Morphine drip----help

Do you have a written policy for morphine drips? We have one for every drip I've encountered I'd check that first or ask the charge nurse. With the comment about the pt's family members explain what you're doing and why. We're giving your loved one enough morphine to control his pain and ease his suffering.

I work in a neuro ICU and our orders usualy just say to titrate per pt comfort. I will increase the rate if the pt does not look comforable. Meaning... if their work of breathing increases or their rate. Also, I will go up on the drip if their blood pressure starts to get high. I like to make them look almost like they are sleeping... in a way. I have been told by families that they are very gratful to me for makeing their family member comfortable.

I had one assingment where they had withdrawn on the pt the evening before. A morphine drip was started at 2 mg and orders to titrate. When I went in to see the pt she was agonal breathing/gasping. I went up on the drip to 4 mg, used a prn order for 4 mg SIVP, and repositioned the pt making her look more comfortable in the bed. When the spouse came in later he thanked me and mentioned that she was breathing real hard all night. It is hard enough to see your family member die let alone suffer

you titrate upwards, whenever you see any type of distress or pain.

this includes restlessness, grimacing, muscular tension (like, stiffening up), guarding, fretting/knitting of brows, pursed lips (again, a form of muscles tensing), increasing vs, and of course, any type of moaning/groaning.

be alerted to clenched fists as well.

a pt that is pain free, will appear completely relaxed.

also, and unless you're experienced it can get tricky, but you need to stay ahead of the pain, and don't want to chase it.

i like to get resps as close to normal as possible...

so if a pt is sleeping and they're breathing in the 30's, even 20's, give that morphine until you cut resps in half.

leslie

I would also confirm with the MD about whether or not the order meant "may" titrate up to 8 mg. That does not mean the same thing as you "must" titrate up to 8 mg. But your question about when - always always document why you made the decision to change doses. What did you observe that made you believe the patient was in pain?

In my state palliative care must be ordered, not assumed, in order to protect the MD and the nurse from family and friends suing you later. This also means the MD has to provide what is required to fulfill the law in regards to palliative care (for instance, terminal illness with pain may meet the guidelines, but other conditions with pain may not). You sound like a caring nurse. Hope the patient/family appreciate that

My mom had a morphine drip at 10mg per hour with 5mg Q30min pops when she was on a vent after suffering a massive subarachnoid hemorrhage. She was also getting 4mg of Ativan Q30min. I made sure she received her morphine pops and the ICU nurse was wonderful in making sure she was bringing the Ativan every half hour. As a former ICU nurse who had worked in that very same unit (and room) where my mom passed, I knew how much could be done to alleviate any suffering my mom would have once we removed her from the ventilator and wanted to make sure she would pass away without any respiratory distress.

My family was okay with how much she was getting because they knew it would keep her from gasping for air and be able to pass peacefully. She died about 6 hours after removing her ETT. I'm glad I was familiar with comfort care; otherwise, I might not have been able to understand the large amounts of morphine/ativan she was getting. Explaining to the family members that the morphine will help ease any respiratory distress is important so they understand you are not "euthanizing" their loved one. It's a touchy subject for family members who are not familiar with comfort care. Watching respiratory rate, heart rate BP, and seeing how hard the patient is working to breathe will help you figure out when it's time to go up in the drip.

you titrate upwards, whenever you see any type of distress or pain.

this includes restlessness, grimacing, muscular tension (like, stiffening up), guarding, fretting/knitting of brows, pursed lips (again, a form of muscles tensing), increasing vs, and of course, any type of moaning/groaning.

be alerted to clenched fists as well.

a pt that is pain free, will appear completely relaxed.

also, and unless you're experienced it can get tricky, but you need to stay ahead of the pain, and don't want to chase it.

i like to get resps as close to normal as possible...

so if a pt is sleeping and they're breathing in the 30's, even 20's, give that morphine until you cut resps in half.

leslie

Leslie is excellent in describing this--but you really, really need to see this on your own too. Do you have a mentor? Do you have an educator? Do you have a Pain Management specialist? Oncology Nurse specialist? They are excellent resources.

Unless you see this frequently or even see someone on a large amount of narcotics, it is a very, very scary experience as a new healthcare provider. I questioned my skills for a LONG time before I felt comfortable titrating to a large amount. Good luck--once you do get a hang of it, it is the coolest skill to have.....

I would also confirm with the MD about whether or not the order meant "may" titrate up to 8 mg. That does not mean the same thing as you "must" titrate up to 8 mg. But your question about when - always always document why you made the decision to change doses. What did you observe that made you believe the patient was in pain?

In my state palliative care must be ordered, not assumed, in order to protect the MD and the nurse from family and friends suing you later. This also means the MD has to provide what is required to fulfill the law in regards to palliative care (for instance, terminal illness with pain may meet the guidelines, but other conditions with pain may not). You sound like a caring nurse. Hope the patient/family appreciate that

In most states palliative care does not require a terminal diagnosis, hospice does.

