I had a pt last night who was well over 500lbs, in terrible pain rating at 10/10. He'd received 1mg Dilaudid in the ED with no effect, admitting doc sent him to the floor with no orders for PRN pain meds. I called the doc who initiated Dilaudid 6mg IV for severe pain, 4mg for moderate. I've given Dilaudid plenty of times, we have a lot of pts who use this drug, I've seen 2mg q1h pretty frequently. I've never given it to a person this large, and didn't have a good understanding (obviously) of how it would affect the pt. A more senior nurse was assisting me in taking-off my orders, and she didn't even blink at this. We had to override for it together, and I gave it. All the while I had a teeny tiny nagging voice telling me waaaaaaaaaaaaaaaayyyy in the back of my mind "this might not be right".
Fast forward an hour, and the guy's 02sat is 70%. Now, there were multiple factors at play, namely that his respirations were still 12, so I thought his oxygenation status was OK. He was also supposed to wear BIPAP when he slept, but didn't have it with him.
I ended-up calling the doc and then respiratory to come-up and set-up his BIPAP, at which point his sats improved to 98%. He remained totally unresponsive for several hours, and woke-up just before I left, but was still totally out of it.
Anyway - I feel really reluctant to post this as it makes me look like such an incompetent idiot, but I think I might be able to keep another new nurse from putting their client in peril. Large client does not = a need for an astronomical amount of Dilaudid. A person who has developed a tolerance to opioids may, but this pt did not have that kind of history. Make this humbling experience worthwhile and learn from my mistake as I have.
Specializes in NICU, PICU, PCVICU and peds oncology.
Ativan most certainly drops BP. In our PICU we sometimes will give it to our post op cardiac babies for just that reason, and others we won't for the same reason. We can have some very hairy situations where a kid is trying to climb out of bed, so they get a dose of chloral hydrate (which also drops BP, especially if the patient is on furosemide too), is still wild after 15 minutes and gets a dose of Ativan. All of a sudden, they're sedate and hypotensive. My endogenous epi gets goosed first in those situations...
Thanks for sharing your experiences so that new nurses like myself may learn from you!
I too have a story to share, although this was not my patient. There was a man on my unit in his 50s (not obese, but big guy) admitted d/t uncontrolled HTN (not newly diagnosed). The patient apparently had been "feeling weird" and expressed it to his RN or RT around breakfast (~08:00). About an 1.5 hours later, the RT found him "passed out" and his O2sat was in the 40s%. The patient only responded with moans/cries when stimulated with pain. I found out later that he had received 1mg Dilaudid at 05:30 and 2 vicodin pills around 08:30. The rapid response team was called and was able to rescucitate him using Narcan and without intubation. The doctor believed that he had too much pain medication, although the Dilaudid should not have been a problem since he only had 1 mg and 4 hrs prior. He didn't have renal or hepatic dysfunctions, and he takes vicodin regularly at home for chronic back pain. This was an experienced nurse who didn't catch the "signs."
I guess the lessons I learned from it are:
1.) Just because the patient takes medication to control chronic pain, the nurse should not overlook possible signs of over medication.
2.) Be sure to check on your patient 30 (if IVP) or 60 minutes (if PO) after administering narcotics or phenergan.
***If patient is asleep, makes sure that they are arousable. (I learned that the hard way while in school when my preceptor administered 12.5mg phenergan to a patient who resulted with respiratory depression. She ended up being intubated.)
3.) Pay attention to the patient's complaints/symptoms. This patient had told his RN and RT that he wasn't "feeling right" and they should have investigated a bit more.
I think the best advice I was given when it came to administering meds was that I could always give less than what was ordered, providing I had good rationale. It came into being with the insulin gtt protocol in our institution. If you follow it, you spend the whole night chasing blood sugars. I had done just that as a new nurse and the nurse that I gave report to told me I could always give less insulin than what the protocol stated. I kind of carried that with me with everything else I was giving.
When it comes to narcotics, my personal rule of thumb is to find out if they are opiate naive, and then find out how the last dose of meds worked for them. That is where I tend to start my dosing.
Like others have said, don't beat yourself up. Just learn from it.
I had a similar experience once, not so dramatic, with a very large pt had out of control pain, and I gave the hefty dose the doc had ordered without questioning. My pt did not become totally obtunded, but I will definately question anything over 2 mg from now on, especially when they come up from ER with some other narcs on board.
I think some of our docs are still new to prescribing dilaudid, in my facility we've been really switching over to it in the past year or two and some of the less active, older family docs don't always keep up on dosages.
NotReady4PrimeTime, RN
5 Articles; 7,358 Posts
Ativan most certainly drops BP. In our PICU we sometimes will give it to our post op cardiac babies for just that reason, and others we won't for the same reason. We can have some very hairy situations where a kid is trying to climb out of bed, so they get a dose of chloral hydrate (which also drops BP, especially if the patient is on furosemide too), is still wild after 15 minutes and gets a dose of Ativan. All of a sudden, they're sedate and hypotensive. My endogenous epi gets goosed first in those situations...