okay, i've been trying to look this up online and in my drug books but theres no exact answer, so i was hoping to get some others opinions...
Last week i had this pt, 59y/o (looked more like early 70's), maybe 130lbs max, chronic pancreatitis w/painful exacerbations 1-2 times/mo. pt came in around 9am to ED, pain rated 10/10, constant crying and moaning, (only place we were all able to get an iv was her thumb! four of us tried for over an hour), MD ordered 2mg dilaudid ivp.. ok no prob, half hour later, shes still yelling at us, so is her husband, that hasn't helped her pain at all, MD orders another 1mg dilaudid ivp, half hour later STILL no relief, another mg dilaudid... well this continues on till 1pm, w/in those 4hrs this smaller sized woman has gotten 10mg dilaudid ivp.. VS stable, but K+ is low so we're giving KCL super diluted at only 50cc/hr because its hurting going thru the thumb IV.. well now its not just the pancreatitis, now she wants something for the KCL infusion discomfort, AND saying that shes going to sue us all because we're not doing anything for her pain, even though i stated we were trying everything we could just short of killing her, i reported her c/o pain to the MD and said "frankly im not sure how shes still conscious but i told her i'd tell u about her pain" and hes like, "yeah nothing makes her happy, just do a 4mg IVP of dilaudid, maybe that'll knock her out and she'll be quiet for awhile". well I didn't feel comfortable giving that dose so my preceptor did, putting his pt at 14mg dilaudid IVP w/in 4.5hrs. sure enough, DOESN'T knock the pt out, and shes STILL complaining of pain! luckily my shift ended soon after so i'm not sure what the next shift did w/her but i guess my question/concern is, has anyone ever given that much dilaudid like that before w/the exception of hospice pts? its way more than the recommended doses i've been able to find and honestly im not sure how she was still conscious, most of my pts are out after 1 or 2mg ivp. obviously this lady has quite a tolerance and isn't making much of an effort to just control her pancreatitis in the first place, but after a certain point shouldn't the doc just have said NO, we cannot give u anymore? or am i just way off base?
Trust me i absolutely HATED the idea of her having to get it through her thumb vein, we had five diff. nurses work for 2 hours trying to get a vein on this woman, and the doc was just so blaise about it i was irritated, but i'm still on orientation what was i supposed to tell my preceptor that we shouldn't run it until we get the doc to put a central line in, and then tell the doc hes a moron, and to go do it? lol i dont think i would've lasted there much longer had i done that. and yes i'm sure this woman has a HIGH pain tolerance, my only issue is that we could NOT work out any plan of care with her, anytime u said anything to her all she'd respond is "pain pain pain" and start moaning and sighing, but we'd see her resting quietly from our desk and the minute one of us walked by the room she'd start back up with it. then the son got into it w/all of us claiming that we weren't treating her, and she started yelling at us as well saying we just wanted her to suffer bla bla bla its so frustrating! eventually i just said "look mam i know ur in a lot of pain, but you have a very high tolerance to this medication, and just because you do, doesn't mean we can give you an unsafe dose! frankly we're suprised ur still awake as it is, so i want u to know that we ARE doing everything we can, but screaming and yelling at us instead of trying to relax and rest in a more comfortable position will NOT help your pain".. i should've saved my breath coz she went right back to PAIN PAIN PAIN.. if i see her again i'm runnin the other way! i should've told her to start taking better care of herself and she wont need to be in the ER 4 times a month!
sounds like a typical "sickler." Frustrating, to be sure.
I have put thumb/finger IV's in people before, but like I said, I would never run potassium through a thumb IV (let alone any site below the wrist). Most people who need IV potassium will be admitted, and I have had no problem saying to a doc "we can't give the potassium through the IV we have; wanna do PO instead and have the admitting doc send for a PICC in the am, or do you want to do a central line here in the ED?" And there is nothing that says you have to follow what a doctor says, should you believe it would cause harm to the patient. I have no problem saying "I refuse to give that medication, so if you want to give it, you can." 99% of the time, the docs don't want to take the risk that they were so willing to pawn off onto you. I understand that you were with your preceptor and its difficult to decide when to interject - its just something to think about. People have lost fingers due to potassium infiltration, and a lawyer would eat that up (loss of work, productivity, blah blah blah). And what if the med was given at the wrong rate, or what if the wrong dose was mixed - and now you suddenly have a critical patient with only a thumb IV to work with?
