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
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...
The problem is that another PRN should have been ordered, and if the doctor didn't order it, then it's up to the nurse to make that happen. Think about if that was your dad or your grandfather...you wouldn't have just sat there holding his hand all night. You'd have crawled up that nurse's butt until she got him some pain mess that he could tolerate. Of course, I doubt he could have been made pain free, but some oxycodone definitely could have taken the edge off.
I know it's a tough situation and that you're new, but I think if you're honest with yourself you'll see that as much as you cared about the patient, you were more concerned about not stepping on any toes.
Fentanyl in 12.5 - 25 mcg iv doses is a good option if the patient is borderline hypotensive. It has little to no effect on BP.
Some hospitals only permit IV fentanyl to be given in critical care areas. Check your policy.
The next time you see a patient receiving inadequate care, report it privately to your immediate supervisor and ask him or her to see the patient and intervene.
As I said, I am a new nurse. ... thank you so much for putting down a new nurse coming to this site looking for supportive help on how to handle a problem...
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.
Here's my 2 cents. I can't fault you for how you handled the situation. It was not your patient and while the care by the other nurse might not be optimal, it was not dangerous.
If that had been my patient first I realize that once I've given an IV med I cannot un-give it. I'd check the chart to see his vital signs history and trend. Some people have a baseline of 90/60 and are rock solid. I'd check to see if he'd had 0.5 mg Dilaudid IV and how he responded to it. Since the pt had cancer, he probably was already on narcotics and would be able to tolerate the dose.
I once gave a 30 yr old female 6 mg IV dilaudid followed by 25 mg IV benadryl. She was an addict and had been receiving those meds like clockwork without ill effects. That dose would be enough to kill me but each patient is different.
I do like the advice of giving it in divided doses. I've done that. If half a dose drops his BP I'd hold the other half and call the MD to get an order for my half dose and different pain orders. If he tolerated the half well, then I'd give the other half and consider it a slow push over 5-10 minutes. A PCA is a great idea as is long lasting PO narcotics with IV for breakthru pain.
I like the advice above of looking back to see how the pt's vitals looked with prior doses-if the bp is really his baseline and the med is q3, which I took to mean atc based on the op, then you should be able to get some insight as to whether he is always like this and fine with the med, or not.
Not sure what kind of setting this was. If an order is needed for everything (I once worked where we needed the doc to put in "death"order when the pt died...true story) call the doc, pt x has a bp of y. His baseline has been z w/wo the med. Would you like to give hold parameters because it has been held for low bp at times? If not, can we write may give dilaudid with spb over whatever as an order (if needed where you work)?
If the med the pt is on causes unacceptable virtual sign changes then his meds need to be changed, particularly as this pt is likely to get worse not better. Is hospice/palliative involved? They may be able to write suggestions for md on a colleague/consult level.
If there is a problem, fix the problem. ie, blood pressure low, give volume or pressor . If in pain, give pain medicine. If the nurse was so concerned about the blood pressure, she needed orders to treat it.
Why was an alternative medication or medication regime not discussed with a doctor? Even if it were not my patient, if I had left that man in pain as a new nurse, as an experienced nurse or even as a student, I would have felt guilty if I had not explored every possible option.
Pain should never be used as a pressor!! If she was concerned, she should have notified the covering provider about the pain and voiced her concerns. The pain should have been treated with SOMETHING!
Specializes in Med-Surg/Neuro/Oncology floor nursing..
Where I work if the patients blood pressure is low we are able to give half the dose. Now in something like cancer pain it may not be enough but its certainly better than PO apap. I agree an alternate should have been ordered if half dosing isn't possible. I'm wondering why a long acting narc wasn't ordered like methadone or MS contin in a patient with obvious cancer pain. Could have helped tremendously to have that on board especially if IV meds were contraindicated at one point or another.
Specializes in acutecarefloatpool. BSN/RN/CMSRN. i dabble in pedi.
And just a note, I would not ask a provider if it was ok to give pain meds if a patient is hypotensive.
Interesting - I would've done just this to cover my own behind. I don't want to be at fault if the patient's BP happens to tank after getting Dilaudid.
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.
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SubSippi
911 Posts
The problem is that another PRN should have been ordered, and if the doctor didn't order it, then it's up to the nurse to make that happen. Think about if that was your dad or your grandfather...you wouldn't have just sat there holding his hand all night. You'd have crawled up that nurse's butt until she got him some pain mess that he could tolerate. Of course, I doubt he could have been made pain free, but some oxycodone definitely could have taken the edge off.
I know it's a tough situation and that you're new, but I think if you're honest with yourself you'll see that as much as you cared about the patient, you were more concerned about not stepping on any toes.