Narcotics, benzo, phenergan etc...

allnurses Guide · May 12, 2017

if I'm not comfortable giving a lot of meds at one time, as in the

patient in example 1... I simply say "Ma'am, I'm worried about giving

you too many meds at one time and causing you to be over

sedated... that can be very dangerous/life threatening." I would

give the dilaudid, followed fairly soon by the Phenergan as you

did... then I would want to wait at LEAST another hour or so,

at LEAST, for any Xanax. And... that's it. I'm not trying to

have to get out any Narcan and give it.

You don't want to over sedate anyone, but as far as do you give

the medication as ordered? Well, if the doctor orders dilaudid IV

q2 and the patient is asking for it q2 hours and saying that their

pain is a 9 every time... I'm going to give it, unless the patient

is over sedated. I'm not contributing to their addiction. It's not

my place to say that their lying or that they are just trying to get

high. Maybe they are... but it's not our responsibility to determine

that. It IS our responsibility to be safe, to not give more medications

at one time than is safe to do so.

OlivetheRN, ADN, BSN, RN · May 12, 2017

I kinda take issue with what you're coworker did. Sure, I agree that all those meds at the same time aren't necessarily safe together, and it's particularly frustrating if the patient is calling out and asking for additional meds over and over. But if they're already drowsy and showing signs that they are overmedicated that's when you do as the PP said and don't medicate her and educate her as to why you're not and/or call and talk with the doc about getting some orders changed. What you don't do is lie to the patient and tell her you're giving her a med you're not actually giving her.

This comes up frequently in the ER and came up a loooot in PACU. A fresh surgery patient would want to know why in the hello I wasn't giving them more than what I was and every 2 minutes I would have to explain, "Sir, not only do to have a heck of a lot of drugs circulating around your body already but these here pain meds make you breath not quite as deep and a little bit slower than you otherwise would and the anesthesiologist overseeing your care would prefer it if I make sure you continue to breath." Or the ER patient who expects the morphine he just got 5 minutes to miraculously take his pain away. "Sir, pain medication is not instantaneous and as the doctor explained to you earlier, we may not get you completely pain free while you're here with us. In the meantime, what else can I do to make you more comfortable?"

twinmommy+2, ADN, BSN, MSN · May 12, 2017

The first thing that came to my mind when reading your post is that this is probably not as much as they usually take on the outside.

Trauma Columnist · May 12, 2017

Moved to Pt Meds

~Mi Vida Loca~RN, ASN, RN · May 12, 2017

Example 1 (These are the available meds that a patient has)
Xanax
Dilaudid 0.5 mg IV for pain 4-6
Dilaudid 4mg P.O (pain >6)
Phenergan 6.25 mg IV
Zanaflex (muscle relaxant)
She states her pain is 9/10. I brought in the P.O dilaudid but she refused. I told her that it wasn't time yet (she had to wait another 30 minutes). I finally gave her the IV dilaudid. Less than an hour, she said she was nauseous and wants her phenergan. In no time, she is anxious and wants xanax plus Zanaflex. I know pain is what the patient says, but who is in pain wants to wait 30 minutes when something else is available. Is it safe to give all these meds pretty much at the same time? The Doctor wrote it this way. How do you guys deal with this situation?
Example 2 (Patient has Chronic Inflammatory Demyelinating Polyneuropathy which is similar to MS and her joints get painful and swollen)
Percocet 10/325 PRN
Ambien
MScontin (rscheduled dose)
Lyrica (scheduled dose)
I gave her the MScontin with her Lyrica along with her nighttime meds. 2hrs later, she wants the Percocet which she was due for and 30 minutes after she said she wants ambient because she couldn't sleep.
Example 2 doesn't bother me much but example 1 seems like she is trying to get high. I know the doctor ordered her medications that way. But is it even safe to get that many of these types of meds? The nurse that had her 2 nights later said at one time, she went into the room after she had called for her meds and she was so drowsy. She pretended to draw up the meds but instead with saline and she didn't even know the difference and continued to sleep like a baby.
Please guys how do you deal with drug seekers. If the doctor orders it , do you just happily give it? Please help me because I don't want to be contributing to someone's addiction.

