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???

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.

Yes, you make some good points, but remember that the patient was whisked off to the ICU without a Narcan drip. The drip would have been started in the ICU. We don't know if that occurred, and if it did, what the outcome was.

Specializes in Emergency Room, Trauma ICU.
Yes, you make some good points, but remember that the patient was whisked off to the ICU without a Narcan drip. The drip would have been started in the ICU. We don't know if that occurred, and if it did, what the outcome was.

True, who knows what happened after getting to the ICU.

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