For myself, I've found that the biggest timesaver in the ED is to think "what is the worst that can happen, and how can I prevent it from happening?" Some of the worst things that can happen with IV potassium includes cardiac abnormalities and IV site infiltration with tissue necrosis - and this can be prevented by having a proper IV site in a "hearty" vein, having another nurse double-check IV pump settings, and keeping the patient on continuous cardiac monitoring. If it infiltrated, how much time would be spent calling pharmacy, restarting an IV, filling out an incident report, etc.? Sometimes "doing the right thing" takes more time and other staff may object (often because it requires more work on their part). But there will be a time when it pays off and we all should adhere to high practice standards because it is the best for the patient and will stand up in court should a lawsuit arise.
As far as the family goes - I do not tolerate yelling and I will tell the person "you cannot yell at me". I have had family removed by security for yelling at me and I have no regrets. I'm a very kind and tolerant person, but a family member being upset and frustrated is different than yelling and being verbally abusive towards staff. Its ok to be frustrated, its ok to be upset. But its not ok to yell, and I do not tolerate that behavior. End of story.
EXCELLENT POST!
I bolded my favorite statements-- I tell this to my orientees all the time!
I printed out your post and am giving it to my orientee I have now--
Specializes in Emergency/Trauma/Critical Care Nursing.
ok well i really appreciate you guys helping me out, my primary preceptor had an unfortunate series of events including family deaths and such so for two weeks i had like 6 different preceptors and it was so hectic i hated it because i couldn't build up a rapport w/them you know? and to be perfectly honest i did not even remember that about the KCL being below the hand = no no, thats where i was leaning on my preceptor to help bridge the gaps in things i haven't necessarily given in a long time and since hes the one that got that first iv and hooked up the kcl to the pump, i didn't even think to question it. luckily since that particular situation a grew my own "pair" lol the kind u need to work in ER, so i have been taking on the rude pts head on, but in a nonconfrontational way, and i've had lots of success so far... so score 1 for me lol. i DID confront my preceptor and say "are u sre this dose is safe for the dilaudid it seems awfully high" and he had some long winded explanation that ended up sidetracked onto something completely different, and i just let HIM keep giving it after a while, i didn't want that responsibility anymore, i didn't like the dosing. so i guess the only complaint is, it sucks to be on the bottom of the food chain in the ER when u want to learn, but some people teach u the wrong things, and sometimes those people teaching them to you also happens to be the charge nurse! yikes, i dont think i'm ready to confront the charge AND the doc lol.. but i'm working on it! Thank u so much everyone for ur input and helping answer my questions!
WOW! that is a ton of Dilaudid. Pancreatitis is a very difficult pain to get under control but I'm thinking 1: this person has a well exercised liver to handle that much narc.
2: maybe it's time to switch to something else- If Dilaudid isn't working after 4-5mg it's time to think about fentanyl, and/or Toradol, or maybe some sedation-Xanax, ativan, versed or such. All have a risk of resp depression (except toradol) but you're not going to get any more relief from Dilaudid after 4-5mg IV- you are just going to shut down thier resp.
By the way- 50 or 100 mg of lidocaine in the KCL IV would have been kind. The doc should have been considering a central line until a PICC could be established. You were really pushing your luck with that thumb IV.
Specializes in Emergency/Trauma/Critical Care Nursing.
yes, i believe we've established this... i've already said that i didn't start the iv or hang the kcl, i was merely observing my preceptor and then asked for opinions on here. and yes i agree that it WOULD have been a good idea for the MD to order that, or to get up off his butt and get a line himself, but i can't change what happened a month ago, i just wanted to know about the dose of dilaudid...
