Giving Narcan to Your Own Patient

[MickeyMarieRN]

Have you ever done this? How could I have had better judgement.

I I was assigned a new admit that came to my unit, an ortho floor, from the ER the previous shift. The patient had a fractured tibia that was awaiting placement of an external fixator. The Ortho doc did not write for a hospitalist consult, and the patient clearly needed one. He had a long list of general medical history that no one paid attention to... cancer, copd, ect. The patient was given 15mg of ketamine in the ER and 0.5 of dilaudid at 11:30pm. At 7:50 am I go in the patients room to reposition him and he is screaming out in pain. The night shift RN said that she didnt give any more dilaudid because that evidently snowed the patient "all night". But here he was at 7:50 screaming in pain. I didnt do a full assessment before giving him his pain med. I administered 0.5 of dilaudid. I come back 30 minutes later to do the prn response, it looks like he is sleeping and more comfortable. Two hours later I walk in and he has mucus and froth around his mouth and will barely wake up to a sternal rub. His pupils are 2mm and he has a glazed look on his face. His 02.was 96% on 2L, but i wasnt confident about his respiratory effort. It appeared shallow, even though his 02 sat was fine. The new hospitalist that I requested from Ortho asked that I give Narcan after I called to report symptoms, the patient was given 0.4 and then woke up. He was again in severe pain, but able to answer questions appropriately. After several lab tests and a pan scan CT he was found to have an acute kidney injury, pneumonia, and his external fixator surgery was delayed by a day. I feel responsible for making a mistake because I had to give Narcan two hours after giving a PRN med to a patient that I hadn't fully assessed. What would you have done differently?

[kp2016]

I probably would have done a quick reassessment 1 hour after the Dilaudid with vital signs.

Honestly 0.4mg of narcan is too much for that clinical presentation. I would have "requested" the Doctor order 0.1mg Q3 minutes MAX 4 doses.

Don't beat yourself up. I don't think you did anything you need to feel bad about.

[JKL33]

54 minutes ago, MickeyMarieRN said:

After several lab tests and a pan scan CT he was found to have an acute kidney injury, pneumonia, and his external fixator surgery was delayed by a day. I feel responsible for making a mistake because I had to give Narcan two hours after giving a PRN med to a patient that I hadn't fully assessed.

Can you explain your line of reasoning a bit more?

Are you saying that, because upon medical investigations he was found to have AKI and pneumonia, you should have done an assessment to help discover these things before having treated his pain? And if you had done so then narcan may not have been necessary?

[MickeyMarieRN]

3 minutes ago, JKL33 said:

Can you explain your line of reasoning a bit more?

Are you saying that, because upon medical investigations he was found to have AKI and pneumonia, you should have done an assessment to help discover these things before having treated his pain? And if you had done so then narcan may not have been necessary?

I feel that had I known he had an AKI i would have given him a lower dose. Perhaps the AKI played into his ability to clear the dilaudid, which may have been why he was "snowed all night long" according to the night shift nurse. I gave the dilaudid primarily because I felt he had an altered mental status and was not able to cough up secretions, which is an airway patency issue.

[viprn21, BSN, RN]

1 hour ago, MickeyMarieRN said:

I feel that had I known he had an AKI i would have given him a lower dose. Perhaps the AKI played into his ability to clear the dilaudid, which may have been why he was "snowed all night long" according to the night shift nurse. I gave the dilaudid primarily because I felt he had an altered mental status and was not able to cough up secretions, which is an airway patency issue. 

Wait, you gave him narcotics because you thought there was airway compromise and altered mental status? This was absolutely the wrong reason to give dilaudid. Narcotics decrease your respiratory drive, making it less likely to clear those secretions and will worsen the mental status. Mental status doesn't decrease from pain alone, there was most definitely something else going on--especially if he only got 0.5 of dilaudid. Narcotics can be used for respiratory distress, but that's when the work of breathing is increased; in those cases, morphine is preferred, unless the patient has an allergy in which case yes you'd use dilaudid.

It also sounds like this patient was not properly monitored. If you're not able to safely monitor a patient, something is wrong with your assignment or you are not properly prioritizing your tasks. I'm questioning the judgment of the doctor for putting them on the floor when it sounds like they should have been put in a step-down. The fact that it took you two hours to check on a patient with priority needs is a huge red flag. I understand ortho floors are VERY busy, but you are never too busy to ensure your patients are safe. It takes 30 seconds to pop in the room and look at the patient.

