Morphine and respirations

hollybear · Apr 13, 2003

titrate to comfort does not equate to prescribing. latest guidlines on pain control of the dying patient statesthat pain meds are to be given freely to maintain comfort even if it hastens the patients death.

angiebaby · Apr 13, 2003

I think that if they are comfortable and have a decent o2 saturation, leave them alone.

**SKM-NURSIEPOOH, BSN, RN** · Apr 13, 2003

...opioids use and the terminally ill patients on palliative care.

read page #17, point #5 of the pain module #2 and page #10, point #4 of the last hours module #7

hope this helps.

cheers!

moe

p.s. you'll need to have adobe acrobat reader installed in order to read the *.pdf links above. this is a free down that's available at the abode website. just click here & download it.

Glad2behere · Apr 13, 2003

I work in CCU, and we are seeing more and more of these type patients. We titrate for comfort using ABGs as the yardstick. Seems we never run MSO4 by itself, but with a combination of Ativan. Usually 2 to 1, and the scopolamine patch. The patient is usually on AC with a relatively high TV, increased I:E ratio, and plateau waveform, FIO2 adjusted to maintain SaO2 as high as possible at 8 bpm. Everything is then adjusted to the patient's individual comfort from ABGs. Most patients will settle at 10-12 bpm once the ABGs are in line, but we leave the ventilator at 8, assuming too much sedation and pain control if maintained there, and ABGs usually verify this.

nimbex, RN · Apr 14, 2003

ummm, I'm confused, vented, or non vented.... If DNR status and comfort measure order was the protocol with a drip, I would titrate to comfort, based on HR, BP, visual signs, .... look at resp. but no as a sole determinine factor....

speak with family or friends.... the patient needs a higher dose, it may speed their passing, but their comfort is a priority, and I'm worried that they may not be comfortable based on....

renerian, BSN, RN · Apr 14, 2003

Good discussions here.

renerian

whipping girl in 07, RN · Apr 17, 2003

Originally posted by Mistynurse
I wish they would cover some of these situations in nursing school, instead of learning on the job. I am thankful there is this forum with many different nurses to give advice.

Hehehe. I had to laugh when I read this. I thought the same thing right after I graduated, but after a year on the job, I realized...nursing school has to end SOMETIME. They just can't teach you everything. So you get a lot of general information and then you build on it when you get a job. Someone who does not work in a unit that cares for vent patients doesn't need to know all about vent settings, someone who doesn't work oncology doesn't need to know everything about chemotherapy, etc. You gain specialized information as you work in a specialty. In some areas you see a wider variety of situations so you naturally have a broader body of knowledge. And of course if you're interested in something, you can study up on it more on your own.

Good question though and it also brings up an ethical dilemma. Some people equate MSO4 gtt with euthanasia because you are titrating up. And it IS scary when you go up another cc an hour for comfort and the patient draws his last breath 15 minutes later. You gotta at least think, OMG, did I hasten this guy's death? So that's when I remember...despite all we do, we really don't have control as to when someone dies.

I had a patient last year; CHF, could not get her off the vent, finally trached her, still couldn't get her off the vent, got to the point where she was no longer responsive, not breathing over the vent. Family decides "it's time." Start MSO4 gtt for comfort. MD says, OK, we take her off the vent and put her on a trach collar. Guess what, she breathes. 8 bpm, same as she'd been on the vent. For several hours. It looked like the end was nowhere in sight. So we had to transfer her to oncology so I could get another patient waiting in ER. I went to see her when I got off work that AM. Still plugging along, breathing 6-8 BPM. I called oncology when I woke up that afternoon, the nurse said she'd died peacefully midmorning. Sometimes you just never know.

whipping girl in 07, RN · Apr 17, 2003

Originally posted by Snookie
In the state where I practice, doctors are not to give orders such as "titrate for comfort" or "morphine 2-4mg IV q2-4 hrs prn pain" -not to say that it doesn't happen. The info I received says that the MD needs to give specific guidelines on such orders for when to give the med. From what I understand orders like the one above constitute prescribing without a license on the nurses part. Anyone else with any info on this?

Hmm, I don't know where you work, but I know it's within the scope of my practice to titrate meds if there is an order to do so. Also, sometimes I get an order for (example) MSO4 5-10mg IVP q2h prn pain. It happens to be orders for an 89# lol who never takes anything stronger than Tylenol at home. So for her I may start with 2mg and see if it helps her. If it doesn't, maybe give her 1mg more in 30 min. Even though the order says 5-10mg, I make the judgement, AS A NURSE, that that much may just knock out her respiratory drive and HARM MY PATIENT. Contrary to popular belief, a lot of doctors don't picture that patient when prescribing (especially for phone orders or when an on-call doctor is writing the order). I personally do not see that as "prescribing." But you have to do what your nurse practice act and facility policy dictate.