Opinions please--Did I do the right thing?

[RN-TO-BE]

I am a new RN of approx. 5 months. I work on the Medical floor normally night shift. I worked Tuesday night and I had this pt.--he is 38 years old, quadraplegic, has a suprapubic catheter, turn and reposition q2hrs and family that threatens to sue every nurse that comes in the room. Got to his room around 19:45, did assessment, and took VS. BP was only 67/42..(Pt. alert and oriented talking to me and family...states "BP always runs low"). I thought 67/42 was way low and called MD. MD gave orders to give 500CC NS bolus X 1...gave bolus...BP up to 148/84..good gave 2100 scheduled meds...percocet, valium, zanaflex, oxycotin, rifampin, neurotin, and more that I cannot think of at this time.BP remeained stable remainder of shift. Pt. went down for surgery Wednesday for left AKA and was then transferred to the surgical floor. Well, Thursday night when I went into work I was pulled to the surgical floor and guess who I had for a pt...this same man. Went in to assess pt. @ 1925(family not there), pt. was very lethargic, eyes rolled back in head, hard to arouse and only mumbling words, respirations were only 12, BP 89/60, no blood drainage from AKA. Went to look at MAR to see what meds given on previous shift, @ 1500 rec'd scheduled percocet 10mg, oxycotin 80mg, valium 10mg, and others and @ 1730 rec'd 2 Darvocets PRN. Pt. had percoet, valium, oxycotin, neroutin, zanaflex, rifampin and other meds ordered to give @ 2100. Talked with charge nurse and she told me to pull all of the 2100 meds out of PYXIS and just stagger times that I gave meds. I did go ahead and pull all meds out of pyxis but before giving ANY meds I retook pt. BP...BP now 64/43..did not give any meds and immed. called MD on call...order for NS bolus 500ccX1 and to hold ALL 2100 PO scheduled meds. Gave bolus and BP only 70/49. Charge nurse got upset with me and said that the pt. was going to have to have his Valium for muscle spasms sometime during the night..told her that I was following MD orders and would not give the Valium. Around midnight pt. woke up enough to ask why he didn't get 2100 meds... explained that his BP was low and he was lethargic and MD ordered for the meds to be held. Pt. went on to inform me again that his BP always runs low and that we didn't know what we were doing. At 02:30, pt. demanding pain med. BP 94/63 talked with overhouse supervisor (since charge nurse basically washed her hands of the situation after the incident with the valium) and overhouse said to give 1 Darvocet PRN...gave 1 Darvocet...pt. took. Needless to say this man was asleep everytime I went into room to turn q2h. Went in around 05:00 to turn pt. pt. was very upset still about not receiving 2100 meds and stated that he had been laying suffering all night and all that I would give him was 1 darvocet for pain. Informed pt. that I was only following MD orders. Pt. then states that he is going to hit the MD when he comes in the room and that when his sister-in-law gets here she will give him his home meds. I felt really bad about not giving meds but I couldn't see loading this man upon pain meds when after bolusing BP was only 70/50...After the bolus on Tuesday night his BP came up good, but I figure Thursday night that the anesthesia may not have been out of his body good.

Opinions, please. I am dreading going back to work b/c I know that his family made a big deal out of all of this.

[papawjohn]

Hey RN-to-Be

You did the right thing. Sorry that you've discovered the truth of that old saying 'no good deed goes unpunished.'

Papaw John

[suzy253, RN]

This is exactly the kind of situations that I fear when I graduate and start on the floors.

[Ruby Vee, BSN]

sounds like you handled everything just fine. i have questions about that charge nurse, though. and as for the family -- you already know they're inappropriate. don't liet them get to you.

ruby (28 years of experience)

[Adam D. RN2005]

I am a new RN of approx. 5 months. I work on the Medical floor normally night shift. I worked Tuesday night and I had this pt.--he is 38 years old, quadraplegic, has a suprapubic catheter, turn and reposition q2hrs and family that threatens to sue every nurse that comes in the room. Got to his room around 19:45, did assessment, and took VS. BP was only 67/42..(Pt. alert and oriented talking to me and family...states "BP always runs low"). I thought 67/42 was way low and called MD. MD gave orders to give 500CC NS bolus X 1...gave bolus...BP up to 148/84..good gave 2100 scheduled meds...percocet, valium, zanaflex, oxycotin, rifampin, neurotin, and more that I cannot think of at this time.BP remeained stable remainder of shift. Pt. went down for surgery Wednesday for left AKA and was then transferred to the surgical floor. Well, Thursday night when I went into work I was pulled to the surgical floor and guess who I had for a pt...this same man. Went in to assess pt. @ 1925(family not there), pt. was very lethargic, eyes rolled back in head, hard to arouse and only mumbling words, respirations were only 12, BP 89/60, no blood drainage from AKA. Went to look at MAR to see what meds given on previous shift, @ 1500 rec'd scheduled percocet 10mg, oxycotin 80mg, valium 10mg, and others and @ 1730 rec'd 2 Darvocets PRN. Pt. had percoet, valium, oxycotin, neroutin, zanaflex, rifampin and other meds ordered to give @ 2100. Talked with charge nurse and she told me to pull all of the 2100 meds out of PYXIS and just stagger times that I gave meds. I did go ahead and pull all meds out of pyxis but before giving ANY meds I retook pt. BP...BP now 64/43..did not give any meds and immed. called MD on call...order for NS bolus 500ccX1 and to hold ALL 2100 PO scheduled meds. Gave bolus and BP only 70/49. Charge nurse got upset with me and said that the pt. was going to have to have his Valium for muscle spasms sometime during the night..told her that I was following MD orders and would not give the Valium. Around midnight pt. woke up enough to ask why he didn't get 2100 meds... explained that his BP was low and he was lethargic and MD ordered for the meds to be held. Pt. went on to inform me again that his BP always runs low and that we didn't know what we were doing. At 02:30, pt. demanding pain med. BP 94/63 talked with overhouse supervisor (since charge nurse basically washed her hands of the situation after the incident with the valium) and overhouse said to give 1 Darvocet PRN...gave 1 Darvocet...pt. took. Needless to say this man was asleep everytime I went into room to turn q2h. Went in around 05:00 to turn pt. pt. was very upset still about not receiving 2100 meds and stated that he had been laying suffering all night and all that I would give him was 1 darvocet for pain. Informed pt. that I was only following MD orders. Pt. then states that he is going to hit the MD when he comes in the room and that when his sister-in-law gets here she will give him his home meds. I felt really bad about not giving meds but I couldn't see loading this man upon pain meds when after bolusing BP was only 70/50...After the bolus on Tuesday night his BP came up good, but I figure Thursday night that the anesthesia may not have been out of his body good.

