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I made a big mistake

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Last night I had a patient who was in for pneumonia and cxr showed a small pneumo on the left. The patient was in no distress, 02 sat 96-98%, reparations 18. It was an 83 year old man, but he looked as if he had taken care of himself....maybe 70. Anyways, he had a pain pill due and so I gave it at 1930. He had been getting that, so I had no worries. About 2300 he asked for something to make him sleep and I looked and saw that he had gotten a Xanax the night before. Not thinking, I gave it. I should've thougbt more about his diagnosis and age, but for some reason I just gave it. The man was so sweet and I felt so bad because he was in pain from an abscesss that he had drained earlier that day. Plus, we give out Xanax like candy where I work. Everyone gets that or ambien or Ativan and regardless of if theyre in there with respiratory problems. I've never had any problems with patients handling it with pain medicine either. But this patient was different. He didn't take hem often and it just didn't go well for him. By about 0300 he was saying he felt awful, drowsy, weak. I knew immediately I made a mistake. His 02 was still 97% and no distress, but I'm positive it worsened his condition. His lungs sounded worse on the right and he just felt terrible. I felt so bad. I know the doctor who sees him will be upset that he got that, but I honestly feel like it shouldn't have been on his list. A lot of times people just use a list of meds from the nursing home or go by the patients last home med lost from their past admission. They don't always ask what the patient actually takes(depends on the nurse). But I always do. Unfortunately I didn't admit that patient and I had looked to see if he had been taking it and he had....so I gave it. It's definitely a learning experience and I will be treating all of my patients exactly the same when it comes to passing meds from now on. I understand now why were taught to do things a certain way in school. Give the lowest dose, least amount of meds to ease symptoms....not the most u can give. Start with a pill and then dilaudid for breakthrough, and so on. That would save me from hurting patients who can't tolerate a whole lot. It's just that since I've started working almost every patient asks for and gets dilaudid. If they're ordered a pain pill they don't even bother trying it. We're pretty much just feeding addictions. It's rare to see a patient who doesn't ask 30 minutes early for their dilaudid that's due very 2 hours. Anyways, I just had to get hat off my chest. I hope that I didn't harm the patient too much and will definitely never just give something again.

AJJKRN

Specializes in Medical-Surgical/Float Pool/Stepdown. Has 6+ years experience.

If the patient had been tolerating the meds before I would be more concerned about the pneumo getting bigger or a pleural effusion or PE, etc...not that the drugs could not have caused his symptoms but a chest X-ray and a blood gas may have helped narrow down what was going on.

Did you check his vitals before giving the pain pill? It sounds like you did. More importantly, did you check vitals (including mental status) before giving the Xanax? If everything was stable then, it would be appropriate to give the Xanax. It is possible that his condition deteriorated more primarily due to other factors like pathophysiology (see previous post) of his diagnosis or a personal drug intolerance reaction (did he have any kidney/liver issues). Primary responsibility of the nurse is to administer medications responsibly. Check vital signs before administering high-risk medications and understand the implications of a change in vital signs. Low BP, decreased respiration, and low O2 sat would all contraindicate narcotic administration.

calivianya, BSN, RN

Specializes in ICU.

I wouldn't say you screwed up at all. If it was on his list, he had taken it the night before, and I had not gotten in report that he had a bad reaction to it, I would also have given him the Xanax.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

I think you're being overly critical of yourself and seeing harm that doesn't appear as evident as you make it out to be.

You seem to base your regret over giving him Xanax on his 0300 complaint of feeling "awful, drowsy, and weak". It was three in the morning after all so drowsiness is sort of expected. "Awful" and "weak" are not particularly unusual complaints for an 83 year old with pneumonia. If anything it's possible he could have used more pain control if the last dose was at 1930.

You are correct that you need to be careful with opiates and particularly benzos in a patient who in their 80's and ill, but that doesn't necessarily mean they are never appropriate. I would avoid the ambien, but one of the worst potential harms that can come to this patient is to not get any sleep, so if a little Xanax is the difference between a little sleep and no sleep then that's not necessarily a horrible choice.

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 10 years experience.

Think of it this way, you gave a "pain pill" 7 hours before and Xanax 4 hours before his c/o "awful, drowsy, weak." You also said his R lung sounded worse than it did on your first assessment. Now, think about it--was it caused by your narc and benzo or was it deterioration of pulmonary status?

My question is: What did you do about the real reason for his complaint?

iluvivt, BSN, RN

Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience.

Why do you think it was the Xanax that caused the change in his condition? My first thought would be perform a complete respiratory assessment to make sure the pneumo was not worsening with decreasing lung reserves and worsening pneumonia. I am concerned about your statement that, "We're pretty much just feeding addictions and It's rare to see a patient who doesn't ask 30 minutes early".

