Please Help my narcotic situation

[AngelofLTC]

Ok so I had a scare tonight when administering a new narctotic order. HX. Resiedent has broken femur and pre existing MS. Sent to Er where we are told in the ltc facilty that they will no be treating the fracture. Pain is 10/10 at all times since readmission. Nurse practioner calls doctor on my behalf to increase medications. Currently the resident in on 20 mg oxycontin BID with dilaudid 1mg 1 to 2 tabs q 4 hr for breakthrough pain. The NP nad doc decide that they should streamline the meds and switch the oxycontin to hydromorph contin 9mg with the dilaudid (being the same med class). I come in on Evening, resident received the first dose of 9mg in the monrnign and I ask what her pain scale is ( at 10/10) so I give the extended release as ordered and give prn .

Residnet is very snowed and scaring me. O2 sat 90% and resp 12. Doctor comes in and suggests we reduce the meds tomorrow and monitor. Rn charge nurse comes up and assessed the resident as not needing narcan though she is mostly unreponsive. I monitor the remainder of my shift with no change.

I left feeling a bit uncomfortable with the situation....but I followed orders and wanted to only help her. What would you have done

[Flo., BSN, RN]

Narcan rescue is not without its risk. At my work we give it based on resp status not on LOC. So if RR >8 and o2 sat >88 then no narcan. Just let them sleep it off. I would apply O2, cont pulse ox and monitor frequently.

[SweetseRN]

I would need a little more Hx but with 10/10 pain, RR 12 and SpO2 @90% doesn't really sound that bad. I would like to hear what others have to say. This sounds like a difficult situation for you and the pt. I'm so sorry

[FLArn]

My setting is hospice so I am coming from probably a different mindset but here goes. I would give the pain meds as ordered. She has an unrepaired fractured femur and is uncontrolled pain. Every time she is turned for repositioning or peri care she is in pain whether she is awake or not. If the MD wants to back off the Dilaudid is up to him of course and may be wise if she is previously opiate naive. I would request a non-narcotic pain med as an adjunct such as Trilisate which is very effective for bone pain.

[xtxrn, ASN, RN]

Yeah. Would love to see some Toradol for this... we used it post op for hip ORIF, and many of the patients never wanted PRN meds.

[AngelofLTC]

mmm...I will question orders from now on...I was so scared tonight

[wooh, BSN, RN]

Toradol is nice, but not for long term. And if they aren't fixing the fracture, this is going to be long term. I'm thinking something muscle relaxing to stop the quads from spasming around that fracture.

Why are they not fixing the fracture? That's just inhumane.

I wouldn't narcan, and I wouldn't worry about the respiratory depression. My RR right now is 12 and I'm WIDE awake. And 90% while asleep? That's fine too.

[AngelofLTC]

The argument is that she is non ambulatory before #. However she had an electric scooter that kept her a little independent. We are taking all independece away and its likely she wont get in her chair anytime soon with no tx. So you its inhumane in my opinion.

[Flo., BSN, RN]

Why are they not fixing the fx? He would feel much better after the surgery.

I think it would help if they went back to the Oxycontin and upped that dose. We usually try to get coverage from several types of narcs. If dilaudid is not working for him why not try norco or percocet? People react differently to pain meds its all about finding the right combo for him.

I totally agree with wooh, get some muscle relaxants and that should help big time.

[elthia]

Toradol is nice, but not for long term. And if they aren't fixing the fracture, this is going to be long term. I'm thinking something muscle relaxing to stop the quads from spasming around that fracture.

Why are they not fixing the fracture? That's just inhumane.

I wouldn't narcan, and I wouldn't worry about the respiratory depression. My RR right now is 12 and I'm WIDE awake. And 90% while asleep? That's fine too.

Sometimes if the fx requires surgical repair, and the pt is elderly, frail and has multiple comorbidities, you have to weigh the risks. Sure, you can be all gung-ho and and put the pt under for surgery...but what about when they don't wake up from the anesthesia? Then you have an elderly pt with a fx, post op wound, on a vent. Who now is a risk for ventilator acquired pneumonia, and will need tube feeds, putting them at risk for aspirations, etc. OR worst case scenario...they code on the table..so then there is CPR, rib fx, vent, pressors, ICU, multiple organ failure...

Which is more humane? It is all sad. IMHO. Sometimes it is the least harmful 2 not so great choices. If it were me and my family, give me good pain management, some muscle relaxers, and let me go back to my "home". For a lot of pts, LTC facilities are their "home".

[SuesquatchRN, BSN, RN]

Resps of 12 are fine. Let her sleep. And Narcan not only reverses narcotics, it also shuts down the body's natural endorphins and she will awaken in incredible pain.

Is the resident now at least comfort care?

[xtxrn, ASN, RN]

The argument is that she is non ambulatory before #. However she had an electric scooter that kept her a little independent. We are taking all independece away and its likely she wont get in her chair anytime soon with no tx. So you its inhumane in my opinion.

Non-ambulatory, and too unstable for surgery aren't the same. (not saying YOU don't know that....my guess is that some orthopedic surgeon blew her off). Surgery isn't always about getting someone ready for a triathlon - sometimes it IS the fix for the pain.... I've worked LTC where the only residents who didn't get palliative surgery for a fracture are the ones who were too medically unstable to survive anesthesia. JMO- this is cruel (and not your fault, OP- not ragging on you :)).

I hear what elthia is saying...... can this resident make any decisions on her own to weigh in on this?

Yeah- the facilities are their homes- very true