Opinions, please. I am dreading going back to work b/c I know that his family made a big deal out of all of this.

I would've done the exact same thing. No if ands or buts. Period. I'm sorry, a BP 64/43 is not normal, no matter what the pt says that their bp runs low. I stop giving anti-htn meds at 100 systolic. And I call the MD when the pt is below 90 systolic. Below 75, I hold all PO meds and some IV meds, especially narcotic pain killers (and valum). I don't need the pt to aspirate on a pill or water when they suddenly pass out, because it could lead to even bigger problems, including death. Or drop the pts BP even lower. (Narcotic meds can drop BP.)

If this would go to court, as long as you documented the BP's, and the situation, then you will come out on top. The PT has bigger problems then pain. With a BP at 60's/40's, that needs to be addressed.

Let the pt and family be angry with you. Your first focus should always be for the safety of the patient. No if ands or buts. It is your license, and you need to make choices based on what you know. And one final thing, supose you gave the meds and the pt coded. And also, you had an MD order to hold all meds.

It is better to always err on the side of caution, no matter what the patient says. It is your license.

Adam, RN

[kadokin, ASN, RN]

Yes.:)

[Nurse956]

Yes you did. You acted cautiously and competently. Only patients know how they feel but sometimes B/P, and pain meds are a catch 22. Sometimes what the pt says and whats going on (behavior such as seemingly sleeping peacefully and vitals wnl) makes us question our next action.You did the right thing and whats more is you had the backing of the patients doctor. Like I have been told numerous times, though it never sinks in until after I'm already upset and stressed over it for days, is that you can't please everyone. I have had incidents where I give 110% and the pt finds the tiniest most trivial detail to make me feel incompetent over, and you can't tell them "you are overreacting." Just knowing that you did the best you could for that patient with the intentions of helping not hurting is sometimes the only real validation of your actions in sticky situations like this. Them threatening to sue every nurse makes it a stressfull environment and I am curious if you management has spoken with the family to explain the POC and perhaps how their behavior may make it difficult for nurses to feel comfortable working around them. Also the MD should be responsible for coming in during rounds the following day and backing you up on the meds decision. Those are just my 2 cents...

[pugmum]

Yes - you did exactly what any prudent nurse would have done under the circumstances...acted safely and responsibly...

Man, oh man, its tough sometimes. Keep doing what you're doing!! :flowersfo

[Daytonite, BSN, RN]

Unfortunately, we are always going to run across patients and their families who are like this. I read your post very carefully. You did exactly what I would have done. You have doctor's orders to back you up. I hope you charted all this as well as you did your post. Let the family complain. Your defense is to pass the buck to the doctor. This is a time when that is what you want to do; this is what the doctors train for. Don't be in fear of being sued. You're in the clear because you sought the doctor's direction all along the way and you were paying attention to the patient's body response as well as his requests for pain medication. People threaten lawsuits in order to get a one-upmanship and control. It doesn't mean they are valid lawsuits. The really good lawyers recognize these kind of people for who they are--believe me.

[moonchild20002000]

I also agree that you did the right thing.The MD on call thought it was the right thing to do. I do have a few concerns about the charge nurse.

You just can't please all the patients and families. Don't let them get you down!

[firstaiddave907]

Yes - you did exactly what any prudent nurse would have done under the circumstances...acted safely and responsibly...

Man, oh man, its tough sometimes. Keep doing what you're doing!! :flowersfo

i agree with you and i think if the family has a problem they should take it up with the md and thats the main thing being safe and act responsibly i would ingorne the family when they start up with im goignt o sue who ever comes in here. i give you cerdit Adam D. RN2005 keep up the good work.

[Spidey's mom, ADN, BSN, RN]

Yes, you did the right thing.

Good job. :)

steph