There is no dosage on the Xanax of Zanaflex. However, I would like to point out that the bioavailability of PO dilaudid is not very much and can vary greatly. That's how you have sickle cell patients on prescriptions for like 8-12 mg PO dilaudid every 4-6 hrs and you don't even see them with the signs of being high and wonder how they are breathing. It's really not a good pain management medication at all in pill form. The patient would have been better off with like 10mg oxycodone over the 4mg dilaudid pill. I mean honestly 0.5mg Dilaudid IV isn't that much either, especially if the patient is on chronic pain meds. 6.25 mg of Phenergan also is not that much and given together they can potentiate each other and be very effective and last longer. If a patient is on long term medication they can build a tolerance and require more to be effective then what someone naive may need. It's all very individual.

So had it been me, and I am hurting pretty dang bad and I know this 4mg PO dilaudid pill is going to do nothing for my pain, not to mention it will take about 20 mins to even start working, then yes I would be willing to breathe it out and wait that 30 mins for the medication I know will work quick. Personally if it were me I would rather have the phenergan and then some percocet or something once the phenergan kicks in (if nausea is an issue) since PO medication will last longer and you will obtain better pain control.

In case number 1 how is it you know she is trying to get high and that she isn't in genuine pain or anxious or having any of these ailments. See this is the problem with our profession and with the stuff going on. It's so easy to judge and decide someone is drug seeking and make statements that we don't want to contribute to their addiction. But unless you're an addiction specialist and evaluating this patient, how do you determine they are an addict? What kind of training do you have to determine this? Sure some situations might seem more obvious and easy to draw a line in the sand.

But consider for just a moment that maybe the patient does have a tolerance, maybe the patient does have genuine ailments and pain. How are you advocating for them and doing best for them by you making a moral decision based off your own beliefs that they are drug seeking and wanting to get high and you're not going to contribute to it?

It's a very slipper slope.

So often we also tell patients "Don't wait until the pain is severe to call out, it's easier to stay on top of pain then to chase it" but then patient calls out saying the pain is coming back and we determine they want to get high and they aren't withering in pain yet so they are fine.

Munch · May 14, 2017

I'm with Olive, I really think what your co-worker did was wrong on so many levels. I think ideally you should be able to trust your health care providers. A friend of mine is a LPN at our county jail. One of the doctors there constantly tells the nurses to tell the inmates they are getting a shot of ketorolac meanwhile the doctor tells the nurses to give them a placebo. How hard is it to tell the truth? If you don't want the inmate to get the ketorolac or in this patients case the dilaudid explain why not.

The doctor ordered the meds for a reason. If the patient seems too schlogged and they are requesting another sedating medication and you don't feel comfortable giving it for safety reasons tell the patient you are going to hold off for a little while and will be back in a little while to access.

Dilaudid PO isn't very effective, I know from personal experience and from professional experience. As far as PO meds go, oxycodone and hydrocodone seem to supercede morphine and dilaudid PO.

As far as the drug seeking behavior you are concerned with that really is irrelevant. The doctor ordered the meds. If the patient says they are in pain they should receive the meds unless of course safety reasons say the meds should be held. You can't prove the patient isn't having pain and even if(a big if at that) the patient has a drug problem, even drug addicts have legitimate pain and that pain should be treated just like anyone else who walks in the door with pain. If someone with a drug problem is seeking chances are(not always) they are actively using and giving them pain meds are not going to make their addiction any worse. Detox is for another time and another place.

Please don't take my above comments to mean that I think your patient is a drug addict. I'm just making generalizations based on IF your patient was an addict. No real way to know unless they reported they are or if its in the medical records. Don't be so quick to judge.

K9lover, ASN, RN · May 22, 2017

It just does not bother me if they get a high along with their pain relief and so far I have not heard a rational answer as to why it bothers anyone else. If they are not opiate naÃ¯ve' and it is safe to give(and) they have pain to treat what difference does it make if patient 'A' gets pain meds sans buzz and patient 'B' gets pain meds and a buzz? I'm not their 12-step sponsor.

A lot of nurses have a couple drinks after work, I am sure they 'feel' something, I am guessing if all the social drinkers wanted no effect they would drink alcohol-free wine or no alcohol at all. It takes a lot of hubris to want to control other peoples (perceived) addiction.

K9lover, ASN, RN · May 22, 2017

I don't think it is legal to tell someone you are medicated them and give normal saline, I know it is not ethical.