I made a big mistake

AJJKRN · Apr 14, 2015

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.

LovelyBlue · Apr 14, 2015

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 · Apr 14, 2015

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 · Apr 14, 2015

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 · Apr 14, 2015

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 · Apr 15, 2015

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?

Birdy2 · Apr 15, 2015

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...

Birdy2 · Apr 15, 2015

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 · Apr 15, 2015

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.

imintrouble, BSN, RN · Apr 15, 2015

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.

Birdy2 · Apr 15, 2015

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.