Opioid overdosing?

[darren_callcareer18]

How are you all? Just wanted to ask for your inputs if you already dealt with patient who seems to be having an opioid overdosing? What are the symptoms you have seen to that patient?

I don’t know if I am just overreacting but I was working night shift last night and I had this patient who is very sluggish and her pupils were 4-5mm dilated but they are reactive to light. I have noticed that she is bradypneic (RR 2-3bpm) but the rest of her vital signs were okay. She seems to be alert and oriented plus GCS-15 but her response was very delayed. It is just her respiratory rate was seems to be depressed. This patient is on methadone but only 10mg PO BD and has PRN morphine 10mg PO. 

According to the handover that I have received from previous nurse that the patient LOC was “abnormal” since AM shift and up to PM shift. Her baseline was normally conversant, walking around and alert and oriented.

I called a second nurse and ask her to count the RR of the patient and she got 7. I could not think of any reason why her RR was low so I thought she could have OD herself with opioids. I informed my supervisor and she told me that the patient was in our ward before and she had this history that she secretly take some of her opioids without telling the RN on top of the opioids that nurses were giving her as regular pain relief. So I called the doctor on call plus 1 of the code team nurse to assess (I did not coded the pt since she seems to be not in distress). 

The patient vomited as well and apparently a little bit confused as she was going to drink her vomitus from the receptacle but I stopped her. 

So, while the oncall doctor was assessing the patient, this nurse from the code team angrily arrived, and was so upset to me and telling me “I almost dropped my phone when you sent me this message! Your message is ridiculous!” She poked her head in the patient room and said “she is breathing it is just very shallow!” 

I looked at the patient chest and I can see the normal deep breath she is taking and I couldn't see a VERY shallow breathing. For me she was really bradypneic. She was so upset to me but the doctor wasn't. The other RN rechecked the RR and it was 7bpm. 

I told her that I am not going to bother sending this message to all of you if I am not worried that the patient might have overdosed of opioids. I just felt bad after that incident as I questioned myself if all this years working as a nurse I still haven’t mastered taking respiration rate. 

[0.9%NormalSarah, BSN, RN]

The code nurse was rude and shouldn’t have behaved that way. It is best to cultivate an environment where nurses feel safe calling rapids and codes. If not, inevitably there will be times when no one calls a rapid because they fear being “that nurse that called a stupid rapid for no reason” and will wait to call until the patient has severely deteriorated. 

I think you did a good job. The only thing I would say is that if you have patients on opioids, there should be PRN Narcan and I would have retrieved and used it if this patient was somnolent and bradypneic, you can save a person from intubation. Sounds like you did great, though, you got a physician and others to the bedside for evaluation. You took care of your patient. 

As a side note, I’d check into the policy for belongings for patients like this. In my ICU we go through everything to make sure they don’t have any contraband or substances they can take under the radar. I know it’s tough with visitors bringing things in though. 

[JBMmom, MSN, NP]

Sounds like that nurse overreacted, not you. For an opioid overdose I would definitely expect to see bradypnea, but I would expect pinpoint pupils, not dilated. With all other vital signs WNL it's hard to say. But you had a concern, you addressed it appropriately and the patient is fine. If that nurse is going to be responding to rapids and codes she should be supporting and educating nurses, not berating anyone for doing what they think is in the best interests of their patients. 

I agree with normalsarah, it's so important to go through patient belongings for medications. I once had a patient in ICU, maxed on levophed and in septic shock. His wife gave him his night time meds when I had walked out of the room, included coreg and lopressor!! My intensivist was NOT happy, to say the least. And we recently had a very sick young lady in ICU, she was an overdose patient. We got her extubated and up to the floor and her significant other brought pills in for her. She overdosed again and later died. So sad. 

[Stillcrazyafteralltheseyears]

I worked in a methadone clinic for 7 years, and  yes she was definitely over dosing. Good call. The one thing I wanted to tell you is that after you give a dose of narcan you need to continue to monitor their respiratory rate hours later due to methadone's long half life. At one ER a old patient of ours when in for methadone over dose. He received the narcan and then was sent home. He later died of the methadone because he needed to be monitored for further administration of narcan. Methadone is a scary drug to give. I left that job because of it.

[londonflo]

On 4/3/2021 at 1:09 AM, darren_callcareer18 said:

“she is breathing it is just very shallow!” 

Shallow breathing does not guarantee good oxygenation. You were as Florence Nightingale said "keeping careful watch over the sick".  What an ineffectual support team member, I hope she has some better qualities. I may have missed it but what was her pulse ox?

[Hannahbanana, BSN, MSN]

Somebody who wants to swallow their own vomitus in this scenario (decreased resps and level of consciousness) isn't confused. They're trying to recover the pills they took so they can take them again.