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?
