Deciding what to give to the patient who gets everything

Esme12, ASN, BSN, RN · Dec 28, 2014

Wow...and they are still cognitive? What is their diagnosis/complaint?

sallyrnrrt, ADN, RN · Dec 28, 2014

i want to know their diagnosis, so i can complain of it next time , sorta opiate buffet, little benzo for a garnish.......

Birdy, i am just being sarcastic , love ya girl, hope your career is evolving well,......remember us ole'fossile nurses are goning to need a break soon :)

calivianya, BSN, RN · Dec 28, 2014

I'd give whatever would last the longest and is the weakest - so I'd give the Percocet first.

What kind of trouble breathing and what kind of low BP are we talking about? Some people's normal BP is lower than what we are used to seeing, and being short of breath could be improved with a little benzo/narc. Also, I'd hope the previous nurse would tell you what he/she gave the patient and how the patient reacted to it before you arrived. That's possibly your best indicator of how the patient is going to handle the drugs and whether they are safe to give together.

RschIVF40 · Dec 28, 2014

I agree with what the other RN's have said regarding: 1) checking what the patient had previously and how they reacted to it; 2) giving the med that is the weakest / lasts longest, & 3) keeping the benzo/narc close by in the event it is required. I'd also check back with the attending MD to apprise him/her regarding the patient's BP & shortness of breath & continued request for pain meds. I'd also make sure to document everything ( i.e. following up with the attending MD or HBS MD, as well as your concerns) in the event that the patient has a negative outcome. You didn't mention the patient's diagnosis, so it is not clear what they are suffering from, nor did you mention how long they had been on all these pain meds.

Some patients experiencing long-term chronic pain, are in fact actually just anxious and depressed due to the chronic pain and thus, may be more hypersensitive to pain. They may just "feel" as if they need more pain meds, when in fact, they do not. Taking that many pain meds over a long period of time can affect the pain receptors in their brain. Chronic pain is difficult to treat, especially if the patient is weak. Caution is essential if the patient has a low BP along with breathing issues in order to prevent over-sedation, etc. Good Luck

Birdy2 · Dec 28, 2014

The pt had the flu and pneumonia but was in fact a pain mgmt pt and her pain mgmt dr prescribed those things. She had been getting her scheduled morphine and Ativan PO and then one person gave all of those together at one point. When I had her BP was lower than normal, around 80's/50s-110/80 and she was suffering from a lot of congestion because she refused to be suctioned (perm trach). She just kept requesting mucinex, which I paged the dr about and he ordered, but I told her she really needed to let us suction her. She was definitely not happy about me holding her pain meds though.

KelRN215, BSN, RN · Dec 28, 2014

Was the scheduled morphine MS contin and the breakthrough just plain morphine sulfate? If so, that makes sense. Give the scheduled morphine and if breakthrough pain, give a PRN. I agree start with Percocet.

SierraBravo · Dec 29, 2014

I love the fact that you are so diligent and meticulous with respect to this case. Not only that, but you're also thinking critically (i.e. hypotension, trouble breathing, etc...) with respect to meds and the clinical picture of the patient. There is no easy answer to your question, it's kind of a mix between your clinical judgement and the clinical picture of the patient. The patient could be dyspneic because there are a bunch of secretions in their airway, which could obviously lead to anxiety. Of course, the patient could be dyspneic for some other reason. What was the patients RR? 80/50 is definitely a soft BP, I'd be cautious about giving too many more sedating meds at that point. The other thing to consider is that people with chronic pain often have a higher tolerance to opiates (r/t taking narcotic pain relievers on a chronic basis), so it may take significantly more medication to cause respiratory depression in those patients. Like I said, no easy answer. Your best bet is to know your meds (onset of action, half life, etc...) and then use your clinical judgement to give medications that you feel will address the patient's pain, then reassess and go from there.

Birdy2 · Dec 29, 2014

Well thanks for saying that :) I feel like I suck at this right now and like I know nothing. So that definitely helps. I have more to learn than I ever imagined, but I'm doing it :) thanks again!

nurseprnRN, BSN, RN · Dec 29, 2014

Do not ever hold the maintenance pain med on a chronic pain patient who is awake and asking for it. If they're napping, wake them for it as you would any other scheduled med. As someone alluded to, a chronic pain med is well-tolerated and holding it not only increases pain but will also make your patient experience withdrawal symptoms (stop right now and look up the difference between addiction, habituation, and tolerance-- not the same thing at ALL).

So you held her pain med and she got antsy and irritable and tachy? Imagine that.

The next thing you can do is call the local hospice and ask to speak to an RN about opioid management strategies, equianalgesic dose calculations, how to manage prns, and why you give things on schedules. They will be thrilled to tell you. Yes, do this even if this patient is on chronic pain meds for a non-life-threatening condition. You will never look at pain mgmt meds the same.

NurseGirl525, ASN, RN · Jan 1, 2015

I've had really bad pneumonia a couple of times. Been in ICU for it for weeks on end. I take a chronic pain med every day and then was given diludid also. I usually have low blood pressure. My meds were never held. I was pretty much out of it because of all of the pain meds and yes I was on Ambien at the time also for sleep. Pneumonia can really mess you up. I spent 3 months in a hospital once in ICU. Another time I spent 6 weeks. I've also had pneumonia that can be taken care of at home. But the kind that you have to be hospitalized for, it is really awful and miserable. People on chronic pain meds have a different tolerance that opiate naive people. The morphine sulfate that I take only takes care of long term chronic pain. If I have acute pain, the morphine does nothing. It's hard for people to believe that, but if I fall down and say break my ankle, that morphine does not touch that pain. So they kind of need all those meds with pneumonia. I was really kind of glad I wasn't real with it while I was there. It made the 3 months go by much faster!! LOL

sallyrnrrt, ADN, RN · Jan 1, 2015

as usual, Grntea knocked it out of the park......never hold maintaince on chronic pain pts