Regarding the family member and the comment about morphine killing the patient more quickly...I generally ask that family member, in the presence of the rest of the family, what their personal goals are for this patient. What is it that they would want for this patient. Often these family members are not processing their grief well and they say things that are inappropriate because of it. If we can get them to actually talk about what they are feeling we can get to the bottom of their comments. In hospice, if the family thinks that morphine will kill the patient we will stop it (unless the patient is his/her own voice/advocate). I know it sounds heartless, but THEY are the legal advocates and family...and if THEY need to see him/her suffer in order to get past THEIR egocentric expectations then that is unfortunately how it will work. I do not force anyone to accept my care and recommendations. If, on the other hand, the patient is able to speak for him/herself and has clearly outlined personal expectations that is exactly what I will carry out for them come hell or high water...I will go toe to toe with family members using their loved one's exact words to advocate for good symptom management. When family is integrally involved in a hospice patient's care I make sincere attempts to have the DPOA present anytime I speak with the patient about the goals and POC. Grieving people can be crazy and selfish...especially if they are already part of a fragmented poorly functioning family.

Go up slowly as you see changes in the pt status that would tell you they are in any sort of pain or discomfort as the affor mention posts.

The best thing to do is to follow protocol and to document what type of distress: ie grimace, clenching, htn, crying in your note. These types of descriptive words used in a note when titrating a drip will only protect you legally. Another this sometimes the patients family requests the drip go up because they know of some gesture the patient makes when distressed- document this as well

you titrate upwards, whenever you see any type of distress or pain.

this includes restlessness, grimacing, muscular tension (like, stiffening up), guarding, fretting/knitting of brows, pursed lips (again, a form of muscles tensing), increasing vs, and of course, any type of moaning/groaning.

be alerted to clenched fists as well.

a pt that is pain free, will appear completely relaxed.

also, and unless you're experienced it can get tricky, but you need to stay ahead of the pain, and don't want to chase it.

i like to get resps as close to normal as possible...

so if a pt is sleeping and they're breathing in the 30's, even 20's, give that morphine until you cut resps in half.

leslie

This is an excellent explanation of how to assess pain/discomfort!! Besides titrating the morphine gtt, you probably have morphine IVP orders also and you should give the morphine pushes as needed because changes in the gtt rate take time to be effective (since it's a mg/hr rate).

Another consideration is secretion management. Often, after extubation, the patient will may make gurgling noises during breathing due to pooled secretions in the hypopharynx. It is important to explain to the family what is causing the noise and that the patient is usually not in respiratory distress, since the noise can be very disconcerting to the family at the bedside. There are several ways to manage the secretions:

1) suctioning (NT or deep oral) - NOT with family at bedside, plus even if the family is not there, it's painful!! and you're trying to provide comfort care. I will only suction if the family requests it or if the secretions ARE causing respiratory distress and of course, after I've had the family step out.

2) glycopyrrolate - this often works very well to reduce secretions. My preferred method.

3) Do nothing - if it's just a little bit of gurgling, not causing respiratory distress to the patient and the family understands that the patient isn't "choking":twocents:

Another consideration is secretion management. Often, after extubation, the patient will may make gurgling noises during breathing due to pooled secretions in the hypopharynx. It is important to explain to the family what is causing the noise and that the patient is usually not in respiratory distress, since the noise can be very disconcerting to the family at the bedside. There are several ways to manage the secretions:

1) suctioning (NT or deep oral) - NOT with family at bedside, plus even if the family is not there, it's painful!! and you're trying to provide comfort care. I will only suction if the family requests it or if the secretions ARE causing respiratory distress and of course, after I've had the family step out.

in hospice, we avoid suctioning at all costs, because it is painful and invasive.

(however, there's nothing wrong with sweeping the mouth)

but when a pt is immobile, secretions accumulate.

in anticipation of secretions, we'll put on a scopolamine patch, or use atropine/levsin gtts- aggressively.

and while most of us have heard that secretions don't bother the pt, we need to keep in mind that, depending on comorbids, their lungs can truly be filling up and so, it's important to push that morphine and agent-of-choice-for-secretions.

as for mso4 hastening death, i do tell families that in many instances, this is true...

and this happens r/t the morphine enabling pt to relax to extent that the disease process takes over.

when any of us is in distress, our bodies react accordingly, enabling us for fight or flight (remember our autonomic reactions during stress).

morphine/opioids suppresses these responses, so there are no mechanisms to 'protect' us, and death ensues.

while it can hasten death, it also allows for a much more peaceful one as well.

who wants to die, fighting til the very last minute?

it's a horrible, HORRIBLE way to go.

and so, we carefully and sensitively explain this to the families, so they can understand the process behind the plan.

i sooo believe that all icu nurses, should be inserviced on the philosophy and rationales of comfort care...

and this especially goes for the docs, as well.

leslie

after doing hospice for over 2 years, I've faced the "Morphine will make them die faster", both from people wanting to bring the end faster, and other afraid of bringing the end faster.

titrated approriately for elevated resps and heart rate and pain, I don't think morphine hastens death. I think it ease distress, people expend less energy when they are breathing comfortablely and not in pain.

a quick google search will bring up new research showing the morphine increases length of life in those with severe respitory destress.

before I started hospice I was really nervous about morphine and narcotics. but I learned about them and how they work at the end of life and while I respect them, I no longer fear them