I would like to have you clarify your statements because I am concerned that you may need to do some more study on the complex phenomenon of pain including tolerance and addiction. I have found that many nurses are lacking in this area as well as just what their ethical duties are in relation to a patient's right for pain relief.

I have been in a hospital bed in horrific pain and I can tell you that my IV Dilaudid wore off in appoximately 90 minutes. I was in agony and my only thoughts were to watch that clock and countdown to the third hour when I once again could get some relief. My whole world centered around getting my pain medication because when you are in that much pain NOTHING else matters at all. I really needed an epidural post op but after 3 hours of multiple people trying to get the epidual catheter in place they gave up! it is easy to judge and I hope for your sake and the sake of your patients this is not what you are doing. So what did you mean by your statements?

I did a complete assessment before assuming anything. The patient wasn't in pain, respirations even unlabored, 02 sat 97%, breath sounds same as they were before. I ordered a chest X-ray and he pneumothorax had not increased. It was definitely the Xanax. He had not been that way before. And the time he took it before he stayed asleep until it wore off. Now that I think about it j don't think it was hat big of a deal, but i was worried about depressing his respirations and things like that and also if his condioton was to worsen I wouldn't be able to tell if he was confused because of he Xanax or hypoxia. That's why I said I think it was a mistake. Plus he nurse I have report to said I was an idiot for giving it :(. Whatever, but anyways...

And as for my explanation for "we give them out like candy" > most all of my patients are getting Xanax and only because they asked if they could have it or said they take it at home so the doctor ordered it for them. The people who get it are also getting dilaudid, phenergan with no nausea, and Benadryl with no itching. Also, I'm not one to hold back on giving pain meds because I think they're not hurting. I always listen to my patients, but it's very frustrating when I'm trying to put a foley in, ivs, coding someone, and my other patient calls to yell at me because they're prn pain med is late. It's really the disrespect and inappreciative behavior that gets me. Anyone who even says they're hurting gets dilaudid before a pain pill is even tried. I don't know why some doctors do that. And also, you do not need dilaudid for chronic back pain. That's stupid because you're never gonna get that at home. And with giving it 30 minutes early...were allowed to do that but if you're getting something every 2 hours and have no significant source of pain , plus asking for a cocktail of drugs, then I don't feel like I should give it early at all. Patients have been over sedated due to that. I never refuse to give pain meds unless BP is low or respirations are below 12, or f they're in for AMS.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

I'm still not sure what it was that you think the Xanax did?

You said he wasn't in pain, but you also said he felt "awful". It's not unusual for a patient to describe only a certain type of pain, such a sharp pain, as "pain", which is where further examination of discomfort is useful since they still may require pain control even if they see

the definitions differently than how we might use them.

It's also important to remember that pneumonia is largely an inflammatory process, so it's not unusual for the symptoms to get worse before they get better.

Edited by MunoRN

imintrouble, BSN, RN

Specializes in LTC Rehab Med/Surg. Has 16 years experience.

We administer meds in the moment. We don't say "what if", and theorize about what could happen in two hours, as long as there's no history.

Your patient wanted a pain pill and there wasn't one single reason not to give it.

Three and a half hours later he wants something to relax. I don't see a single reason in your post not to give the Xanax.

I don't see what you did wrong. I would have done the same.

I'll share some advice. Not every patient change in condition is your fault. When a patient deteriorates, it's not because you weren't watching. There are times when you do everything right, and things go wrong. Just because the nurse you report to says you're wrong, doesn't mean you are.

Don't carry that burden on your back. It's pointless and unhealthy.

Edited by imintrouble

Thanks guys! This made me feel better about it. Let me try to explain though. I asked the patient if he was having any sharp, dull, achy pain or discomfort. He said no I'm not hurting I just feel really weird and not good. He was somewhat confused, nauseated, and very weak. I realized that pneumonia can cause some of these things and especially in older adults, But he had not complained of this before. I believe what happened is his condioton was worsening and the Xanax increased his confusion and made him drowsy, which he was describing as weak. I don't know. Maybe that's wrong. The doctor actually said to try to avoid giving that the next day. He didn't say anything else though.

By the way, the nurse who called me an idiot doesn't like to give pain medicine or things like that. Get this, I told her that a patient was complaining of sever pain and that he requested something stronger than a pill before his dressing change. She literally said he can forget it. I was so shocked. I explained again what he had requested and she just got red and said ok, but he ain't getting it. The next day she said she had changed the dressing without giving any pain medicine after the patient requested morphine and that he handled it fine. This was an abscess incision that required one inch packing. Also, with another patient who had testicular cellulitis and perineal abscess the nurse asked permission to dc prn dilaudid. She told the dr that he didn't need it. Same nurse. I reported it to my boss. That is not acceptable in my opinion. These poor patients were not drug seekers. They were in legit pain.

