Question: If there is a PO order for pill medications (especially narcotics), are we able to dilute them in water for administration if you suspect a patient of cheeking them? Or should we consult with the ordering physicians prior to dilution?
Being a newbie ER nurse, in the few couple of months I've been in the ER, it's been one hell of a ride considering the patient population. And I know I am not the first and I won't be the last nurse to experience someone cheeking? But in all purposes of protecting my license and not enabling the sale of controlled substances, ie. dilaudid, on the streets, are we as nurses able to do just that? Dilute the pills for administration?
Specializes in Medical-Surgical/Float Pool/Stepdown.
Why not get the order switched to liquid?
I have known this route to work well when there are suspicions of cheeking or hiding to either take later or to give to other family/friends at the bedside.
I think that deliberately tampering or diluting any medication (in a way it was not meant to be given) technically violates the rights of safe medication administration regardless of whether the med can be safely crushed or not.
Not necessarily true at all. No violation if crushing and giving in pudding or juice is not contraindicated for any medical or pharmacological reason. However, I would not try this with most solid meds because they taste NASTY when you increase their surface area by crushing them to powder to put in something else.
Get the liquid form that's designed to be at least a little less disgusting.
Not necessarily true at all. No violation if crushing and giving in pudding or juice is not contraindicated for any medical or pharmacological reason. However, I would not try this with most solid meds because they taste NASTY when you increase their surface area by crushing them to powder to put in something else.
Get the liquid form that's designed to be at least a little less disgusting.
Yes, this. In pediatrics we crush pills all the time without getting a specific order to do so. Unless it's a med that can't be crushed for a specific reason (like it's an XR form or something) there's no reason why you can't crush it for administration. Some medications are not available in liquid suspension and some people can't swallow pills. For kids, sometimes it's actually more palatable to crush a pill because the volume of liquid medication is so much and there can be high alcohol content in some of these suspensions. Phenobarb is one that comes to mind. The liquid suspension is (if I recall correctly) 20 mg/5 mL and has a relatively high alcohol content. The pills are relatively small and easy to crush. So if you need to give 30 mg of it to a small child, you either have to get them to take 7.5 mL of a gross liquid or crush a small pill and throw it on a spoon of their baby food. That is, of course, kids.
For a competent adult who's ordered for PO narcotics and expects pills, would I take it upon myself to crush it so that he couldn't cheek it? Probably not. With kids, we do it to make it easier for them. Give him the med, make him take it in front of you and inspect his mouth afterwards.
There could be reasons why they have visits that high. I know in my area walk in clinics don't take medicaid. So any time a person gets ill they have to go to the ER. For any little reason. Lots of docs in this area won't take medicaid or are not accepting new patients so they have to go to the ER. I don't think that you judging them and deciding for them what their pain levels are and how they should take their meds is right. There are plenty of people who are addicted to pain meds. But that is not your job to judge and try and take matters into your hands. That is the doctors issue.[/quote']
Well said.
With the external issues being approach that is correct; however, finding out ways to approach how someone can take the med as ordered in the timeframe is paramount; the issue at hand is giving the medication effectively.
OP, always broach the subject as needed with the physician, even if that means changing the substance or, even crushing the med and putting it into applesauce or pudding or tougher if available. You will not necessarily lose your license in terms of a patient cheering meds....some are so good that they can pocket them at the back where you can't see it; then it's moot once you check the buccal and under the tongue. Had a pt like that once as a new grad; meds change to liquid or crushed in pudding once I got the report and the off going nurse told me that during report.
They weren't at all surprised when I brought it up. It's so scary how chronic this issue is. And if we aren't as vigilant, we'll be treating more and more drug overdoses, polypharmacy, and addiction problems.
There could be reasons why they have visits that high. I know in my area walk in clinics don't take medicaid. So any time a person gets ill, they have to go to the ER. For any little reason. Lots of docs in this area won't take medicaid or are not accepting new patients so they have to go to the ER. I don't think that you judging them and deciding for them what their pain levels are and how they should take their meds is right. There are plenty of people who are addicted to pain meds. But that is not your job to judge and try and take matters into your hands. That is the doctors issue.
I don't believe anyone here is talking about the patient that uses the ED 3-4 times a year because they can't afford the $300 to go to a pcp or Urgent Care,..we are talking about patients that have 5-6 visits a month, sometimes more, and as many visits to other area ED's. There are several agencies that track narcotic prescriptions and the docs can see this. Our EMR allows us to see any visit within our large system, I can see that your pcp gave you 90 Norco 4 days ago, your Orthopedic doc gave you 90 Percocet last week and the Urgent Care gave you 20 Norco yesterday, and I see no Rx for the two Fentanyl patches you forgot to remove before you came in. When you tell me that you fell and hurt your back today and are out of pain meds what am I supposed to think? Is it not within my scope of practice to educate you about the dangers of Opiate addiction and to refuse to participate in feeding your addiction? We are talking about people who have 6-8 visits a year for opiate OD requiring Narcan gttps or intubation,....should we believe their stories and hand out more drugs? I work ED and never give more than one dose of PO pain meds at a visit so I don't worry about someone "cheeking" meds. I do however discuss the patients hx with the doctor and firmly explain why we will not be giving the patient an RX for narcotics. I can't help but believe that the medical profession is at least partially responsible for the huge addiction problem in this country. We hand out Narcs like they're candy to keep the patients happy.
