Anyone else see...?

[ninja-nurse, BSN]

My first workplace mixed adult and pediatric med-surg/tele. (which terrified us all, as we'd typically get about 1 peds patient every 3 weeks. I was FAR from the only nurse who carried around a little booklet with peds lab-and-VS ranges and drug calculations)

I had a little boy one night - can't remember how many months he was, but I'll never forget that he weighed 23 lbs. His 6 year old brother tripped while playing, fell on him and broke the little one's leg. He was NPO past midnight for surgery, and when he went NPO we were to start IV fluids and give him 1 mg of Morphine IV every 2 hours.

My gut said this wasn't safe. I checked my drug guide - it wasn't. I called the doctor to clarify - that's what he wanted. Not 0.1 mg, not q 2 PRN, 1 mg EVERY 2 hours. Period. I refused to give it. My coworkers backed me up, my supervisor backed me up. My floor manager WROTE me up.

Needless to say, that was the last of a VERY large pile of straws, and I turned in my notice. It's been over a year since then, but it still bugs me. I was just wondering if anyone else had seen this kind of insanity, and if so, how they handled it?

[wooh, BSN, RN]

Quit that hospital before we killed a kid and went to work in a peds hospital. :)

[Double-Helix, BSN, RN]

Hmm, 23 pounds is 10.5 kilograms. The recommended starting morphine interval dose for severe pain in a pediatric patient is 0.1mg/kg/dose every 2 hours, according to pediatric drug guides. The maximum dose is 0.2mg/kg/dose every 2 hours. To, me (an RN in Peds ICU) the ordered dose was acceptable and necessary to control pain in this patient.

http://www.orthonurse.org/portals/0/pedi%20pain%20card.pdf

See the third page of the guide, toward the bottom, under the Severe Pain heading.

Just last week I had a patient that was experiencing severe pain post abdominal surgery. She was two years old and weighed 11.8 kilograms, or 26 pounds. Her morphine dose was 2mg every 2 hours, PRN, but she was requiring the morphine every two hours. We eventually started her on a continuous drip of 1mg per hour, every hour.

I know it's hard caring for children when you aren't used to it. I'm wondering what drug guide you were using that stated this dose was too high. The doctor probably did not want the baby to under medicated and be experiencing severe pain before he was given more pain medicine, but would rather he had steady pain medicine on board. If the baby became agitated from pain then he is more likely to cause more damage to the bone by moving around and could possibly cause the fracture to become compounded.

I would have given the first dose, and then carefully assessed the patient. If, after two hours, I felt that the patient was too lethargic, his respiratory effort wasn't adequate, and his pain was well controlled, then I would have called the doctor and asked to make the order PRN or decrease the dose if he wanted it scheduled.

[ninja-nurse, BSN]

Ah. See, this is why I posted this - because it's bugged me all this time. I was young and new, and my co-workers, my supervisor, and even the ICU and ER nurses all agreed that it was too much (again, we only got peds once in a blue moon). No pharmacy at night, or we would have asked them. The baby actually slept quietly through the night, didn't seem even discomforted, but it scared all of us on the floor.

Obviously we were all wrong, and I will bow to superior judgement. Thank you for correcting me.

[hikernurse]

But the more important point (since the baby was all right and the dosage appropriate) is that education was sadly lacking. Peds is an entity to itself and it isn't safe to care for little ones as well as adults without appropriate teaching--especially when the little ones aren't consistently patients.

When babies/small children go bad, they don't waste any time and without knowing the appropriate s/s, something could easily be missed--especially when there isn't much of a chain of command to ask questions of during night shift.

[KelRN215, BSN, RN]

I had the same thoughts as Ashley when reading this. Morphine doseage for pediatrics is 0.05 to 0.1 mg/kg per dose q 2hrs. 1 mg q 2 hrs is a perfectly acceptable dose for a child who weighs 23 lbs (10.5 kg).

[ninja-nurse, BSN]

Agreed, hikernurse - though education was FAR from our only peds issue. 3 month old with pneumonia, when RT has been griping for a month that they don't have pedi masks... scary. Or nurses using their lunch break to go to the local walmart b/c the hospital is out of formula...

KelRN, I accept that I was an idiot. Obviously my calculations must have been off (as I highly doubt that I happened to get the ONE drug book in a batch that had a typo) and my poor patient is VERY lucky that I didn't hurt him. Management probably should have thrown me out instead of writing me up.

[hikernurse]

Whoa--what a scary place to work!!

As far as the drug calculation goes, it's a lot tricker doing mg/kg/dose than figuring out typical adult doses. I'm a huge advocate for pain relief, but if your concern was keeping the child alive and breathing, you were right to question. Fact is, sometimes doctors (as well as nurses, etc.) can make mistakes in dosages. I'm surprised the nursing supervisor wasn't familiar with peds dosing, but she wasn't, so that's that.

In any event, you were very wise to get out when you did!

[wooh, BSN, RN]

But the more important point (since the baby was all right and the dosage appropriate) is that education was sadly lacking. Peds is an entity to itself and it isn't safe to care for little ones as well as adults without appropriate teaching--especially when the little ones aren't consistently patients.

When babies/small children go bad, they don't waste any time and without knowing the appropriate s/s, something could easily be missed--especially when there isn't much of a chain of command to ask questions of during night shift.

Yes! The hospital that I left decided that training for peds would be PALS. That was it. PALS. So once the kid was totally decompensating, we were good. (Well except that the peds crash cart was missing a ton of supplies, because it was expensive to stock supplies in EVERY size!) I had an RT try to check a pulse ox on an RSV baby with one of those things you clip on a finger. It was RIDICULOUS.

People just don't know how dangerous some hospitals are. Not because the staff doesn't care, but because they don't know what they don't know. There were plenty of nurses that thought everything was just peachy because we only kept "stable" peds patients. It doesn't take long for a respiratory kid to go bad. Asthma, pneumonia, bronchiolitis... You can go from "stable" to intubated really quick. And a PALS class isn't going to prevent that.

[wooh, BSN, RN]

About the dosages, I think even experienced peds nurses tend to be hesitant with pain med doses. Unless they're PICU or PACU or a surgical floor where they hand out narcotics like candy, peds nurses (and doctors as well, unless they're surgeons or pain team) are stingy with the narcotics.

[applewhitern, BSN, RN]

I think the biggest difference here is "the med-surg floor" vs. "pediatric ICU." I have worked both, and I am terrified when I have a child on an adult med-surg unit, but I also worked for 6 years in a large university pediatric ICU. It is easy to monitor a child in the ICU, hooked up to monitors, etc. But on the floor, it is very different.