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
No, it wouldn't. Non-opiate naive people can tolerate a lot, and a lot of everything is what this lady needs. And her doses are not enough, hydromporhone IS dilaudid, lasts only 3-5 hours with a peak at 90 minutes, and she needs a long-acting with the dilaudid for breakthrough. Now, the facility will have to fight her insurer for it, but what about asing about a fentanyl patch IN ADDITION to breakthrough meds that are regularly scheduled because I can guarantee if they're PRN a lot of people won't give them.
I don't know her age but in people over 90 only 5% survive surgery to repair a hip fracture.
ETA: MS Contin ER would also work - lasts up to 24 hours.
You have unstable femur fracture that could get worse at any time. You would be worried about the fracture causing more damage and bleeding not a GI bleed in this instance. Not to mention that Toradol might cause more problems in healing/fusing of the bone. http://www.medicine.ox.ac.uk/bandolier/booth/painpag/wisdom/NSAIbone.html
OK... I read that (well- part of it, since most of it wasn't relevant).... I'd still argue that SOMETHING is better than nothing when it's not going to be a weight bearing bone, anyway, and the possibility of stress induced GI bleed is also there with the trauma and unrelieved pain. If it were my family, I'd hope for something that helps bone pain. JMO. :) If there aren't s/s bleeding by now (since we're looking at a real situation where there would have been swelling, discoloration, etc by now), they can be monitored for.
OK... I read that (well- part of it, since most of it wasn't relevant).... I'd still argue that SOMETHING is better than nothing when it's not going to be a weight bearing bone, anyway, and the possibility of stress induced GI bleed is also there with the trauma and unrelieved pain. If it were my family, I'd hope for something that helps bone pain. JMO. :) If there aren't s/s bleeding by now (since we're looking at a real situation where there would have been swelling, discoloration, etc by now), they can be monitored for.
There are many ways to help relieve this type of pain. NMDA antagonists, Cox 2 inhibitors, TCAs, tens unit, nerve catheter, are just some of the other things that could be done. I wouldn't personally use Toradol with all the other options.
There are many ways to help relieve this type of pain. NMDA antagonists, Cox 2 inhibitors, TCAs, tens unit, nerve catheter, are just some of the other things that could be done. I wouldn't personally use Toradol with all the other options.
Just remembered what worked when I was working ortho- I'm glad there are better options :)
wooh, BSN, RN
1 Article; 4,383 Posts
For my sister it was a fall. They happen.