I asked the patient if he was having any sharp, dull, achy pain or discomfort. He said no I'm not hurting I just feel really weird and not good. He was somewhat confused, nauseated, and very weak. I realized that pneumonia can cause some of these things and especially in older adults, But he had not complained of this before. I believe what happened is his condioton was worsening and the Xanax increased his confusion and made him drowsy, which he was describing as weak. I don't know. Maybe that's wrong. The doctor actually said to try to avoid giving that the next day. He didn't say anything else though.

I am thinking the same as you.

Older adults can be very sensitive to the side effects/potential toxicity of some medications, particularly if they are very sick, and/or have other significant medical conditions.

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According to my drug guide, Xanax is listed on Beers criteria (2012) in regard to older adults being more sensitive to central nervous system effects of benzodiazepines, including falls. I just checked Beers, and I think you will find some useful information there in regard to what your patient experienced. Xanax is listed under Alprazolam.

From another drug reference, I have also read that as part of the check for contraindications to receiving Xanax, patients who have breathing difficulties should let their physician know this (you mentioned your patient had pneumonia and a small pneumothorax).

Edited by Susie2310

Mavrick, BSN, RN

Specializes in 15 years in ICU, 22 years in PACU. Has 30 years experience.

I'm of the same opinion that your administration of a pain pill at 1930 and Xanax at 2300 would not be the cause of awful, drowsy and weak at 0300.

What woke the patient up in the middle of the night? Residual pain from having a needle poked into his chest the day before? Being drowsy at 0300 would be expected if he was not able to sleep. It can also be exhausting to work at breathing with a pneumo and pneumonia decreasing one's respiratory efficiency. Was the pneumo a consequence of the abscess drainage?

You seem to be awfully hard on yourself by assuming you were totally responsible for things not going well for the old man. Based on what you've said I can't see you did anything inappropriate.

However, there are other things going poorly in this scenario. The nurse calling you an idiot has poor pain assessment skills and is leading you to believe it is bad to treat pain. You must assess. Every situation has it's own set of risks vs benefits. It's never right to pass out pain pills like candy (for pleasure) or withhold pain medication just because you don't like to give it.

In an acute care setting I don't give a flying phig about an addict's intentions. If I can safely give meds I will. I cannot address their addictive disease in the short time I have with them and I am not going to punish them for that.

I agree with everyone else completely. There could have been other factors to cause these symptoms.

Drowsy... Not so bad at 0300 expecially after xanax

Weak/awful... lungs sounding worse on the right doesn't scream xanax administration. If anything I think his pneumo had just gotten worse like stated above. Also, you never mentioned if he had a fever at that time. That makes me feel both awful and exhausted.

birdy2, I hope you will re-read the post by ImIntrouble and take it to heart. Real words of wisdom there. And re the nurse you work with who called you an idiot (you are not - not at all - you are intelligent, thoughtful, and caring) and who has been instrumental in reducing patient access to pain medications when he or she in pain the intuitive part of you knows that a big part of what a nurse should be is missing from that woman. I would advise taking everything she says with not a grain but a BOULDER size rock of salt! Chin up, birdy2!!

Well thanks you guys! This kinda made my day. I don't know why I was so worried and didn't realize that she had made me feel like it was my fault. Even when I read your first few responses I didn't get that. Now that I've had time to think about it and not so tired I don't think it was my fault at all. Even if Xanax made it worse, I was just trying to help my patient who hadn't slept in 2 days and it was ordered for him. His vitals were fine. He had taken it before at the same time. He begged me so politely to please give him something to help him relax. He was so depressed and just pitiful. Coughing all night and hurting no matter what u give him. I think that's the sweetest little old man I've ever taken care of lol anyways, he got worse for probably several reasons. I guess I need to stop letting others convince me of things and not be so hard on myself.

It's not like I didn't do all the things I should have. I watched him closely all night and when he started acting different and complaining I think I did the right thing. I assessed him, ordered a cxr, called the MD, and followed all his orders, which was basically watch the patient, call me if he gets worse, cxr in am, chest cart ready.

Thanks to all of you again. I'm gonna take a nap :)

I feel like the other nurse calling you an idiot is what made you question the Xanax. You had no control over what the patients response would be and have a good justification for giving the med (stable prior to giving.. Has had the medication before and tolerated fine).

Don't let someone else "blame" you!! I feel like this happens often in the nursing world.