I don't believe anyone here is talking about the patient that uses the ED 3-4 times a year because they can't afford the $300 to go to a pcp or Urgent Care,..we are talking about patients that have 5-6 visits a month, sometimes more, and as many visits to other area ED's. There are several agencies that track narcotic prescriptions and the docs can see this. Our EMR allows us to see any visit within our large system, I can see that your pcp gave you 90 Norco 4 days ago, your Orthopedic doc gave you 90 Percocet last week and the Urgent Care gave you 20 Norco yesterday, and I see no Rx for the two Fentanyl patches you forgot to remove before you came in. When you tell me that you fell and hurt your back today and are out of pain meds what am I supposed to think? Is it not within my scope of practice to educate you about the dangers of Opiate addiction and to refuse to participate in feeding your addiction? We are talking about people who have 6-8 visits a year for opiate OD requiring Narcan gttps or intubation,....should we believe their stories and hand out more drugs? I work ED and never give more than one dose of PO pain meds at a visit so I don't worry about someone "cheeking" meds. I do however discuss the patients hx with the doctor and firmly explain why we will not be giving the patient an RX for narcotics. I can't help but believe that the medical profession is at least partially responsible for the huge addiction problem in this country. We hand out Narcs like they're candy to keep the patients happy.
And while I understand what you are saying, when you have patients on medicaid they aren't visiting 3-4 times a year. They visit way more than that for several reasons. They are on medicaid for a reason. If they were working and well, they wouldn't be on medicaid. I guess that nurses who second guess why a patient comes to the emergency room is a huge sore spot for me. I have been second guessed myself on numerous occasions. I had a bad few years when I was very, very ill. I was in the ER all of the time due to seizures and stomach issues and I hate it when nurses in the ER assumed I was there for pain meds. Most people just want an answer to their problems and would give anything to be off of the meds. Not all, but most. Once a doc assumed I was there for pain meds and my appendix had ruptured. I had to beg to be examined. Another doc who assumed I was there for pain meds told me to take some magnesium and there was nothing wrong with me. I had gastropariesis.
And for the people who look at my profile and see I am in nursing school and can't possibly know what I am talking about, I beg to differ. As someone who has been a patient for a number of years, I would probably say I know more than most. I have an intricate knowledge of meds and pathophysiology. I did much research in my years when I pretty much could do nothing but read all day. And this experience and knowledge is going to help me immensely when I do become an RN. My own family physician thinks I am going to make a great nurse because of my empathy and understanding of unique situations. Not everyone who comes into the ER is a drug seeker. That is the point I am trying to get across.
All make good points. Here is my view FWIW coming from a unit where frequently pts are admitted for vague diagnoses with no real medical data to back them up. I could (and used to) get worked up about these pts and their demand for pain meds. However, it is not my place to judge, first off. We're taught that pain is what the pt says it is (even if they say 10 but are griping because they're NPO and they came in with abd pain). I assess (pain level) and provide an intervention (pain med, based on order and pain rating). If they are feeding an addiction or just want to get high, it is not my business. Most meds are ordered Q4 anyway so it's not like I'm medicating constantly. 3 times per shift, tops. They know the system, you're fighting a losing battle. Give them their ordered meds and move on.
All make good points. Here is my view FWIW coming from a unit where frequently pts are admitted for vague diagnoses with no real medical data to back them up. I could (and used to) get worked up about these pts and their demand for pain meds. However, it is not my place to judge, first off. We're taught that pain is what the pt says it is (even if they say 10 but are griping because they're NPO and they came in with abd pain). I assess (pain level) and provide an intervention (pain med, based on order and pain rating). If they are feeding an addiction or just want to get high, it is not my business. Most meds are ordered Q4 anyway so it's not like I'm medicating constantly. 3 times per shift, tops. They know the system, you're fighting a losing battle. Give them their ordered meds and move on.
To add: as long as they are not showing adverse reactions.
Well said.
AJJKRN
1,224 Posts
Why not get the order switched to liquid?
I have known this route to work well when there are suspicions of cheeking or hiding to either take later or to give to other family/friends at the bedside.
I think that deliberately tampering or diluting any medication (in a way it was not meant to be given) technically violates the rights of safe medication administration regardless of whether the med can be safely crushed or not.