Learn From My Mistake - Dilaudid

[NursingAgainstdaOdds]

I had a pt last night who was well over 500lbs, in terrible pain rating at 10/10. He'd received 1mg Dilaudid in the ED with no effect, admitting doc sent him to the floor with no orders for PRN pain meds. I called the doc who initiated Dilaudid 6mg IV for severe pain, 4mg for moderate. I've given Dilaudid plenty of times, we have a lot of pts who use this drug, I've seen 2mg q1h pretty frequently. I've never given it to a person this large, and didn't have a good understanding (obviously) of how it would affect the pt. A more senior nurse was assisting me in taking-off my orders, and she didn't even blink at this. We had to override for it together, and I gave it. All the while I had a teeny tiny nagging voice telling me waaaaaaaaaaaaaaaayyyy in the back of my mind "this might not be right".

Fast forward an hour, and the guy's 02sat is 70%. Now, there were multiple factors at play, namely that his respirations were still 12, so I thought his oxygenation status was OK. He was also supposed to wear BIPAP when he slept, but didn't have it with him.

I ended-up calling the doc and then respiratory to come-up and set-up his BIPAP, at which point his sats improved to 98%. He remained totally unresponsive for several hours, and woke-up just before I left, but was still totally out of it.

Anyway - I feel really reluctant to post this as it makes me look like such an incompetent idiot, but I think I might be able to keep another new nurse from putting their client in peril. Large client does not = a need for an astronomical amount of Dilaudid. A person who has developed a tolerance to opioids may, but this pt did not have that kind of history. Make this humbling experience worthwhile and learn from my mistake as I have.

[TraumaGirl1018]

thank you for sharing. I probably wouldve given the 6mg too under the same rationale that you had:o

[Reeney78]

I am a new grad starting my job in 2 days, so posts like this are really helpful! I think it's great that you are turning this into a learning experience for others.

[AnnieOaklyRN, BSN, RN, EMT-P]

hi,

thank you for having the courage to share your story with the rest of us.

Remember that when you have morbidly obese patients they should be medicated more towards a normal BMI instead of with their actual weight since they have a much higher fat to muscle ratio.

Sweetooth

[the princess]

experience is the best teacher of all...let me share with you a tip: when giving narcotics to fat/obese and thin patients, always start by giving the smallest dose until you reach the highest dose ordered...like if the doc ordered 1-2 mg dilaudid, start giving the 1mg and reassess the pt in 5-10 mins and go from there...but in your case, 6mg for pain level of 10 and 4mg for lower pain levels, then start with the lowest dose even if the pain is so severe...just make sure that you're there to reassess the patient frequently to prevent under or over medication...just explain to pt that you're giving a very strong medication and that you don't want to knock him out to wonderland with the side effect: respiratory distress, he might not wake up...

[cherokeesummer]

Thank you, I think it is best for us coming into the word of nursing to see that everyone makes mistakes and are willing to learn from them and share with others.

Kudo's for sharing!

[ohmeowzer RN, RN]

thank you for this very useful post. i am glad he was doing better. take care .

[NursingAgainstdaOdds]

Thank you for the support, all. The more I think about it, the more I feel like :smackingf. I've definitely learned from this, however.

[abundantjoy07, RN]

Thank you so much for your post! I'm so glad you shared it...

[al7139, ASN, RN]

Hi,

I just wanted to say thanks for posting this. I am a new grad with three months of experience on a cardiac/med unit. We frequently see pts with pain management issues, that MD's order tons of narcs for. I have been lucky to have had such wonderful preceptors, and a good gut instinct for "something ain't right here". Most of the time pain meds are not an issue, and I have given them with no problem. Once on orientation, I had a bad feeling about a pt who was also a health care professional. He had a low B/P, and was in the hospital due to complications from self prescribing meds. We never really thought he had been honest about what he was taking at home. The MD's ordered Morphine for pain, PRN from 2-6mg IV. He also had IV Ativan, and muscle relaxers ordered, as well as meds to control HTN, and diuretics. His heart condition in my opinion was the priority, so those meds were appropriate, provided his vitals were within parameters. He complained constantly of pain that was unrelieved by anything other than a full 6mg dose of morphine, and would insist on getting the full dose. I tried reasoning with him, offering non-med alternatives, but he still insisted, saying his B/P always ran low, and demanded 6mg morphine IV. After discussing this w/ my preceptor, and telling her my gut feeling was to give ativan IV (no real impact on B/P), and flexaril, and the lowest dose of morphine ordered (all staggered of course), she agreed w/my instinct, even though other RN's had just been giving him whatever he demanded. I gave him 2mg IV, and needless to say his B/P dropped into the 80's systolic. NO WAY was he getting any more. He was pissed, but I continued to insist that he was at a potentially dangerous B/P and more Morphine could make him bottom out. My preceptor and the Clin II agreed with my decision. I try to be empathetic to pain, and understand that everyone is different regarding acceptable level of pain, but if the facts are there (i.e. vitals, and assessment), I will withhold if the pts safety is in jeopardy.

Amy

[Sabby_NC]

Awwwwww on you for posting this and sharing. Don't beat yourself up but learn and continue on becoming a great nurse. You are doing a great job. :)

[NYCRN16]

Don't feel bad, I am experienced and I may not have thought that order was a mistake either. I work ED, and I have had plenty of patients who have drug tolerances and 6 mg of Dilaudid is not an unusual dose in some patients. In fact, I wouldn't say 100% that his declining resp status had anything to do with the drugs you gave him, it may have been coincidence. This patient was obese, uses bipap at night, and it is possible that this was the cause and not the drugs. This man may have had multiple health problems that nobody was even aware of, like CHF that caused his decreasing sats. At least you know now to check things that are not right, but don't beat yourself up about this. FYI, someone else mentioned in one of these posts that ativan does not effect b/p. Wrong. I would say from my experience that the ativan will drop b/p faster than morphine will for sure. Im talking about IV ativan and morphine, dont know about PO. You will see me hold an order for ativan 2 mg IV faster than one for morphine 2 mg IV.