ok well i really appreciate you guys helping me out, my primary preceptor had an unfortunate series of events including family deaths and such so for two weeks i had like 6 different preceptors and it was so hectic i hated it because i couldn't build up a rapport w/them you know? and to be perfectly honest i did not even remember that about the kcl being below the hand = no no, thats where i was leaning on my preceptor to help bridge the gaps in things i haven't necessarily given in a long time and since hes the one that got that first iv and hooked up the kcl to the pump, i didn't even think to question it. luckily since that particular situation a grew my own "pair" lol the kind u need to work in er, so i have been taking on the rude pts head on, but in a nonconfrontational way, and i've had lots of success so far... so score 1 for me lol. i did confront my preceptor and say "are u sre this dose is safe for the dilaudid it seems awfully high" and he had some long winded explanation that ended up sidetracked onto something completely different, and i just let him keep giving it after a while, i didn't want that responsibility anymore, i didn't like the dosing. so i guess the only complaint is, it sucks to be on the bottom of the food chain in the er when u want to learn, but some people teach u the wrong things, and sometimes those people teaching them to you also happens to be the charge nurse! yikes, i dont think i'm ready to confront the charge and the doc lol.. but i'm working on it! thank u so much everyone for ur input and helping answer my questions!
christy- it does suck to get so many different preceptors-- i am a strong advocate for having new nurses 'mirror' their preceptor's schedule--just so what happened to you (all that frustration and conflicting info) doesn't happen to others.
you did the best you could and now you know that just because other nurses are 'experienced' doesn't mean they practice good or safe nursing care. and it is very hard to be new and speak up when you question a seasoned nurse's 'expertise'.
and dilaudid- some patients require alot but when you find that you're giving alot of repeated doses--don't be afraid to suggest other things like fentanyl, etc. good luck to you and don't ever worry about coming here to ask questions or vent. many of the posters not only answer your question, but also add their in put so others who may have had similiar experiences can learn as well.
yes, i believe we've established this... i've already said that i didn't start the iv or hang the kcl, i was merely observing my preceptor and then asked for opinions on here. and yes i agree that it WOULD have been a good idea for the MD to order that, or to get up off his butt and get a line himself, but i can't change what happened a month ago, i just wanted to know about the dose of dilaudid...
Sorry, I don't think anyone here was trying to fault you for the IV potassium, so please dont take it as such. Its good discussing things like this so we can all learn. And from my experience starting out in the ED as a new grad (with multiple preceptors ), sometimes you don't get to learn what you should be learning; and sometimes you're not with a preceptor that is up-to-date with current practice. The only reason why I brought up the IV potassium was to augment your practice to help you be the best that you can be.
Its good that you were questioning the dilaudid - not just the dose, but the fact that it wasn't helping. Sometimes we need to say to the doc "How about we try something else instead?"
I've found most ED docs to be really open to nurses, when compared to floor docs. We're a team in the ED and the docs rely on our eyes and ears just as much as we rely on them to care for our patients and get to the bottom of their complaint. Its our job to monitor the patients response to treatment, and if that response isn't beneficial then something different needs to be done. Sure, you'll meet lazy ED docs (one I knew in particular used to surf the web looking at new houses, and writing soft-Media emails to god knows who), and you'll meet stellar ED docs (those who listen to you and do everything they can for their patient). There was one doc in particular who was very intimidating to me and even made me cry once. But I listened to WHAT he said and ignored HOW he said it. As time passed, he saw my eagerness to learn and my persistent advocacy for my patients; we ended up working very well together. Since then, we've both left the facility where we worked together but we email each other and keep in touch.
I hope you found the answer to your question about dilaudid and I hope we helped you learn something extra too.
I see that this thread occured a while back, but I have to ask....
I had surgery last week - sinus surgery. When I woke up, the nurse kept giving me dilaudid in my IV. It didn't work. I never take drugs. She gave me 4 doses. Nothing worked. I was in so much pain. Finally, she gave me an oral vicotin and it helped.
I see that this thread occured a while back, but I have to ask....
I had surgery last week - sinus surgery. When I woke up, the nurse kept giving me dilaudid in my IV. It didn't work. I never take drugs. She gave me 4 doses. Nothing worked. I was in so much pain. Finally, she gave me an oral vicotin and it helped.
How could this be?
Two thoughts...either she was diverting the meds to herself, or the Dilaudid just built up and finally hit you about the same time you took the PO meds...just my 2 cents :-)
:yeah:
), sometimes you don't get to learn what you should be learning; and sometimes you're not with a preceptor that is up-to-date with current practice. The only reason why I brought up the IV potassium was to augment your practice to help you be the best that you can be.
MassED, BSN, RN
2,636 Posts
sounds like a typical "sickler." Frustrating, to be sure.