From what I know from this situation, I would have only given half or a quarter of dilaudid, or called the doctor for a non narctoic PRN (IV tylenol is in many cases a good option). In addition, it's OK to not give pain medicine if you think it is not safe, even if the patient is in pain. If the patient has excessive pain because the doctor did not order the appropriate type or amount of pain medicine, that's on the doctor; but if harm comes to the patient because the doctor ordered an inappropriate type or amount of pain medicine and you gave it, that's on you. The nurse is the last line of defense between the patient and a medical error. If there's any doubt in your mind at all, STOP. Listen to the nurse sense!

I may catch flack for this, but it's perfectly OK to give half a dose of pain medicine or even a quarter if you have any doubts about how the patient responds to the full dose. I've had a lot of people tell me "That's practicing medicine without a license" because you're giving a different amount of medicine than the doctor ordered. That's just not true. You do not have to blindly follow an order because that's what the doctor wrote. Doctors are humans, they make mistakes and bad judgments. You don't need a charted justification, your gut feeling is enough. You can always give the rest later if you need to, and as you've learned reversing narcotics sucks. It's much, much easier to do things right the first time than it is to clean up a messy job later.

I hope I didn't come across as mean. Your value as a nurse is not decreased from this incident. I would be lying if I said I'd never made similar mistakes; I most definitely have given narcan a few times for narcotics I've personally administered. But sometimes that's how the dice roll; these medicines are risky and these things happen. You're not defined by your mistakes, you're defined how you learn from them. In addition, don't be afraid to stand up to the doctors, even if they're mean! They can yell at you, they can be assholes, they can ignore you, but what they CANNOT do is fire you or take away your license. I've even found that standing up to "difficult" doctors is what makes them respect you in the end.

[MickeyMarieRN]

*I gave him NARCAN because I felt his airway was compromised and he had AMS s/p dilaudid administration. Sorry for the typo.

[viprn21, BSN, RN]

Just now, MickeyMarieRN said:

*I gave him NARCAN because I felt his airway was compromised and he had AMS s/p dilaudid administration. Sorry for the typo.

I'm sorry for the long spiel then!

[MickeyMarieRN]

1 hour ago, MickeyMarieRN said:

I feel that had I known he had an AKI i would have given him a lower dose. Perhaps the AKI played into his ability to clear the dilaudid, which may have been why he was "snowed all night long" according to the night shift nurse. I gave the NARCAN primarily because I felt he had an altered mental status and was not able to cough up secretions, which is an airway patency issue.

[JKL33]

46 minutes ago, viprn21 said:

You do not have to blindly follow an order because that's what the doctor wrote.

No you don't. But you do need to communicate with the appropriate person about it. If you appreciate deleterious effects which you believe are related to a medication or you have concerns about the order before you even administer it, yes, your job is to hold the med or suspend the administration of it in order to report your findings and/or concerns. You do not get to unilaterally decide that altering the order is the thing that is going to improve the situation. This isn't about who has the right to do what or the fact that doctors make mistakes. It is about patient safety. And while your judgment theoretically might be prudent, the next nurse may not even have noticed that you'd been giving half the dose during your shift...or the physician might have decided they didn't want the patient to have the medication at all. Or they might decide that, hearing your report, they are concerned about something additional beyond just what you are concerned about. So no, your way is not perfectly fine.

I'm not arguing that you have to stand there and push the full ordered dose if you believe there is a problem or administer a medication order that you have serious concerns about. I'm saying that when you hold or suspend administration, you then document that appropriately and notify the proper people and advocate for the order to be changed/discuss your findings and concerns.

[Sour Lemon]

1 hour ago, viprn21 said:

I may catch flack for this, but it's perfectly OK to give half a dose of pain medicine or even a quarter if you have any doubts about how the patient responds to the full dose. I've had a lot of people tell me "That's practicing medicine without a license" because you're giving a different amount of medicine than the doctor ordered. That's just not true. You do not have to blindly follow an order because that's what the doctor wrote. Doctors are humans, they make mistakes and bad judgments. You don't need a charted justification, your gut feeling is enough. You can always give the rest later if you need to, and as you've learned reversing narcotics sucks. It's much, much easier to do things right the first time than it is to clean up a messy job later.

Like so many other things in nursing, I believe this is regional. In one state, I gave partial doses with some regularity based on my nursing judgement. Where I'm at now, it's simply not allowed.
There is no option to enter a lesser dose than what's ordered on the eMar. And there is no option to waste a dose that's been documented as given. I suppose you could carry off the additional milligrams and dispose of them quietly, but then your documentation is false and you may appear to be diverting narcotics.

Since those are two things I'm not going to entangle myself with, I do call the MD when I need a dose reduced ...as illogical as it seems to me.

