Pain meds and low BP?

[fsh1986]

I had a pt who had scheduled 20mg oxycontin q8, along with PRN narcs q6 and q4. Her normal blood pressure ran low 100s. For a few days before I had her she was mid 90s. I work night shift and the night I got her, she had been maintaining SBP of 87, 88, etc. Mds aware. There was a written order that she was to get her narcs even with hypotension. So she got her 10pm and got her PRNs, but then her AM BP was 83/53. I understand that there's a written order, but don't you draw the line at some point? I didn't want to give her the oxycontin. She had requested the scheduled dose and then fell asleep, so I didn't wake her up and I paged the ARNP who was on call. She said to give it. I still didn't wake the patient as I had a bad feeling about giving it. Charge RN and the other floor RNs thought it was ridiculous that I was told to give it. So I waited until 6AM when the attending was on and I paged her. Told her despite the other MD's written order, I wasn't comfortable giving narcs with a pressure like that. She told me to go ahead and give it, said since it's chronic pain and the pt is used to taking all of these meds, that it wouldn't drop her. I understand that logic... but sh*t happens and that's already a low BP.

So based on my last phone call with the attending, I wrote that as a telephone order, I documented my conversation with both the ARNP and the MD and gave the med.

So I guess I what I want to know is, is my license at risk if something happens to the patient and I followed MD orders? Or am I more likely to get fired/lose my license for NOT following MD orders (and the SAME order from multiple MDS, at that) bc I felt it wasn't safe?? What would you have done in this situation? I've called my nurse manager and left a message for a call back so I can discuss legal ramifications if I'm ever at a crossroads between following/not following orders. I haven't heard back yet, so I figured I'd post. TIA for your responses.

[tewdles, RN]

But you held her long acting opioid rather than the prn. That makes it soooo much more likely that she will experience significant pain.

Because you did not say what the diagnosis was, the type or location of pain was, the resuscitation status or prognosis of the patient we cannot possibly know how to assess this situation.

If that patient is an end of life patient we would give her meds...no matter the setting. Palliation of symptoms is a balance of considering "numbers" while treating the symptoms.

[canned_bread]

It's tricky, because if something happened and you DIDN'T give it (such as patient complaint), you aer in trouble. If you did give it, and something happened, trouble there too! I would document, document, document as well as inform the nurses around me and give it. Then I have covered my butt, because I was TOLD to give it!! I would also inform the doctors about any drop, and also chart the BP frequently, especially prior to dose and perhaps 30mins after to see any change.

[corky1272RN]

The nurse has to rely on her/his critical thinking and assessment skills. You cannot be forced to give narcs if you think it is inappropriate. Go to your charge nurse if the pt starts hollering that she isn't getting it. If the pt is asleep when it is time for a scheduled narc, chart that and reassess later. Even if the pt isn't falling asleep/drooling when it is time for a scheduled or PRN narc, I don't give more than 1 or 2 at a time (depending on the meds/situation), even if they take it all at home at the same time. I just explain that it is different in the hospital and I have to make sure that it is safe. That is my job. Some understand, some get very angry.

I have had times where I wouldn't give certain meds at the same time. The pt became very angry, I explained the situation to my charge nurse, he agreed with me. But even if he didn't agree, he would either support me or give them himself. BUT if he decides to give the meds, he will take over the pt. Noone better demand that you give meds to a pt, because it is your license it anything goes wrong. I try to know beforehand if there will be an "overlapping" of meds. I will talk to the pt and let that person pick which ones are given & omitted. One time the house supervisor even got involved, she disagreed with my decision but still backed me.

Suggestions that it is ok to give a bunch of narcs together just because the person takes it at home that way is a flawed way to think. You must keep in mind that the pt is getting other meds in the hospital that aren't taken at home that could increase (or decrease) the efficacy of the meds. Plus the person's current medical condition can change their tolerance.

As for the BP, don't look at the #, look at the pt (and trend). You have to keep in mind what is the pt's normal, that is part of the critical thinking.