So I want you to fill then her heart rate, her rhythm, her blood pressure, all these items here.

01:23 We didn't put them on the screen for you because I want you to practice that exercise of filling in those blanks as you hear it verbally.

01:33 Okay. Now, you're the ER nurse that's actually gonna take care of Mrs. Taylor in the ER.

01:39 The triage nurse is giving you that brief overall report, you've written down the key facts, now you are the nurse receiving Mrs. Taylor.

01:48 So immediate nursing priorities, we're gonna break these down for you but remember, nurses do multiple things at the same time, don't they? But your top priority is to make eye contact, introduce yourself to Mrs. Taylor.

02:02 Remember, that triage nurse has got her stable or on our way to try to getting her stable by giving her oxygen and getting her back to a level of care.

02:11 So you have time to introduce yourself to Mrs. Taylor. There's always time for that.

02:16 Now the triage nurse is gonna give you any additional bed side report within right there in the room.

02:21 You can check all the things.

02:22 She's on the oxygen, the rate, all that's going on because your top priority, assessment of Mrs. Taylor's airway, breathing, and circulation including her vital signs, cardiac rhythm, and blood pressure because those are gonna help us really assess the stability of her airway, breathing, and circulation.

02:43 Okay, so that's the -- that's our very top priority when you get a patient in.

02:47 Now we have to look at -- we need to safely transfer Mrs. Taylor from either a wheelchair or gurney that she came on from triage to a bed.

02:57 Now I wanna talk to you about Fowler's position too because we wanna safely transfer Mrs. Taylor from the wheelchair to the trauma emergency center bed and put her in a position that's gonna facilitate breathing.

03:09 Now we got a graphic for you there.

03:11 Anyone who's having respiratory distress will not let you lay them down if they're still awake and it's not good for them to lay down.

03:19 So you want them in a position with the head of the bed elevated so that they can facilitate breathing.

03:26 Triage nurse rolls in, you've got a report, you will work together with a triage nurse, and safely transfer the patient over to the trauma emergency center bed.

03:36 Now, you want it to be a quick transfer from the portable oxygen that Mrs. Taylor came with and you wanna make -- switch it over to the cardiac monitors in the room because in order to monitor A, B, and C, we need to have our own oxygen, cardiac monitor, and we'll likely look at a pulse ox because that's our main concern.

03:55 So let's repeat her vital signs. That's what you do now that we've got her in.

03:59 You have your initial set. Now, let's do a repeat set.

04:02 So the repeated set of vital signs were a sat of 87%. High, low, or normal? Right, it's still too low.

04:11 So even though we have her on 87%, her saturation is still not where we would like it to be.

04:17 Also note in your notes, pulse ox was 87% and that she was on 2 liters of oxygen because you're gonna keep track of that.

04:26 What was she on room air? Well, look back on your notes.

04:29 What was Mrs. Taylor's pulse ox on room air? No, I'm not gonna tell you.

04:35 I want you to look back so pause the video if you need to because I'm wanting you to get used to charting on the go as you are with patients in real life.

04:45 Okay, so her respirations are 28. Now, what were they initially? Just look back at your note. Her pulse is 113. Wow, that one is higher.

04:56 Not that much higher but think about what we're dealing.

04:59 She's exerting herself by being transferred and moved so we would kind of expect her pulse to go a little bit up.

05:05 Blood pressure, compare that to her initial one.

05:08 Is it higher, lower, about the same? Temperature, we're not gonna have much of a change from triage to ER so it's also about the same.

05:17 Now you get her on the monitors and she's in sinus tach.

05:21 Now, sinus tachycardia means the heart rate is greater than a hundred but you've got P waves for every QRS, the rhythm is regular.

05:29 So those are the indications that we're in sinus tachycardia.

05:33 She's really working hard.

05:35 So by now, by this point in the case study, you should have notes about Mrs. Taylor's history, her background, her symptoms, what her daughter has told us, what she has told us, and her initial vital signs and now her second set of vital signs or her admission vital signs to the unit.

05:54 Okay, now let's look at our next nursing priorities.

05:58 You've got Mrs. Taylor in the room, we've done the bed side report with a triage nurse, the triage nurse has left, now it's just you and Mrs. Taylor.

06:07 So your goal now is an initial assessment head to toe.

06:11 Of course we're gonna really focus on lung sounds but we're gonna do an initial assessment head to toe because now, I'm going to collaborate with the health care provider in the trauma emergency center.

