New grad with a question

Old.Timer · Mar 30, 2012

When the nurse calls and says patient has dementia, is on xyz narcotic and is confused, the doc says d/c the med and doesn't know what else to do, so does nothing.

Unfortunately, lot's of patients with dementia fall and hence, become orthopedic patients so ths scenario will repeat itself over and over.

I would look to a geripsychiatrist for either a consult or to do some continuing education for the nursing staff. I have found most MD's are open if the nurse calls and says pt x is on med x which appears to be increasing his agitation/ confusion etc, we've had several other patients with dementia do quite well on xyz, would you want to give that a try?

Anna Flaxis, BSN, RN · Mar 30, 2012

I am almost finished with orientation and about to be on my own. I have a concern about a patient I had last week, and another instance of the same issue that popped up again last night. I had a confused patient, elderly with history of dementia, who had fallen and broken his hip. After the surgery to fix it (with pins) he was extremly confused, pulling at ivs and catheter etc. One of the Drs (not the ortho) wrote an order to dc all pain medicine due to confusion. This man was clearly in pain, guarding, grimacing, and moaning that his leg hurt. Bp and pulse high, but still quite confused and pulling at tubes. Long cardiac history had been given prn meds for bp several times. Preceptor said ok to call md. I called the md on call and was given an order for tylenol and ice prn, he would not let him have anything else. Tylenol did seem to help a little bit and of course we repositioned the best we could. But he still appeared to be hurting. Looking back at the chart, this man had had NO pain medicine given for 2 days. None. Ortho Doc had seen him twice. I wanted to call the ortho doc on call to ask for something else but was told no it could be handled in the morning. I passed it on in report, but no one seemed overly concerned about it. The charge nurse said it was fine, because pain med would make him more confused. Preceptor just shrugged her shoulders.

This is really unfortunate. It sounds a lot like postoperative delirium, but it's hard to say whether it was caused by the anesthesia, the opioid, the pain, the patient's comorbitities and the insult to his system of surgery, or a combination of some or all of those factors. Discontinuing ALL opioids seems a little bit rash. Ordering Haldol PRN and rotating opioids seems like a more reasonable approach, to me, as well as continuing Tylenol and ice. Speaking of which, I'm a little confused. You say he had Tylenol ordered, but had NO pain medicine for two days. Do you mean that nobody gave him any Tylenol, or were you referring to OPIOID analgesics?

I came across a similar situation last night, confused elderly woman, fell and broke her humerous. No pain medicine for the last 24 hours. Had only tylenol ordered. Had previously had morphione ordered and given, but patient got agitated after morphine so it was dc'd with no new order for anything else. Different charge nurse, she did let me call the md who gave me an order for pain medicine, got an order for toradol and gave to patient. At shift change day nurse demanded to know why I gave a confused patient toradol. My preceptor told me the toradaol was fine and the patient did need it. Day nurse just rolled her eyes.

In this situation, based on your description, there was a clear link between morphine and agitation. Discontinuing the morphine is reasonable, but the doctor should not automatically assume that Dilaudid, Fentanyl, or oxycodone would also cause agitation. It would seem reasonable to me to try one of those.

As far as the Toradol, even though it is not an opioid, one of its common side effects is drowsiness. Additionally, Toradol is not recommended for use in the elderly, particularly those with a history of cognitive impairment, due to the risk for increased cognitive impairment related to decreased renal function. Also, Toradol is on the Beers List due to the increased risk of asymptomatic GI bleeding in the elderly population. So, the day shift RN was right to question Toradol for this patient.

Again, you say she had Tylenol ordered, but was given no pain medicine for 24 hours. Nobody gave her any Tylenol in that 24 hour period, or by "pain medicine", are you only referring to opioids?

Been there,done that, ASN, RN · Mar 30, 2012

Pain control is secondary only to respiratory issues. Remember Maslow's hierarchy?

Your preceptor needs to be educated, as well as the rest of the unit.

I know it is difficult to advocate as a newbie. Doctors, charge nurses, everybody and their uncle .. telling you what to do.

However, it is simple.. what would you do if it was your loved one lying there in pain.

You are very perceptive... to your patients needs , sorry you have to fight for the obvious.

Yes, they are confused ..that is when we must give all of our efforts to assure adequate pain control. They cannot communicate their needs.

PetsToPeople · Mar 30, 2012

It seems to me that this is happening because these pt's are unable to advocate for themselves and do not have family there to advocate for them....sad....I am glad you are advocating for them when no one else will; don't let the eye rolling, all the hoops you may have to jump through or all the docs you may have to get on the phone stop you or wear you down until you stop advocating for your pt's because it's become too much of a hassle.

beeker · Mar 30, 2012

This is really unfortunate. It sounds a lot like postoperative delirium, but it's hard to say whether it was caused by the anesthesia, the opioid, the pain, the patient's comorbitities and the insult to his system of surgery, or a combination of some or all of those factors. Discontinuing ALL opioids seems a little bit rash. Ordering Haldol PRN and rotating opioids seems like a more reasonable approach, to me, as well as continuing Tylenol and ice. Speaking of which, I'm a little confused. You say he had Tylenol ordered, but had NO pain medicine for two days. Do you mean that nobody gave him any Tylenol, or were you referring to OPIOID analgesics?
In this situation, based on your description, there was a clear link between morphine and agitation. Discontinuing the morphine is reasonable, but the doctor should not automatically assume that Dilaudid, Fentanyl, or oxycodone would also cause agitation. It would seem reasonable to me to try one of those.
As far as the Toradol, even though it is not an opioid, one of its common side effects is drowsiness. Additionally, Toradol is not recommended for use in the elderly, particularly those with a history of cognitive impairment, due to the risk for increased cognitive impairment related to decreased renal function. Also, Toradol is on the Beers List due to the increased risk of asymptomatic GI bleeding in the elderly population. So, the day shift RN was right to question Toradol for this patient.
Again, you say she had Tylenol ordered, but was given no pain medicine for 24 hours. Nobody gave her any Tylenol in that 24 hour period, or by "pain medicine", are you only referring to opioids?

Nope not even tylenol or ice.

When I asked what he had for pain, I was told " oh he's confused".

And I work nights, so I do not get to see the Dr making rounds and I have to get permission from the charge nurse to call an MD at night. It really seems that on this floor, confused people just do not get pain medicine. I saw it again last night. Confused patient, this one HAD orders for several types of pain medicine but had not been given any in the previous 2 shifts. I gave her ultram and it seemed to work fine. She had ultram, morphine, and lortabs ordered. I started with ultram and figured I would try something else if it did not work, but she went to sleep.

My preceptor told me to keep it to myself. She said do everything you can to make sure your patients are not in pain, but I can only call the MD if the charge nurse oks it. I have seen her call the MD even after the charge nurse has told her no, though. But she has been working there a long time.

Anna Flaxis, BSN, RN · Mar 30, 2012

Those poor people. Thank you for caring.

~PedsRN~, BSN, RN · Mar 31, 2012

You can only contact YOUR patient's physician if the charge nurse ok's it???? But who is the nurse caring for THAT patient? You! That doesn't make sense to me. As the nurse, you are the one that knows the patient. You are definitely doing the right thing advocating for your patient.

Keep it up. :)