Administering Narcs and nurse liability

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Specializes in ER, telemetry.

So, after a co-worker expressed concerns about one of our ER doctors prescribing high doses of Dilaudid to a patient with chronic abd pain with frequent visits as well as a couple of past visits for polypharmacy drug overdose, I started wondering what our role as the nurse is and what liability do we have.

The patient in question was receiving IM injections of Dilaudid, being continuously monitored on pulse ox and bp (as is our routine for anyone receiving narcotics in the ER).

So, on the nurse's part, she was doing her job of assessment and reassessment of the patient.

Do we as nurses have any say or rights when it comes to narcotic administration that seems inappropriate? Any documented cases that you all know about where a nurse was found negligent for administering large amounts of narcotics?

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Specializes in Nephrology, Cardiology, ER, ICU.

What are we talking about doseage-wise? Is the pt narcotic dependent?

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Specializes in ER, ICU.

The doctor is responsible for the dose. If you are uncomfortable about the amount you should speak to the physician about it, and just say you are uncomfortable with the dose. When I have done this, they explain that they know the patient or give some rationale. Your job is to monitor the patient the same way any other nurse would do. You may, of course, refuse any task you feel is harmful to the patient, but pick your battles carefully. The way you would be negligent is, not questioning an unusual order, not monitoring the patient, or making an error in administration.

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Specializes in ER, telemetry.
What are we talking about doseage-wise? Is the pt narcotic dependent?

The patient in question was getting 2mg Dilaudid IM at a time, but got 5 doses, totaling 10mg over about a 2.5 hr period. The patient was narcotic dependent, so her tolerance was high, I'm sure.

She was properly monitored by her primary nurse.

Just want to make sure that we as nurses aren't going to get in trouble when doctors dole out pain meds.

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Specializes in Hospital Education Coordinator.

if the patient is a frequent flyer or has a history of polypharmacy he/she might be suffering from pseudoaddiction. This is behavior exhibited when chronic pain is not appropriately addressed. When the right medication and dose is given on a continuing basis, the behavior stops. Could be a deeper problem than just dose. As for the nurse, we have the responsibility to know what is a toxic or dangerous dose and should address that with the MD or chain of command. Could be this person has built up a tolerance too.

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Specializes in Hospice.

When i think of narcotic responsibility i don't really think of it in terms of 'ethical' responsibility in prescribing but more safe administering. for instance giving an ordered dose of a benzo or opiod when a pts RR is at 6

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The patient in question was getting 2mg Dilaudid IM at a time, but got 5 doses, totaling 10mg over about a 2.5 hr period. The patient was narcotic dependent, so her tolerance was high, I'm sure.

She was properly monitored by her primary nurse.

Just want to make sure that we as nurses aren't going to get in trouble when doctors dole out pain meds.

No reason not to give the meds or to get in trouble as long as you are following orders, administering properly, and monitoring, which it seems that you are doing.

Remember, you don't monitor patients just for the sake of monitoring, you are looking for s/s that the pt is receiving too much medication, like RR too low, too sleepy or difficult to arrouse, BP too low, low O2 saturation level, etc. If these things are out of whack and you still give more meds, then yes, you could get into trouble. If the pt is A&O and vitals WNL, no reason not to give an ordered med.

I see that you have 10 years of experience so I know I'm stating the obvious, but it sounds like you just need a little reassuring that you are doing the right thing.

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Specializes in ER.

not in my experience. Of course, if you're giving 4 MG of Dilaudid to a young person naive to narcotics and you didn't speak up and just gave it, then you'd have a problem. If you're giving that same amount to a chronic Dilaudid recipient, and continued to monitor appropriately (as you would to any patient who received Dilaudid), then I don't see a problem. Now I'm just throwing out the 4mg number, that is never an amount that is ordered. Ever. The orders more common are 1 to 2 mg every few hours or so. I don't question (but may hem and haw) when chronic seekers, Pancreatitis, or back pain patients receive this. Many doctors give in, many don't. We don't prescribe, but we have to use good nursing judgment whenever we administer any med, but specifically those that cause respiratory depression. Specifically, the liability you have as a nurse is how the patient will respond to the dose, what is the "usual" dose and how you monitor that patient while the patient receives the dose. You are responsible to know about the med, the side effects/patient response, etc. When working, I am always thinking of documenting as though I'd have to explain myself in court. It's called defensive charting. When you're caring for a patient where you're administering a med, chart as per your hospital policy. Ensure patient safety at all times, and remember to think "what would any other nurse do in this situation" and then go above and beyond that. Protect your patient, but most of all, protect yourself.

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Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.

This is a dicey situation.

"IF": the pt is narcotic dependent (IE chronic pain mgmt) "AND" they have a reason for needing acute pain relief...you're probably okay so long as you do your job of keeping the pt safe, monitoring and reassessing.

However,

"IF" the pt is narcotic dependent (as above), "BUT" has no reasonable explanation for needing acute pain relief - I would be concerned about the RN's role in "facilitating" a substance addiction.

I'd like to hear other responses to this and some other possible outcomes.

Thanks - good question!

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Specializes in Trauma/ED.

Would be easy to chart "dosage verified with MD" after speaking with him. Remember there is no real "max dose" for narcs so we have to go by pt history and vital signs. As mentioned before it would be unwise to give 4mg Dilaudid to a young person in px without history of narc use (worth questioning in case the MD meant Morphine)...but if you are watching the patient what are you going to do if you give them too much? Support breathing and give a little Narcan right? If you aren't watching them and they die then you might have a problem...just sayin :-)

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Specializes in ER, telemetry.
This is a dicey situation.

However,

"IF" the pt is narcotic dependent (as above), "BUT" has no reasonable explanation for needing acute pain relief - I would be concerned about the RN's role in "facilitating" a substance addiction.

I'd like to hear other responses to this and some other possible outcomes.

Thanks - good question!

this is kind of what concerns me. Monitoring patients receiving narcs is a no-brainer for nursing practice in the ER, or at least should be.

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this is kind of what concerns me. Monitoring patients receiving narcs is a no-brainer for nursing practice in the ER, or at least should be.

I agree with what you said, but I don't get what concerns you about the post you quoted relative to monitoring patients receiving narcs in the ER.

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