Pain meds and low BP?

[fsh1986]

I had a pt who had scheduled 20mg oxycontin q8, along with PRN narcs q6 and q4. Her normal blood pressure ran low 100s. For a few days before I had her she was mid 90s. I work night shift and the night I got her, she had been maintaining SBP of 87, 88, etc. Mds aware. There was a written order that she was to get her narcs even with hypotension. So she got her 10pm and got her PRNs, but then her AM BP was 83/53. I understand that there's a written order, but don't you draw the line at some point? I didn't want to give her the oxycontin. She had requested the scheduled dose and then fell asleep, so I didn't wake her up and I paged the ARNP who was on call. She said to give it. I still didn't wake the patient as I had a bad feeling about giving it. Charge RN and the other floor RNs thought it was ridiculous that I was told to give it. So I waited until 6AM when the attending was on and I paged her. Told her despite the other MD's written order, I wasn't comfortable giving narcs with a pressure like that. She told me to go ahead and give it, said since it's chronic pain and the pt is used to taking all of these meds, that it wouldn't drop her. I understand that logic... but sh*t happens and that's already a low BP.

So based on my last phone call with the attending, I wrote that as a telephone order, I documented my conversation with both the ARNP and the MD and gave the med.

So I guess I what I want to know is, is my license at risk if something happens to the patient and I followed MD orders? Or am I more likely to get fired/lose my license for NOT following MD orders (and the SAME order from multiple MDS, at that) bc I felt it wasn't safe?? What would you have done in this situation? I've called my nurse manager and left a message for a call back so I can discuss legal ramifications if I'm ever at a crossroads between following/not following orders. I haven't heard back yet, so I figured I'd post. TIA for your responses.

[eatmysoxRN, ASN, RN]

If you spoke with 2 different doctors who both said to give it, I probably would. I would also ask them if I could start some fluids if her health permitted, just to keep her bp up some.

Now I would never give an IV med with a BP in the 80s. I'm good seeing anything over 100, but less and we are going to check your bp every 15 minutes or 30 minutes until it's up. Patients usually don't give me too much grief when I tell them we will give them as soon as possible..

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

[SaoirseRN]

If you spoke with 2 different doctors who both said to give it, I probably would.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

Agreed, particularly since the patient was well used to taking the meds. In a narcotic naive patient I would feel more hesitant, but for someone with chronic pain, I'd give it.

[fsh1986]

Also:

is my license at risk if something happens to the patient and I followed MD orders? Or am I more likely to get fired/lose my license for NOT following MD orders (and the SAME order from multiple MDS, at that) bc I felt it wasn't safe??

Thanks!

[brownbook]

Yes your license is at risk if you follow the MD's orders and the patient is harmed. Unfortunately most cases are not really clear cut. Your specific case was a difficult gray area and you handled it as best you could.

You take such "gray area" problems "up the chain of command." You couldn't reach your nurse manager (leaving a voice message would not hold much water in a court room) so you would go up the next "chain" to her boss, the director of nursing or whomever it might be, until you reach a live person. Your policy and procedure manual should mention some kind of policy regarding the "chain of command."

Of course if a MD says (for example) give 40 mEq of potassium IV push you don't do it (regardless of the chain of command).

[Spika RN]

I have run across this before on my unit oncology, I refused to give the meds the patient would fall asleep every time I left the room, now if she was awake and didn't show signs of hypotension no problem I would give it, but if something happened and she would of passed your licenses would of been on the line. I dunno I am pretty bold I told a MD one time if he wanted some one to have the narc pain med to come give it him self.... That didn't go over to well but I didn't get in trouble ladies sbp was low 70s but I agree go up chain of command don't be as bold as I was, my facility we go charge RN, RN supervisor, RN manager, medical director on call (after that I dunno we never had to pull it any further) so I would say if you don't feel comfortable don't do it I have not heard of anyone getting fired for that.

[fsh1986]

I only called my mgr so I know what to do in the future and discuss how it can impact me legally. My charge nurse didn't give me a clear answer either way, the day shift charge who was coming on didn't think it was a good idea. My manager said next time I can also get the administrators involved if I really don't want to give a med, and bc of the blood pressure I could also call a MET and get the ICU nurse involved, even though she had been asymptomatic. MD didn't want to bolus her either, even though kidney function was fine, no CHF, etc.

[MunoRN, RN]

83/53 is just a number and doesn't necessarily mean the patient is at imminent risk, it's a good reason to look at other signs of perfusion, but I think we too often see 90 as some sort of magic number.

But at the same time, the final decision to give the med or not is yours, not the Doctors. And no, no sympathy will be given to you because you were just following a Doctor's order, you work under your license, not theirs.

[1RN4Christ]

But at the same time, the final decision to give the med or not is yours, not the Doctors. And no, no sympathy will be given to you because you were just following a Doctor's order, you work under your license, not theirs.

I agree with this statement. In most cases, the patient is typically ok with you refusing to give the medication if you firmly believe it will cause more harm than good and you have explained that to them (at least in my experience). There are a few instances where they may not accept your clinical judgment (i.e.narcotic seeking). Regardless if the patient tells you they have had it before with BP's that are low, the decision to give the narcotic is up to you. Something frequently pounded into my head in nursing is school is that no physician is going to defend your license and I am instantly reminded of that when I do not feel comfortable following a narcotic order.

[somenurse]

My own normal BP is about 80/50. I feel great. I hope if i ever need a pain med, some nurse will give it to me! ha ha. If i jog around, i get up to a whopping 110/70 sometimes. Once, years ago, i actually hit 120 briefly, but, haven't hit it since, not ever.

I didn't see where you ever mentioned this patients normal baseline BP, which can matter. (i just 'assumed' this patient must usually run significantly higher).

We used to get orders for "hold for BP under..." and then we felt covered, we had a parameter then. But i think you did right thing to document, and to write it as an order, too.

[canoehead, BSN, RN]

I would have given the oxycontin, but held any prns if the patient was falling asleep before I could get back. I'd give prns if she was awake and alert, even with the low BP. If a patient is asymptomatic with their low BP you can be much more confident, but if they are sleepy and slurring, or can't sit up, they need intervention.

[EquestrianRN]

Certainly the patient's usual BP in this case is about #1 on the "relevance" scale. I would have (& have) done the following: After the initial order to give the scheduled narcotic, I would not have called for a second MD/NP/other order until I had thought critically and looked at these factors...What was her HR? What was her typical BP & HR about an hour after the sched med every prior dose given? If she had the BP you described, had a HR anywhere below 85, stated in that range, AND I had the order backing up the med order already, I would document all of that info, give the med when due, and document a follow-up BP & HR one hour later. Chances are she would be doing absolutely fine, you were showing due diligence by ascertaining all of her "usuals", & I might also have documented a RR and SaO2...there would be no logical reason to hold the scheduled narc if all of her vs were wnl for HER, and they remained unchanged one hour after the fact. It is one of those "experience provides comfort and covering your a&$ provides safety" situations which luckily we don't see TERRIBLY OFTEN! Best of luck to you in the future! :0)