Conflict with fellow nurse regarding Dilaudid administration, please help!

[NYCRN21]

Hi everyone, I'm a first year nurse and I have a question about Dilaudid administration. Is it necessary to hold Dilaudid pain medication for an 84 year old patient with low blood pressure? Another nurse on my unit refused to give her patient Dilaudid 0.5mg IVP ordered q3h because his blood pressure was 90/60, it had been hovering around this for the past two days or so. He was an average sized man (not a frail elderly man but not large or obese), very distended abdomen that was firm due to fluid build up, it was a monitored step down unit where he was on tele (history of controlled a fib), we could closely monitor his blood pressure and respirations which were about 30-35 because he was having difficulty breathing due to bilateral pleural effusions, fluid buildup in his lungs, was about a week post chest tube removal, and was suffering from a lot of cancer pain- he was screaming out in pain all night. She adamantly refused to give him any pain medication and I felt it was extremely inappropriate to not give him pain medication- he had not had any pain medication in 6 hours and his respiratory rate was not depressed. I sat in his room with him for a most of the night holding his hand while she sat at the nurses station texting. Because I did not know whether it was appropriate to give him the Dilaudid, I eventually gave him a prn order of Tylenol 650mg PO after she went on her break while I was covering for her. She had told the doctor that she held the Dilaudid because his blood pressure was too low, but never actually told the doctor what the pressure was. I didn't think that a blood pressure of 90/60 would be too low to give someone who was not having any respiratory depression. Would it have been contraindicated for me to have given him the Dilaudid 0.5mg IVP order with a BP of 90/60? This situation happened a few weeks ago but I haven't been able to shake it and it has been bothering me for a long time- to be honest I think she was just being lazy and didn't want to get the medication. Please tell me how to best a situation like this should it ever happen again. Thanks! - frustrated first year nurse

[Kooky Korky, BSN, RN]

As I said, I am a new nurse. I did the best I knew how at the time to help a patient in need. It was not my patient and the doctor said not to give the medication, so Been There Done That, it was not appropriate. I gave the Tylenol because the doctor did not order any thing additional and that was the only prn medication that he was ordered for. The nursing supervisor was aware of the situation, and the doctor had seen the patient at the bedside. But thank you so much for putting down a new nurse coming to this site looking for supportive help on how to handle a problem...

When did the doctor see the patient? While he was screaming? Hours before?

Did the Supervisor hear the screaming? How much experience does she have?

Was the BP ever rechecked? It's hard to believe that the pressure didn't go up some after a while.

Have you ever spoken with the doctor? Give all of the details when you do and see what he thinks

about the patient screaming all night long.

How did the Day shift handle this patient? Was he ever properly medicated? Did he ever get comfortable?

This sounds like Auschwitz, not a place where people get medical and nursing care.

Maybe you can approach your Manager and tell her you are troubled about a situation that occurred a few nights ago. Explain it all to her, including the screaming all night long. Ask how you should handle such

a situation in the future.

I seriously pray that my loved ones and I get to die quietly in our beds at home and never have to be in

the "care" of such a cruel nurse, such a stupid, ignorant nurse. (hopefully not intentionally cruel, just ignorant - but, nevertheless, a nurse who let her patient suffer unspeakably). It takes a fair amount to

rattle me but I am literally just shaking after reading your post, OP.

[Kooky Korky, BSN, RN]

Yes, welcome to nurses eating their young. Some people think they were born knowing everything...

I had a similar situation. Old man, bad pain, pressure 95/60-ish. I actually gave the dilaudid (new nurse, fresh off orientation with too many patients and no time to think so I did not even think of the low pressure). By midnight his pressure dropped to 70's/40's. Had to call the doc, get a bolus, and got chewed out by my charge nurse for giving it. A few hours later, guy's in pain again and pissed that I'm holding dilaudid and offering PO perc/tylenol. Damned if you do, damned if you don't.

What did your Charge want you to have done instead?

[Kooky Korky, BSN, RN]

I'm on the same page as loriangel14. Sounds like the patient needs a PCA and I would recommend fentanyl first because of his age. Then if that doesn't work change it to dilaudid. Secondly, I would absolutely give the dilaudid; it's only 0.5mg which is just a whiff and worst case scenario his SBP drops to mid 80s, not going to harm the patient because it's not going to stay there for long. The patient's nurse is being straight up lazy and in my opinion acting unethically. If a patient says they are having pain you MUST treat the pain. You cannot hold pain medicine for any reason, even if the patient is hypotensive. Since a lot of times providers don't order pain meds that adequately treat pain, in my hospital (don't know if you have it where you work) you can get a Geriatrics consult and a Palliative consult (for pain). Both consults will evaluate the patient and then give recs for how to best treat his pain. They are the experts.

And just a note, I would not ask a provider if it was ok to give pain meds if a patient is hypotensive. Where I work we don't need to go to the provider for every little thing; the nurses are very autonomous and are encouraged to use their brain. Treat the pain.

You likely can't get those consults in the middle of the night, which is when this situation took place.

You can't hold treatment of pain for ANY reason? Doesn't sound right. You might need to get a different treatment going in place of the one currently ordered, but to say you can never withhold pain treatment doesn't sound right.

Asking the doctor if it's ok to give pain meds if a pt is hypotensive might be necessary if the nurse involved doesn't have the knowledge and experience to deal with the situation on her own. The patient's nurse did act autonomously, just autonomously incorrectly.