How does this happen???

Nurses Safety

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I'm just a little confused and kinda of angry!! How does this even happen??

I'm a PCA at a local hospital who gradutes for ADN in December. Yesterday at work I had one of the most horrible days ever in my 4 1/2 years of working in the field. I thought the day was going fine moving right along doing my ADLS when the charge nurse comes running in and said I need a STAT finger stick in a room. A go back and the patient who is in his early 70's bka( Rehab floor) is completey diaohoreitc and very VERY lethargic. I get the finger stick its 64 after a juice with sugar in it. I run get more juice hes still not coming around we take vitals bp up to 160/80 from 94/54 a few hrs ago and heart rate 50. They call RRT they say give a amp of d 50 pt comes back around for just long enough to tell us he thinks its a reaction to the pain medication. Turns out his doctor decided to give him a fentanyl IV when he already was on the patch!!!?????? Oh yea did I mention he is a dialysis patient as well?!?? So after 2 doses of narcan and increased confusion, labored breathing, and pulse ox dipping into the mid 70's he is finally transferred to the ICU to receive a narcan drip and further monitoring... How does happen???

the patient received the meds on evenings this was days. The nurse who admin both meds did notify the md(pain mang who prescibed both) to ? the order was told it was ok. pt ate 75% of his bf tray earlier and after the d50 went up to 242. As for the fingerstick situtaion i was in another room hoyering a pt mid air without the glucometer and we have 2 on floor.

Specializes in Trauma Surgical ICU.

Also, I'm thinking this had more to do with his blood sugar than reaction to pain meds.

Completely agree with this statement.. The pt received the IV meds on nights and this incident did not happen until later the following day !!

Emergent situation.. The nurse or charge nurse should have gotten the FS instead of wasting time looking for a PCA/CNA/tech..

Specializes in Emergency, Telemetry, Transplant.

I had a pt with type 2 diabetes and a degree of renal insufficiency. As such, her body could not filter out one of her oral DM meds (I now forget which one). A RRT was called in the hospital for a blood sugar in the 30s. After 2 amps of D50 she improved back to the 80s, ate something. Blood sugar check an hour later...back in the 50s. More amps of D50, each with a small improvement, but quickly the BG drops again...theory being that this med was not being cleared by her kidneys. Any possibility that something like that was happening here? Was he type 1 or 2?

Specializes in Emergency Room, Trauma ICU.

The blood sugar was in the 60's, not dangerously low, actually that's within normal limits (60-100) so it wasn't that. And considering how high the bs went after the amp of D50 and that they had to put him on a narcan drip shows that it was related to the pain meds. Due to the kidney failure he must have had a build up of narcs in his system, otherwise the narcan wouldn't have had an effect on his LOC nor would they have started a drip.

It is not uncommon for diabetics to experience symptoms of hypoglycemia when their CBG is within normal range.

Specializes in Emergency, Telemetry, Transplant.
It is not uncommon for diabetics to experience symptoms of hypoglycemia when their CBG is within normal range.

Particularly if they are used to running high...which, based on the pt's hx, the pt's body is used to high glucose level.

Specializes in Emergency Room, Trauma ICU.

But if it was just about the blood sugar, the patient wouldn't have been placed on a narcan drip.

Specializes in Emergency, Telemetry, Transplant.
But if it was just about the blood sugar, the patient wouldn't have been placed on a narcan drip.

I don't disagree; however, I also wouldn't say it was just about opioids.

Specializes in Hospital Education Coordinator.

lots of things could have been at play here because so many people were involved. This is why it is impt to complete incident reports, so the root cause can be determined and a plan created to limit future incidences.

But if it was just about the blood sugar, the patient wouldn't have been placed on a narcan drip.

Sometimes you can have more than one thing going on. Sometimes docs order interventions to rule things out, or to get the problem to declare itself. There are a lot of possible explanations.

Specializes in Emergency Room, Trauma ICU.

Sometimes you can have more than one thing going on. Sometimes docs order interventions to rule things out, or to get the problem to declare itself. There are a lot of possible explanations.

Yes but a narcan drip is pretty rare so for them to place the pt on it, rather than just doing IV pushes I think it's safe to say it was a narcotic issue. Granted it can all be exacerbated by the diabetes and slow clearing of the drugs. But if it was mainly a sugar issue there wouldn't have been a need for the narcan drip.

Specializes in Medical Surgical Orthopedic.
I can't believe a nurse came looking for a PCA when they needed an URGENT finger stick!!

I've asked a PCA for a fingerstick right now while running to grab D-50 from the pixis. Result of less than 28 was popping up when I walked back into the room and we were ready to go.

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