[Jennifer, RN]

We have a particular md who orders prn pain meds every 15 min. One of our nurses ended up giving 12 mg Dilaudid over 1.5 hr period to 20 yr old girl for flank and abdominal pain. Pt was not hooked up to any monitoring device such as bp or pulse ox, even though both are readily available at bedside on all of our beds. The pt's mom happened to be in room, came out and said she thought her daughter was breathing funny. Turns out, pt resp arrested, had to be bagged and narcaned. Pt was admitted to critical care unit for observation. Wouldn't you question giving that much pain med? Seems unreal to me to give that much pain med and not talk to the md about it. Even worse, pain meds were verbal order, nurse taking verbal order did not write it as verbal order (just wrote pain med order, not v.o. dr so and so/jennifer, rn.) and the md did not sign chart. So, no md documented on order sheet. I always thought I was overly anal about charting, monitoring and documenting, now, I am grateful for being overly cautious.

[stefannie]

You can never be too anal about protecting a patient. That is our job, our responsibility and our promise, not just to the patients but to ourselves. If you don't ever have to regret your actions as a healthcare provider, you are probably not living or working in the real world of medicine. We should never have to regret standing up for another person's well being. We are in charge of the care of people who are unable to care for themselves. Just because someone is a doctor doesn't make him/her smarter or more righteous than you. Stay with your instincts and your smarts... you are right and the fact that this patient respiratory arrested probably means that she wasn't awake enough to ask for more pain medicine or writhing in pain. Pain control is important, but breathing is the "A" in ABC!

[bill4745]

In my opinion, both the nurse and doctor should be reported to the director of their departments. Their behavior is incompetent. If I exceeded 2mg of dilaudid on any patient in less than an hour I would at least use a pulse-ox.

[Tweety]

The idea behind giving pain meds q15 minutes isn't that you give it nonstop, it's that if it's not relieved in 15 minutes, you can give it again, and maybe again a couple more times, until the patients pain is relieved. Then you stop giving it. Nothing really wrong with that kind of order. In fact I rather like it because it beats having to hunt the doc down if one dose isn't effective, or have to wait an hour or longer. PACU nurses have similar orders. PCA's are similar, but have limits and it's understood the nurse is going to monitor the patient for side effects.

The nurse was horribly negligent here and needs some very serious counciling about the effects of pain medicine and monitoring for side effects.

[jojotoo]

Usually I like to think of the RN and MD as a check and balance system on each other. But if they're BOTH idiots, who"s going to check on them?

[Altra]

Originally Posted by Tweety

The idea behind giving pain meds q15 minutes isn't that you give it nonstop, it's that if it's not relieved in 15 minutes, you can give it again, and maybe again a couple more times, until the patients pain is relieved. Then you stop giving it. Nothing really wrong with that kind of order. In fact I rather like it because it beats having to hunt the doc down if one dose isn't effective, or have to wait an hour or longer. PACU nurses have similar orders. PCA's are similar, but have limits and it's understood the nurse is going to monitor the patient for side effects.

The nurse was horribly negligent here and needs some very serious counciling about the effects of pain medicine and monitoring for side effects.

Agree ... this sounds like a typical prn order. I wasn't there, but it sounds like the nurse missed the pain reassessment = prn (AS NEEDED) part of the order.

[TazziRN]

I see orders like that all the time, but the key is to REASSESS!!!!! Once pain relief has been achieved or the pt's status deteriorates because of the med, you STOP!!!

BTW....something I often have to explain to pts and families: our goal is not necessarily to get rid of the pain entirely (unless it's cardiac CP), but to at least get it to where it's tolerable to the pt.

[rjflyn]

Something is definately a miss here. Where i work its not unusual to see a Dilaudid 0.5-1mg q15 prn order esp from one specific doc. It is rare however to have to use it more than one or 2 doses beyond the inital dose.

Our facility now infact with pts on PCA narcotics is implimenting continuous pulse oximetry monitoring through the pump system(Alaris).

At another facility a couple years ago they had issues with pts having excessive sedation on the units. They were getting repeated doses of Dilaudid in a short period of time and due to delayed onset 2-5 hrs after the last dose was given pts were being found on the floor with depressed resps and in one case an arrest. They implimented a policy of no more than 0.5mgs in a single dose, no more than 1mg in a hour and if 2mg exceeded the anesthesia/pain service had to be consulted.

Rj

[nuangel1]

i have seen orders for meds q 15 but with set limit and as a nurse continuous reassessment of pt i would never have given that much dilaudid.and obviously since the pt arrested she shouldn't have gotten it. the nurse and md should have known better .the pt should also been on a monitor

[jojotoo]

We semi-routinely give Dilaudid 4mg IV (especially to the sickle cell patients). And may have a repeat order X1. But MOST of us know that doesn't mean to run in at 15 minutes and give the second dose. (It means that in an hour you don't have to bother the MD for a repeat dose.)