06:22 Now, the health care provider might be a physician, a nurse practitioner, might be a physician's assistant or what we call a PA but my job is the one to be first on scene to assess Mrs. Taylor, to take all the information that we've gathered from her daughter, from her, from our physical assessment, and put that together in a very short, succinct but effective report to give the health care provider the information they need to determine the next best step. So you're not passive in this process.

06:56 You are active.

06:57 You're the one who's determining what's the most important information to give to the health care provider so we're gonna do an assessment.

07:05 Now as I'm walking through this, I want you to take notes because we're gonna use this information to create and synthesize a report for the health care provider and you're gonna get the opportunity to practice that.

07:17 So this isn't just a matter of listening to me rattle these off or skimming through those.

07:21 I want you to make note of what parts of this information you think you need to communicate to the health care provider.

07:29 Now, how do you decide that? We've already spent a lot of time laying down the groundwork.

07:35 We know that she has COPD, we know she's had a respiratory infection, we know she's showing us multiple signs that it's difficult for her to breath.

07:43 So we've got that background information.

07:46 Now let's take a look at what we're observing.

07:48 So you're talking to Mrs. Taylor and she's -- you ask her questions and she's having a hard time answering the questions.

08:02 Why? Because of her shortness of breath. Okay.

08:08 Sometimes it wears me out talking to people that are having this difficult time talking to you.

08:14 However, it's really important that you be aware of this, that you ask Mrs. Taylor short, clear questions, hopefully that she can answer yes or no to a lot of them. I know that's not therapeutic, right? We're not -- this isn't the part or how you develop a therapeutic communication and a relationship with these type of questions.

08:35 This is just getting the facts so that you can help make a good assessment of Mrs. Taylor because she is so short of breath.

08:45 But you're gonna note just from watching her, a sentence wears her out.

08:50 So that's another indication of how significant her shortness of breath is.

08:54 So of course, you're gonna auscultate Mrs. Taylor's lungs.

08:57 Now when we say anterior and posterior, front and back.

09:03 Why? Well, patient with COPD, now she's had it 3 years but we don't really know since we've not seen Mrs. Taylor before, how difficult it is.

09:13 We know that a patient with COPD can have elevated pulmonary pressures, right? They have that pulmonary hypertension which can cause cor pulmonale.

09:26 Right-sided heart failure because the lung pressure was so elevated.

09:32 So not just because we wanna hear what her lung sounds sound like as far as you have wheezing or rhonchi or is it diminished or is it absent in some areas, we're also listening for crackles.

09:44 COPD, risk for cor pulmonale, right-sided lung failure, that's why I'm gonna really listen close to those lungs to know what her fluid volume status.

09:53 One indication of that.

09:55 Now you auscultate Mrs. Taylor's lungs and you don't hear any crackles.

09:59 She has diminished breath sounds with wheezes and rhonchi bilaterally but no crackles.

10:05 Just a hint that would be really important for you to make sure that you have very clear in your mind before your talk to the health care provider.

10:14 So lung sounds, pause the video for just a minute and practice reminding yourself about what you auscultated on her lung assessment.

10:26 Okay, welcome back.

10:29 So you know she has diminished breath sounds with wheezes and rhonchi bilaterally.

10:34 Now you can get even more specific about is one side greater than the other, do you hear it in one place and not the other because lung sounds are all over the map.

10:42 They're not usually equal, exactly, precisely.

10:45 So the more information you can give the health care provider, the better that is.

10:49 Now if a patient has a chest x-ray taken, you wanna compare your lung sound assessment for what is seen on the chest x-ray.

10:57 That'll also help you sharpen your assessment skills.

11:00 Now pulse ox continues to run at 87%.

11:04 So she's short of breath at rest, her pulse ox is 87%, and her breathing is taking a really noted effort.

11:12 Now remember, she's got diminished breath sounds, wheezes and rhonchi bilaterally but no crackles so she has abnormal assessment. We clearly need to intervene.

11:23 So I wrote in here the vital signs for you. So you'll see it there.

11:28 You've got her vital signs over there. Now we're gonna repeat her vital signs.

11:32 On admit, the sat was 87% on 2 liters. Her respirations were 28, her pulse was 113, right? Her blood pressure was 170/98, temp was 99, and she's in sinus tach.

11:45 I filled some of these in for you just for you to kind of get a feel for it.

11:49 Double check your notes, make sure you have those kind of set in your mind is we're setting up what we're gonna communicate to the health care provider.