Giving Narcan to Your Own Patient

neuron · Oct 21, 2019

9 hours ago, MickeyMarieRN said:
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?

I probably would have asked the previous nurse if they called the doctor about the patient being 'snowed'.

Sour Lemon · Oct 21, 2019

55 minutes ago, viprn21 said:
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.

I have no idea, but I was really shocked that I was supposed to call the MD at 3AM if I wanted to give 2mg of morphine instead of 4mgs ...at the patient's request, no less.

I was also instructed to call for a diet order for a patient who was obtunded and scheduled for feeding tube insertion the following day. I couldn't just enter NPO into the system.

JKL33 · Oct 22, 2019

13 hours ago, viprn21 said:
Lol I knew someone would get upset I said that. Of course. I presumed that didn't need saying.

Not upset. Your first comment was only advocating part of our responsibility.

13 hours ago, viprn21 said:
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.

Pausing/holding in order to communicate a concern is not deviating from orders.

The portion of your comment that is being discussed is that of not giving as much medication as had been ordered out of a belief that this would be adequate correction of a problematic scenario, and that doing this independently is appropriate nursing judgment.

13 hours ago, viprn21 said:
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.

Again, this isn't about whether we have the right to refuse to do harmful things to patients. It is about whether it is best that we each make our own independent modifications to orders without communicating that we believe there is a problem.

With regard to your example above, I don't know what happened there, but one way to have it happen is by not communicating. There are several ways to refuse to do something we believe is dangerous...one of them is just shrugging and walking away and not implementing the order instead of appropriately communicating and escalating things as necessary. That may help that one nurse who keeps him/herself out of trouble, but might not help the patient too much.

13 hours ago, viprn21 said:
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.

You are moving way out of the context of my reply to you.

I'm saying that there is a process that can always be followed that is prudent. It begins with basic assessment and communication and follows all the way through to refusing to do something and escalating the situation up the chain of command when that is necessary.

I'm not arguing unreasonable what-ifs. For example, in the OP scenario, the first nurse and the OP believe that dilaudid has snowed this patient who has a fresh traumatic injury. You (appear to) believe the same and your solution (one of the options you advised) is to independently decide to give a quarter or half of dilaudid in order to take care of or mitigate the problem with the patient's altered mental status...meanwhile the fact of how this patient messed up his leg in order to need surgery hasn't yet been asked/mentioned.

Quote
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.

Independently altering orders is on my list of things that I don't want to try to explain to judge and jury when something has gone wrong. I often (but not always) know exactly what I believe should happen when I contact them about a problem. It would never occur to me to think of this process as having my hand held.

Twinmom06, ASN, APN · Oct 22, 2019

as an aside, dilaudid is the preferred drug for AKI/CKD because it is metabolized by the liver not the kidneys like morphine, so that part would not have contributed to his AMS.

Mini2544, ASN, RN · Oct 22, 2019

On 10/21/2019 at 12:57 PM, 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.

Same thing for me. There are many times when I don’t think it’s necessary to give 6.25 of Phenergan or 50mcg of fentanyl. However according to the powers at hand, if we don’t give the exact order.. we are practicing outside our scope. We always have to have a specific order. It’s annoying. I think adjusting a med dose in certain situations is the exact definition of nursing judgement.

murseman24, MSN, CRNA · Oct 23, 2019

You did a fantastic job of recognizing that a normal SpO2 with supplemental oxygen does not equal normal ventilation and gas exchange. The patient may have been retaining CO2. Next time, if you mix 1 mL of the 0.4 mg Narcan in 9 mL saline and start with 2 cc, then give 1 cc every couple of minutes, you may be able to titrate the drug to combat the respiratory depression while not taking away the full analgesic effect. 0.5 mg Dilaudid is not a large dose, and elimination of the drug was not a factor within the time frame that you specified. You did a good job within the confines of the hospital policy and your scope (giving the ordered dosage of each medication).

agome029, BSN · Oct 24, 2019

Hey, don’t beat yourself over this. I work in the ED and this happens quite frequently, we give marcan like it’s free candy . Sounds like you patient had a lot of cormborbities- such a renal issues, pneumonia etcs- sounds like he was a hot mess- what’s his/her age ? Hx - etcs- a good assement in the am priority - never believe or trust what the prior nurse day - always double check— regarding narcotics - I don’t think 0.5 was a big dose - I mean he had a fracture- people bodies just respond differently - the only thing I can tell you is to check on your patients more frequently , after 30 mins- if they are sleeping - just wake them up - they will go back to sleep , make sure they are arosuable — next time this happens just override the narcan and give it - call the doctor for the order -promise you you won’t get in trouble for saving his life - sit the pt- none rebreather- very very painful stilmulartion- sooo don’t feel bad I given narcan 5 minutes after giving opioids - many time I had to help intubate - you cant predict how anyone will respond - sickle patients come tot he ed- sometimes we give them -6 mg Diulated- 50 Benadryl in 2 hours and sent them home lol- my point is - *** happens - just learn for the next time

**canoehead, BSN, RN** · Oct 25, 2019

I think I would have done a bit more assessment before giving Narcan. Lots of people drool in their sleep and take a minute to wake up. If he could waketo answer questions briefly, and his sats were fine I'd just let the med wear off, and put him on a sat monitor. Once you give Narcan his pain control is gone.

agome029, BSN · Oct 25, 2019

2 hours ago, canoehead said:
I think I would have done a bit more assessment before giving Narcan. Lots of people drool in their sleep and take a minute to wake up. If he could waketo answer questions briefly, and his sats were fine I'd just let the med wear off, and put him on a sat monitor. Once you give Narcan his pain control is gone.

She stated. she tried to wake up the pt but he didnt respond. He sat were 96 on 2 Liters. no great but okay. Nursing 101. You need to look at the patient and not the monitor. Im telling you if she would let the med wean off. He would prob go into respiratory failure and arrest eventually. This guy just had a fracture with a long medical history. Those are the pt who go down very quickly. Who care about the pain control ? when the patient is not responding. Seriously you are scaring me, I wouldnt trust you with anybody

azhiker96, BSN, RN · Oct 25, 2019

Good experience. I've seen patients go apneic from 2 mg of Morphine and had pt's ask for Benadryl after a 6mg Dilaudid push. Individual patients respond differently.

I would second the comment about a lower dose of Narcan. In the field or ED with an overdose pt it makes sense to give the full 0.4 mg amp. In PACU I usually titrate in 40 mcg doses or 20 mcg if peds. I want the patient breathing, not screaming.

With my docs I can ask for a lower dose, and generally get it, based on my assessment and judgement. Narcotics should be titrated to effect but I know the Joint Commission don't seem to want or respect nursing judgement. Glad I work at a facility that uses DNV instead. In PACU I have several PRN meds for pain and give them based on patient history and response.

Kooky Korky, BSN, RN · Oct 25, 2019

On 10/21/2019 at 10:31 AM, viprn21 said:
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.

Very Important Person, RN

Yes, you are very important. Everyone is. But I wonder if your name might sum up the reason for the unsafe practice you recommend. Not giving the ordered doses might be the safe thing to do, but you must let others know, not just take pride in being powerful.

As someone else pointed out, we do use nursing judgment. We do not blindly obey orders. Doctors do make mistakes and we are the last line of defense for patients to not be harmed by their errors.

It is imperative to COMMUNICATE, though, so that other nurses, doctors, etc. know what is going on with the patients.

Power is fine but equally important is communication.

Kooky Korky, BSN, RN · Oct 25, 2019

3 hours ago, agome029 said:
I wouldn't trust you with anybody .

Rather a strong statement.