If they can ask for it..they aren't too sedated...

[faline1973]

I recently had a patient on my unit that had fractures to BLE. She had been high when she wrecked. This patient had surgery, then went to a physical rehab center. She was back again to have her external fixator removed.

She was her for SIX weeks.

When I had her, she had:

A dilaudid PCA with the maximum dose for her height and weight

Two Percocet 10 mg ordered q 4 hours for "breakthrough" pain

1 mg Ativan IVP q 6 hours

25 mg Benadryl IVP q 6 hours

She requested her percocet everytime she could crack one eye open. She wanted the benadryl and ativan given at the same time.

One night, while I was taking care of her, she was extremely sedated. She would call out for percocet, but when you went in the room she was asleep and wouldn't rouse to verbal stimulation. When she did wake, she stuck out her tongue and mumbled "Juth put them on mah tongue" even though there were no injury to her upper extremities. She was too sedated to hold a cup of water. Other nurses had poured the water into her mouth. I refused. I told her that I would not give her the pills unless she could put them in her mouth and swallow water. She still had her PCA and it wasn't maxed out. Later, when she was more alert, I did give her the percocet.

She reported me the next day.

My manager wrote me up and said: "If they can ask for it, they aren't too sedated."

I had been taught in nursing school that we are to use our judgement. A physician's order will not save our license. If we give a patient narcotics when we see they are too sedated and a sentinel event occurse, we are liable.

What do you think about my manager's statement? I was written up for "withholding pain medicine". I refused to sign it because she had a PCA. Since it wasn't maxed out, she still had access to pain medicine.

What do you think?

[Be_Moore]

And had she aspirated them you would've been in a world of poop too. I think you made the right call.

[qt2168]

You did the right thing in my opinion.

[LyndzBenz]

You did make the right call, although you were written up. You could think of so many what ifs. What if you oversedated her? Or what if she aspirated on the water that the other "wonderful" nurses were pouring into her mouth. And I thought that normal people actually swallowed their water! I would do the same. At least you are thinking ahead. I have had it the other way around though, mostly people with chronic pain that sometimes gets Dilaudid 2-4 mg every 1-2 hours. Nurses didn't want me to give it because they were scared to, but I look at all of the parameters. How is their breathing? What is their neuro status? Can they speak without slurring, or better yet even form words in the english language? Am I going to have to Narcan this poor fellow? I say again, you made the right call. Better to be safe than sorry, even though others don't see it that way.

[kanzi monkey]

I told her that I would not give her the pills unless she could put them in her mouth and swallow water.

I think you made yourself clear. If she wasn't able to comprehend this, or follow commands, she was too sedated. If she can't move her arms (even with prompting), why would you think she can swallow? I'm sorry your manager doesn't see it this way. You used your judgement and it was a good call. I hope you would make the same choice if faced with a decision like that again.

-Kan

[Be_Moore]

Realistically, I think the mistake was in telling the patient that you weren't going to give them. My process for people like that: "Can I have drugs?" "Yes, I'll be right back with them." Go get meds..re-enter room 4-5 minutes after the request. If patient awake/appropriate, give. If not, wait till they wake up.."Can I have pain meds?" "Yes, I'll go get them." Rinse and repeat. I never really tell them they can't have them...but even if I have them in my pocket from last time I say I'm going to get them and wait 4-5 minutes to see if they fall asleep again.

[LyndzBenz]

That's hilarious, I have seen other nurses do that and it works like a charm.

[ChristyRN2009]

You did the right thing. In fact, had you given the percocet and the patient was not maxed out on her PCA, the argument could be made that it was violating a physician order (since the percocet was for breakthrough pain). But I have said "I'll go get that if its time for your medicine, and if I go back in to a knocked out pt, I document "patient snoring loudly upon returning to room to administer pain medication, behavior pain assessment scale level 0, will return when patient wakes up." Not saying I'll give it when I return, but at least it addresses that I did return and they didn't hold up their end of the bargain by staying awake.

[Christen, ANP]

You did the rigth thing, you're manager should have backed you up with this!

[DManAZRN]

Wow, sounds like you need to report you manager. Don't you have a union or are you not in California? Report it to them.

You made the right call.

I tell oversedated patients that it is too dangerous and they could OD, but only if they are exactly that sedated.

Was your manager there to assess the patient? Nope. So it's your call. She has NO IDEA PERIOD.

As long as you document the s/s of the patient i.e. severely slurred speech, inability to rouse the patient for more than a few minutes etc... VS, O2 sats. Inability to swallow effectively. I would have even dialed back the PCA a notch. Sorry, but I didn't become a nurse to euthanize people manager! What are you managing exactly, outcomes or press/gainey scores? I am the bedside nurse, it is my job to manage the patients condition. Where were you? At home asleep *****!

[GOMER42]

I hope you documented all this.

C.Y.A., folks!

[nitenurse02]

I would have done the same thing. If she cant move her upper arms to take the pills then I would have been scared to give the pills as well. And she did have access to pain meds.

People like this are why nurses get so jaded.