Its been one of those weekends...

I have been an LVN for almost 2 years now. And this weekend made me feel like I know nothing!

I work in home health. The case I have isn't that complicated, and is generally pretty easy and its peds, which makes it more enjoyable for me. However, this weekend my patient decided to give me a couple scares. Last night with his O2 sats -- he kept dropping for no reason at all. And ended up taking double the amount of O2 than he usually uses. And then there's tonight... his O2 ran out.

Now, when I was in school, we were barely given instruction on how to work O2 tanks. But its easy to pick up. This patient has liquid oxygen, something I'm not used to, nor have I been properly trained on it. His tank is always full when I come on. I never have to worry about running out. Tonight was ridiculous though. When I came on, his mom still had him on his portable tank. I looked at the big one, and it was basically empty. I asked her if she thought it would last thru the night, and she said if it didn't to hook the tubing back up to the big one. Then she made it sound like the spare tank in the other room wasn't working properly... So, 3am rolls around and his portable runs out, just in time for his breathing tx. I try and hook it up to the big tank, and nothing. I can't even get it to turn on. Meantime, my patients sats are slowly dropping. I hook him back up to the portable, and luckily it had a little left in it. My options are limited here... Call the RN case manager and wake her up -- however, if I do that I run the risk of his sats dropping too low while she explains to me what to do. Or, wake up the parents who are in the house and know what to do right now and keep his sats from going too low. I chose the latter. In my mind it makes more sense to put the patients safety first, right? Anyway, apparently the tank in the other room works fine. Mom just grabbed it and hooked it up. Making me feel stupid and incompetent. Plus, it doesn't help that when I went thru orientation the nurse orientating me didn't show me how to use these kinds of tanks. It made me feel a little better when the dad came back in and was upset that the tank that was empty wasn't switched out before the night started.

I like my job. It has its flaws, but its good for me right now. I now know what to do if this happens again, but I hate that I didn't know what to do to begin with. I know I can't be the only nurse this has happened to. Gah! Does it ever get easier?
My first question would be why is your pt on O2? That might help figure out why his sats were dropping. I worked PICU for 2 years. What are your pt's normal sats and what were they dropping too? Any cardiac hx? Fever? Was his resp rate increased?Did you try (not sure what supplies you have): suctioning, repositioning, was the patient actually symptomatic? Chest pt, getting a new pulse ox or putting it on a different site, have the pt cough (if he/she can), was there any upper resp issues like a cold or congestion? I just got off work but I those are my thoughts real quick. Good luck, dont beat yourself up over it, the more experiences (good and bad) you have (and we all have good and BAD) the better nurse you will be in the long run! And you did the right thing, if you dont know you ask someone!

I guess the takeaway lesson from what you went through is to never take assignment unless you feel comfortable using all the equipment. Also, perhaps to be more assertive next time in resolving an issue before it becomes an actual problem......maybe to have asked mom to show you how to hook up the spare tank from the other room before they settled down for the night. Hindsight is 20/20, of course. Nursing can be pretty technical at times. I'm the type of person that has to do things a few times before I am proficient at it, so it can be frustrating. But your patient was ok and I think you did the right thing in waking up the parents; after all, you showed that their child's safety was most the most important thing to you.I'd try to flush it for now and just learn and go on. You obviously are trying to be great at what you do, and I'm guessing you are already great at many things.

Quote from marilynmomMy first question would be why is your pt on O2? That might help figure out why his sats were dropping. I worked PICU for 2 years. What are your pt's normal sats and what were they dropping too? Any cardiac hx? Fever? Was his resp rate increased?Did you try (not sure what supplies you have): suctioning, repositioning, was the patient actually symptomatic? Chest pt, getting a new pulse ox or putting it on a different site, have the pt cough (if he/she can), was there any upper resp issues like a cold or congestion? I just got off work but I those are my thoughts real quick. Good luck, dont beat yourself up over it, the more experiences (good and bad) you have (and we all have good and BAD) the better nurse you will be in the long run! And you did the right thing, if you dont know you ask someone!

