Hello. I'm posting this for a girlfriend of mine. I'm a new nurse working on a med-surg floor (9 months experience). I had a situation arise that I need some insight on from some experienced nurses. And of course for HIPPA purposes details will be changed to protect privacy. So I'll paint a scenario thats not real but with enough details to make my point.
I worked a 5 day week and I had this patient (John Doe), who was in a MVA and broke his back and had surgery about 3 weeks ago. Mr. Doe also has had chronic pain and has taken opioids for 20+ years. He is about 90lbs. Mr. Doe is also a very needy person who wants his pain medication constantly. He tells his family on the phone that we don't give him anything except Tylenol when Mr doe has 10mg of oxy er schedule bid, 10mg oxy ir prn q 4, scheduled zanaflex, prn tylenol 1000mg q 8, and prn valium 5mg.
The first day I had Mr Doe I didn't want to give all these meds because its clearly enough to cause harm. So I only gave the scheduled and quickly realized that nothing helped him. As the week went on I began adding the prns closer together at bedtime, realizing the even when all the meds are given together (except the oxy ir) that the patient still wants more.
His RR and vitals were never afffected by these meds. The patient had slept maybe 3-4 hours a night. So the last night I worked I gave all these meds including the oxy ir and oxy ER together. But before I did I looked to see that the prn oxy had not be given in 12 hours. I also looked at the onset, peak plasma level time, and duration of both Er and IR oxy. The IR peaks around 1.5 hrs and last about 4-5, and the ER peaks around 5 hours. So my thought process was, if I give them together the ir would be at the end of its effectiveness as the ER starts working its best. Giving Mr Doe a more consistent pain relief.
Well one of the older nurses found out I gave all these meds together and took it straight to the house supervisor. To make a long story short, all hell broke loose and they made me call the doctor because they thought the patient would need to be moved to a different floor for higher level of care. I called the doc and told him what I did and my reasoning behind it, and told him we were concerned. (Pt was still fine and 100% stable and alert). The doctor cracked up laughing and ask me how Mr. Doe was sleeping. He said there was nothing wrong with what I did and he had those orders in because he knew the patient would have pain and that he was a chronically addicted patient. But it wouldn hurt to space the oxy's out, but it was fine.
My question is, do you all feel like I made the right choice? Was that really stupid to give all those together considering the patient and situation? Was my rationale ok? I would clearly never give that much medicine to someone new or that I didnt know well. And I'm well aware of the cns depression that can occur with mixing narcs with benzodiazepines and zanflex. I feel like what I did was ok because I slowly worked up to this point cautiously. I never gave anything that wasn't ordered or more of what was ordered. And the patients RR never dropped below 18 that night and their other vitals remained wnl. Mr Doe said that was the best that he had slept in days and the best relief he had had from the pain. He didnt even ask for a pain pill that morning. Just a heat pack. If this was dumb I want to know. I'm open to constructive criticism. I need some insight and opinions please. Thanks in advance
In retrospect it's obvious you did the right thing. Even the doctor supported what you did.
I can't swear I would have given them all together. But you knew your patient and he tolerated it fine.
I gave a chronic pain patient one milligram (no not a typo) over (to be honest I forget exactly) probably less than 20 minutes. He remained awake, alert, ambulated without assist, and was discharged home probably half an hour afterwards.
This was per anesthesiologists written instructions and verbally letting me know it was the right thing to do and the patient would tolerate it.
You had the orders. You critically thought through your actions. You treated your patient. You spoke to the physician. Maybe do that before the fact next time just to CYA, but frankly, you did pretty much everything right otherwise. You have nothing to worry about or feel badly for. Just call the doc first next time so they can't call you out on it.
My thought is that where the doctor said that "It wouldn't hurt to space the oxy's out but it was fine," I think it would be appropriate for the doctor to specify how close to the scheduled oxy he/she wants the prn oxy to be given in his/her orders, so that everyone taking care of the patient is clear as to how close to the scheduled oxy the doctor wants the prn oxy to be given. Otherwise you have the situation where you interpreted the order one way, and other nurses taking care of the patient may interpret the order another way, and this could result in the patient receiving more oxy (total mg; scheduled and prn) in a given time period than they should receive, which could have harmful consequences for the patient (particularly as they are also receiving scheduled zanaflex) even though they have taken opioids for 20 years for chronic pain and are addicted to opioids. If I was taking care of the patient I would want to clarify the order with the doctor. I also think it would be appropriate for the doctor to specify in their order (as valium is also ordered prn) how close to the oxy and the zanaflex the doctor wants the prn valium to be given, and would ask for clarification on this also.
I would also keep in mind that the prn tylenol 1000 mg q 8 hours can also be given and will help to relieve the patient's pain without the risks of giving more opioids.
Last edit by Susie2310 on Nov 6
Thank you all for the input. I spoke to my friend again and she said the doctor talked to her later and they commended her on her judgement and how she thought it out. She said it made her feel a lot better.
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