[MickeyMarieRN]

4 hours ago, JKL33 said:

No you don't. But you do need to communicate with the appropriate person about it. If you appreciate deleterious effects which you believe are related to a medication or you have concerns about the order before you even administer it, yes, your job is to hold the med or suspend the administration of it in order to report your findings and/or concerns. You do not get to unilaterally decide that altering the order is the thing that is going to improve the situation. This isn't about who has the right to do what or the fact that doctors make mistakes. It is about patient safety. And while your judgment theoretically might be prudent, the next nurse may not even have noticed that you'd been giving half the dose during your shift...or the physician might have decided they didn't want the patient to have the medication at all. Or they might decide that, hearing your report, they are concerned about something additional beyond just what you are concerned about. So no, your way is not perfectly fine.

I'm not arguing that you have to stand there and push the full ordered dose if you believe there is a problem or administer a medication order that you have serious concerns about. I'm saying that when you hold or suspend administration, you then document that appropriately and notify the proper people and advocate for the order to be changed/discuss your findings and concerns.

I feel that this is exactly why the night shift RN who admitted the patient from the ER should have called the ortho doc and had the dose changed and then asked for a hospitalist instead of passing it on to me. Only to repeat administration and have the same effects. I dont know why I didnt listen to her, I guess it's because I felt that she wasnt sound in her judgement. Yes, he was in fact "snowed" from the dilaudid. My question is... where was the documentation and intervention from that reflected in the chart from the previous shift? If your patient is "snowed" for 8 hours, wouldnt you want to do something about it?

[viprn21, BSN, RN]

5 hours ago, JKL33 said:

No you don't. But you do need to communicate with the appropriate person about it. If you appreciate deleterious effects which you believe are related to a medication or you have concerns about the order before you even administer it, yes, your job is to hold the med or suspend the administration of it in order to report your findings and/or concerns. You do not get to unilaterally decide that altering the order is the thing that is going to improve the situation.

Lol I knew someone would get upset I said that. Of course. I presumed that didn't need saying. My point is that nurses have move power than most of us seem to realize. However, I've seen plenty of mistakes made because "that's what the doctor ordered" and I can't stand for that. And no, we never make unilateral decisions. However, I AM the one who is directly responsible for keeping the patients safe, and if that means deviating from orders, I'm going to do that. That being said, I'm fortunate to work in a facility where physicians and supervisors take my concerns seriously, so it's very rare that situations escalate that far.

There was a case recently in my area where a physician ordered an inappropriate treatment. The day nurse refused to follow it, full stop, would not even consider doing it. Night shift carried out the order and the patient died. Guess who got canned? Not the doctor who wrote the order, the nurse who carried it out. Sure, you can point at a lot of points where the system failed (including the supervisors who refused to listen to the day shift nurse), but at the end of the day, you're responsible for your own practice.

1 hour ago, MickeyMarieRN said:

And while your judgment theoretically might be prudent, the next nurse may not even have noticed that you'd been giving half the dose during your shift...or the physician might have decided they didn't want the patient to have the medication at all.

It's easy to argue all day about the what-ifs. Sure, I've gotten into disagreements with physicians and supervisors over my actions, but I consider that an important ongoing discussion and part of the job. My litmus test is this: before I do something, I ask myself if I'm willing to stand in front of a judge and jury and the patient's family and explain what I did and why. If the answer is no, I don't do it. It's never let me down. Edit to add: Sometimes the doctor can't/won't call you back and it's important to be able to handle a situation without having your hand held. It's your job.

1 hour ago, MickeyMarieRN said:

I dont know why I didnt listen to her, I guess it's because I felt that she wasnt sound in her judgement.

I'd imagine you were probably under a bit of pressure from the patient and/or his family to get his pain under control. It's understandable, especially since the administration frequently prioritizes patient satisfaction over patient safety. It is good that you are reflecting on all of this and you recognize what went wrong and where, but also, don't dwell on it too much. What happened, happened, and all you can do from it is learn from it and move on.

5 hours ago, Sour Lemon said:

Like so many other things in nursing, I believe this is regional. In one state, I gave partial doses with some regularity based on my nursing judgement. Where I'm at now, it's simply not allowed.
There is no option to enter a lesser dose than what's ordered on the eMar. And there is no option to waste a dose that's been documented as given. I suppose you could carry off the additional milligrams and dispose of them quietly, but then your documentation is false and you may appear to be diverting narcotics.

Since those are two things I'm not going to entangle myself with, I do call the MD when I need a dose reduced ...as illogical as it seems to me.

Is that a facility rule or a state rule? That sucks a lot. I've worked at facilities that micromanage like that and quit because of it.