My first thought is to wonder why you were so worried about an oxygen saturation of 95%. I don't wish to be antagonistic, but I am curious

Quote from SaraO'HaraMy first thought is to wonder why you were so worried about an oxygen saturation of 95%. I don't wish to be antagonistic, but I am curious

Quote from SaraO'HaraMy first thought is to wonder why you were so worried about an oxygen saturation of 95%. I don't wish to be antagonistic, but I am curious

Quote from raekaylvnHis alarms start going off at 93%. So for him to be at 95% is him in the middle of a downward trend. Chances are, if he's hanging out around 95%, he'll be below that soon enough. Plus, this is also a personal preference, I try to maintain my patients levels @ 97% or above. Keeps me feeling safe about where they're at.

Quote from SaraO'HaraThat makes decent sense. I'm used to COPDers - "91% on 2L? Fine!"

I just reread all you guy's advice tonight. I'm having issues with the kid.... again! This time he's been alarming all night. He was fine and at 100% on 0.5L, then out of nowhere he dropped to 89%. I finally got him stable at 97-98% on 1L, but man, I'm a wreck! I find myself doing nothing but watching the monitor. Its shifts like this that make me feel not cut out for nursing.

Have you tried repositioning before upping the O2? And how long does she stay at 89%? Transient dips to the high 80s are pretty normal.

Quote from woohHave you tried repositioning before upping the O2? And how long does she stay at 89%? Transient dips to the high 80s are pretty normal.

My thoughts are all out to you. I have the ff. to share, forgive me if I sound rambling, ' hope these will be useful. 1. Check the client for ss sleep apnea, document findings, document and document, report to MD your findings and follow up for an immediate response. Make sure that you include all pertinent vitals to the MD. CPAP and BIPAP evals for use maybe considered. Is the client fully awake, half awake, asleep during these episodes? client's anxiety level? Check emotional/ psycho component of illness, there could be concerns and fears that need to be expressed by client, family dynamics during normal waking hours? Is client a CO2 retainer? check history.2. Double check medication doses and side effects. Check rebound effect potential of some. Do you have bronchodilators, inhalers, corticosteroids, nebulizers, etc. Check time and quantity last dose given, you know the works. Carefully note medications in their containers, just to make sure that pills in the bottles are what they really are inside. Home environments are very different from the hospital setting and personally I don't feel comfortable with the fact that anyone can put anything inside anything in the privacy of the home. Not to be overly zealous here, just to double check safety.3. There is no room for errors for mishandling liquid oxygen. I would prefer to come to work earlier to take time to familiarize with the O2 tanks used for the client. If you are the touchy feely kind of person like me you will definitely have to get more hands on contact with the tank and the accessories that come with it. Use an empty ( sometimes they are not completely empty so care should still be observed at all times) unit and simulate hooking up to an imaginary patient, familiarize with how the tubings and fittings perform. Do you have all the instruments you need to install e.g. small plastic wrench. Do you have a spare in case the spare you think you have won't work? How many portables on hand? In the storage location are the empty ones staged separately from the full, from the partially used, from the ones which have "problems"? I would like to identify a functional back up on hand when the need arises; something that's ready for use. Are all tanks stored upright? Check gauges - its graduations, are the arrows at zero when it is supposed to be at zero? It would be worthwhile to check product manual for basic operating procedures especially the safety part. Have on hand important telephone numbers. Do you have manufacturer/supplier info? They should be on a wall or bulletin type thing some place, if not it should be on your notes.4. At times the CDC protocols for humidifiers, masks and nasal cannula tubings I don't remember as quick so I post the replacement dates in my calendar notes. I put soft fabric bandage around the tubing part that comes in contact with client behind the ears. Back to the tank ,Oxygen can give you freezer type burns and wow the burn is terrible. At first it looked like a rash then skin came off with slightest touch ugh! I wonder if you will have to refill the portables from a main larger source, but you did not mention this so probably you don't do this.5. Arrange for supplier to demonstrate basic operating procedure : Check the gaskets around the pressure gauge area, inlet/outlet, leaks are nasty, at times what looks like a serious leak is actually condensation, but then again no condensation should be oozing, certainly there should be no bluish smoke coming out with it. A full tank that sits for way too long in the storage may not be full tank r/t condensation, oxygen gets lost through condensation, it is always better to check contents. Many times a unit will have all the indication that it will last long for 8 hrs, and then of course it lasts for some 4 hrs only. Many causes to this e.g. leaky gasket, more O2 gas in the tank than liquid O2 could be something to do with the leaky gasket during refill process by the supplier, supplier related problem, etc. The only way to feel empowered is to know the basic operation. Take care, good luck, wish you more success