Question/Concern about pt and Dilaudid IVP

The highest dose of dilaudid that I have given was 8mg IVP (patient had sickle-cell disease and had home pain medication management abuse issues). She begged me to "just push it all in". Yeah, sure thing...

If the dilaudid didn't work for your patient, some other medication should have been used (ie fentanyl). Since your patient has several pancreatitis episodes per month, she probably has a very high opiate tolerance. Pain is pain, and there's not a whole lot that we can do in the ED to "fix" it, other than treat it as such (in the ED we can't really follow up, devise a pain management program, or wean patients from opiates...). Was she truly in pain? Perhaps. Was she drug seeking? Perhaps. But rather than get upset about it or complain about it, I find that it's best to work with the patient and do what you can do. At one ED that I worked at, we would develop a care plan for patients that would frequent the ED; this way, we were consistent with their care each and every time they would present to us (and the sickle-cell patient that I gave 8mg of dilaudid to was one of those "care plan" patients, and this dose of dilaudid was included in her care plan).

On a side note and straying from your original question: I would NEVER run KCL through a thumb IV. I would tell the doc to put in a central line or send out for a PICC before running KCL into such small veins. If the vein were to blow, the person could have permanent tissue/nerve damage (KCl is very necrotic to tissues). It is a lawsuit waiting to happen. If I know I'm going to be running KCL, I use an IV site where the vein is stable and I use the smallest catheter possible (for example, lets say a vein in someone's forearm can handle an 18g; if I'm giving KCL, I'll use a 22g instead to minimize any irritation to the vein; this also helps to lessen irritation, since there is more bloodflow around the catheter). To minimize irritation, I've given KCL diluted in 1000ml 0.9%NS; I've also given KCL in 250ml 0.9%NS with lidocaine added by pharmacy. We're all in charge of our own nursing practice, but I personally would never administer KCL at any IV site below the wrist. Having a proper IV site ensures the patient is getting the medication in a timely manner; it's not effective to be running 20 mEq KCL IV over 4+ hours...oh yeah, and if you're running KCL, don't forget to put the patient on the tele monitor

Trust me i absolutely HATED the idea of her having to get it through her thumb vein, we had five diff. nurses work for 2 hours trying to get a vein on this woman, and the doc was just so blaise about it i was irritated, but i'm still on orientation what was i supposed to tell my preceptor that we shouldn't run it until we get the doc to put a central line in, and then tell the doc hes a moron, and to go do it? lol i dont think i would've lasted there much longer had i done that. and yes i'm sure this woman has a HIGH pain tolerance, my only issue is that we could NOT work out any plan of care with her, anytime u said anything to her all she'd respond is "pain pain pain" and start moaning and sighing, but we'd see her resting quietly from our desk and the minute one of us walked by the room she'd start back up with it. then the son got into it w/all of us claiming that we weren't treating her, and she started yelling at us as well saying we just wanted her to suffer bla bla bla its so frustrating! eventually i just said "look mam i know ur in a lot of pain, but you have a very high tolerance to this medication, and just because you do, doesn't mean we can give you an unsafe dose! frankly we're suprised ur still awake as it is, so i want u to know that we ARE doing everything we can, but screaming and yelling at us instead of trying to relax and rest in a more comfortable position will NOT help your pain".. i should've saved my breath coz she went right back to PAIN PAIN PAIN.. if i see her again i'm runnin the other way! i should've told her to start taking better care of herself and she wont need to be in the ER 4 times a month!

Trust me i absolutely HATED the idea of her having to get it through her thumb vein, we had five diff. nurses work for 2 hours trying to get a vein on this woman, and the doc was just so blaise about it i was irritated, but i'm still on orientation what was i supposed to tell my preceptor that we shouldn't run it until we get the doc to put a central line in, and then tell the doc hes a moron, and to go do it? lol i dont think i would've lasted there much longer had i done that. and yes i'm sure this woman has a HIGH pain tolerance, my only issue is that we could NOT work out any plan of care with her, anytime u said anything to her all she'd respond is "pain pain pain" and start moaning and sighing, but we'd see her resting quietly from our desk and the minute one of us walked by the room she'd start back up with it. then the son got into it w/all of us claiming that we weren't treating her, and she started yelling at us as well saying we just wanted her to suffer bla bla bla its so frustrating! eventually i just said "look mam i know ur in a lot of pain, but you have a very high tolerance to this medication, and just because you do, doesn't mean we can give you an unsafe dose! frankly we're suprised ur still awake as it is, so i want u to know that we ARE doing everything we can, but screaming and yelling at us instead of trying to relax and rest in a more comfortable position will NOT help your pain".. i should've saved my breath coz she went right back to PAIN PAIN PAIN.. if i see her again i'm runnin the other way! i should've told her to start taking better care of herself and she wont need to be in the ER 4 times a month!

I have put thumb/finger IV's in people before, but like I said, I would never run potassium through a thumb IV (let alone any site below the wrist). Most people who need IV potassium will be admitted, and I have had no problem saying to a doc "we can't give the potassium through the IV we have; wanna do PO instead and have the admitting doc send for a PICC in the am, or do you want to do a central line here in the ED?" And there is nothing that says you have to follow what a doctor says, should you believe it would cause harm to the patient. I have no problem saying "I refuse to give that medication, so if you want to give it, you can." 99% of the time, the docs don't want to take the risk that they were so willing to pawn off onto you. I understand that you were with your preceptor and its difficult to decide when to interject - its just something to think about. People have lost fingers due to potassium infiltration, and a lawyer would eat that up (loss of work, productivity, blah blah blah). And what if the med was given at the wrong rate, or what if the wrong dose was mixed - and now you suddenly have a critical patient with only a thumb IV to work with?

For myself, I've found that the biggest timesaver in the ED is to think "what is the worst that can happen, and how can I prevent it from happening?" Some of the worst things that can happen with IV potassium includes cardiac abnormalities and IV site infiltration with tissue necrosis - and this can be prevented by having a proper IV site in a "hearty" vein, having another nurse double-check IV pump settings, and keeping the patient on continuous cardiac monitoring. If it infiltrated, how much time would be spent calling pharmacy, restarting an IV, filling out an incident report, etc.? Sometimes "doing the right thing" takes more time and other staff may object (often because it requires more work on their part). But there will be a time when it pays off and we all should adhere to high practice standards because it is the best for the patient and will stand up in court should a lawsuit arise.

This exerpt from a book entitled "Nursing Malpractice" pretty much states that IV potassium shouldn't be infused into the hand. This book would be handy for a lawyer should a lawsuit ensue. http://books.google.com/books?id=otf...feTA#PPA402,M1

As far as the family goes - I do not tolerate yelling and I will tell the person "you cannot yell at me". I have had family removed by security for yelling at me and I have no regrets. I'm a very kind and tolerant person, but a family member being upset and frustrated is different than yelling and being verbally abusive towards staff. Its ok to be frustrated, its ok to be upset. But its not ok to yell, and I do not tolerate that behavior. End of story.