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

[Karou]

That sounds like one miserable, very ill and unfortunate patient. I feel terrible for him. I wonder why the nurse would not give him Tylenol?

Most of our physicians would hold IV narcotics for a systolic blood pressure less than 100. Of course, that is not even close to being set in stone and depends entirely on the patient in question and the overall picture. I had one special patient (literally, she was very unique) who we had an order to administer IVP narcs unless the SBP was less than 80. She was truly a special case.

I can't judge the nurses decision to hold the dilaudid based off of the information provided. I would literally need to know everything about the patient and really be able to get a full, clear picture before I could decide what I would do in that situation.

Regarding the blood pressure- unless it was well documented that the physician was already aware of the BP trends and okay with the pt receiving dilaudid, then I would absolutely hold it and call the physician prior to administering it. If the physician agrees with holding it, then I would ask about other medications to control pain that wouldn't further hypotension.

[KatieMI, BSN, MSN, RN]

Patients like described may have low BP precisely because their high respiratory rate. That (plus increased intrathoracic pressure due to fluid collection, plus respiratory alkalosis) decreases venous return. When they stop breathing like that, their BP either remains stable or even goes up a bit.

I do not see any problems with giving that dilaudid in two or three installments q5min or so while taking BP in between the doses. This way you at least will know how patient reacts on medication (for those who might say that it was not what doctor ordered, I work in a place where it is OK to think).

[BecomingNursey]

He has cancer. He's sick. He's hurting. A pressure of 90/60 (especially if that's what it's been trending the last few days) is not enough reason for me to not give him his pain medication.

I would, of course, need to see the patient and dig through his chart a little more to make sure giving the pain medication was appropriate. But just off of the information you provided, I would give the Dilaudid.

[loriangel14, RN]

It sounds like he needs a PCA. I would give the medication.I would be more concerned with decreased respirations. He is in pain and very sick. He needs to be kept comfortable. If he is in that much apin I wouldn't worry about the BP. What was she thinking?

[traumanightsRN, NP]

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.

[neuron]

It seems to me that 'she told the doctor that the blood pressure was low' should have been inquired about by the doctor, or this nurse isn't conveying the right words to the doctor. Either the doctor should have specifically asked what the b/p was, or the nurse should have said, 'the b/p was 90/60, should I give the medication?' She should have conveyed this answer to you, not let the patient scream out in pain.

When I ask the nurse if I should give a medication, I say 'this person's b/p is 90/60, should I give the medication?' I always get a yes/no answer.

[WKShadowNP, DNP, APRN]

That makes me so mad for that patient. How cruel. But you are an angel for advocating for him and holding his hand. I'm proud for you.

That reminds me of post-partum pain in the hospital after delivery of my first-born. They'd given me an episiotomy and I was cramping very uncomfortably. I had a order for percocet and for ibuprofen. The LPN would not give me the requested Ibuprofen because I'd received percocet recently. The perc did nothing for the uterus pain. The episiotomy felt fine. I was still in nursing school at the time but I knew better. But she was a stern witch and I never did get the dose until my "time was up." From then I declined percs and only asked for the ibuprofen because that was my primary pain.

Some people.

[NYCRN21]

Thanks everyone! I know it's hard to give advice based off what I told you but what you all said helped. The nurse I was referring to is very bad about giving patients pain medication when they need it (we work on a surgical step down unit, so that's pretty much all the time!) I'll definitely be able to advocate better for the patients next time a situation like this presents itself!

[Been there,done that, ASN, RN]

So.. a patient is suffering and you and the assigned nurse let it go on .

Assigned nurse needs to be written up. YOU need to grow some ovaries.Call nursing supervision and the doctor on call to the bedside.. until you do so.

[SubSippi]

Even if dilaudid would drop the blood pressure too much, that's not a good enough reason not to give pain medication. Call the doc and get something different, giving Tylenol is ridiculous to someone who is in that much pain.

It's sad, because if that patient had family with him, that nurse would have been on the phone, figuring out a way to help that patient.

[NYCRN21]

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...