rapid response team

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I had a pt that was admitted for intractable back pain, imaging was negative, Neurosurgery workup was negative. pt. seen by pain management MD who ordered a boat load of new narcotics and sedatives (Scheduled oxycontin, PRN roxicodone, flexerill, baclofen, and neurontin and ativan) gave the patient his 8am scheduled meds, then at 9:30 upon reassessment pt. c/o 8/10 pain. pt requested his PRN roxicodone and ativan, which I gave at 10 am. At 11:00 am, pt a+ox3 speaking in full sentences, still c/o "excruciating pain". VSS. I went in around 12n to give him insulin, he was hunched over in the chair lethargic, but arousable. Assisted him back to bed VSS. At 12:30 went in to get another pt. OOB. glanced over and his RR was 10, more lethargic. called attending MD for narcan order, who told me to call pain service. paged pain service-no response. paged anesthesia attending who supervises pain service- who said they didnt want to step on pain service's toes. I'm at the pt's bedside and his RR is now 7 and he is only responsive to sternal rub. I called a rapid response, the hospitalist arrived gave me the narcan order, pushed the narcan and pt. awake and alert...c/o pain.

it seems like the attending and pain services gave me an attitude for calling a rapid response. just wondering if maybe I shouldnt have given all those meds (I didn't question them because this was day two on this regimen) or if it was the right thing to do by calling a rapid??should I have called it sooner?

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I can't believe no one would give you a Narcan order! That's crazy and the fact that they got mad when you called a rapid response.

I would have staggered some of those meds but either way the MD should have introduced them more conservatively. But again those darn patient satisfaction scores. I've had patients complain when I stagger their meds but I've had to push Narcan one too many times and my gut tells me don't give all of this at once. I don't care if you take 80 mg of MS Contin and 3 mg of Ativan and 5 mg of PO dilaudid at home (just an example not using actual dosages) at home I'm going to start off conservatively to see how the patient reacts to the meds given. Even though it's ordered it's up to us to use our judgement if the med is appropriate to give or not.

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If you're unsure, call a RR and stand by your decision. I would have done the same. Let them get mad. Your job is to keep the pt safe, not worry about the doctor getting upset. If you hadn't called the RR and the pt coded those same doctors would've placed the blame on you. You did the right thing!

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Next time override narcan, give it and then call the physician stating why you gave it and write the order. But cover yourself... SAts were 70%, respirations 8, pt non responsive to verbal stimuli, low GCS....

If asked why u gave narcan, "it's because i didn't feel like over riding etomidate and succs and putting together an intubation tray along with calling report to the Icu and filling out another transfer sheet on top of an incident report.

And the next time they look mad point it out. Is rather yallbe mad than for this patient to die.

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Specializes in MICU - CCRN, IR, Vascular Surgery.

The fact that you had to call rapid to get Narcan because the MDs wouldn't give the order is shocking. You did the right thing by calling them!

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Specializes in ICU.
Next time override narcan give it and then call the physician stating why you gave it and write the order. But cover yourself... SAts were 70%, respirations 8, pt non responsive to verbal stimuli, low GCS.... If asked why u gave narcan, "it's because i didn't feel like over riding etomidate and succs and putting together an intubation tray along with calling report to the Icu and filling out another transfer sheet on top of an incident report. And the next time they look mad point it out. Is rather yallbe mad than for this patient to die.[/quote']

I get what you're saying, but I would be wary of advising someone to override and give a medication without an order. It sounds like the OP did the right thing and followed the proper channels to protect their nursing license as well as the patient.

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Specializes in Critical Care.

I give the Narcan then notify the MD I gave it. Your license is far more at risk for not giving Narcan when by your assessment the patient requires, than you are delaying time sensitive interventions because the system is failing you.

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Specializes in ICU.

Ok maybe I wasn't clear enough. We all do things without an order when an emergency arises. However, it is terribly unwise to give someone advice to do so on a public forum. At our hospital, if the patient was still somewhat arousable and was able to maintain their own airway(which this patient was doing even if their RR was 7) our pain management docs would lose their minds if we gave Narcan, especially since Ativan was part of the patient's problem. I feel certain that our pain management docs would make a huge deal to management and maybe even the BON over giving the Narcan without an order. This patient had not suffered a respiratory arrest and was in no immediate danger as the situation had been going on for several hours. Not the time to do things without an order!

That's why I think the OP did the right thing by monitoring the pt and selling rapid response to get an order from the hospitalist. Then if the other doc has a problem with it, he can take it up with the hospitalist. I don't disagree that the pt probably needed Narcan, but not so urgently that you should risk practicing out of your scope.

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Ok maybe I wasn't clear enough. We all do things without an order when an emergency arises. However, it is terribly unwise to give someone advice to do so on a public forum. At our hospital, if the patient was still somewhat arousable and was able to maintain their own airway(which this patient was doing even if their RR was 7) our pain management docs would lose their minds if we gave Narcan, especially since Ativan was part of the patient's problem. I feel certain that our pain management docs would make a huge deal to management and maybe even the BON over giving the Narcan without an order. This patient had not suffered a respiratory arrest and was in no immediate danger as the situation had been going on for several hours. Not the time to do things without an order!

That's why I think the OP did the right thing by monitoring the pt and selling rapid response to get an order from the hospitalist. Then if the other doc has a problem with it, he can take it up with the hospitalist. I don't disagree that the pt probably needed Narcan, but not so urgently that you should risk practicing out of your scope.

Ativan was not the only medication givin. It depends on the individual's style of nursing. After that first phone call to the first doctor, conversation should hAve been....."I am not about to call and run up behind several md's awaiting orders for a patient that can barely breathe. Give me an order or I am going to call rapid response."

Hopefully there are standing orders for the admin of narcan. For everyone that had a problem with it, I'd ask if it was your family member what would you like the nurse to do in a time sensitive situation. Don't gamble with someone's life. Out of all the things one could do to lose their nursing license for, I'd hand deliver this License over to the board inside of a pretty nicely wrapped Christmas package if they wanted it.

Id just start making calls to the mortgage co & let them know y'all can have this.. Get a lit garage sale going. Pick me up a lit apartment book. Call salliemae and ask for a deferment/forebearNce and prAy..

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Specializes in Surgical, quality,management.

You did the right thing calling a respond. My hospital has criteria for calling a rapid response BP X RR Y HR Z 'or any patient that you are seriously worried about'. It is a no blame action. The pt safety is the priority here.

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You did the right thing. Remember, you are the patients advocate, you're there for the patient, not the doctor.

My facility uses computer order entry and a lot of doctors have order sets that include narcan

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You definitely should not regret your decision to call a rapid response. In this situation, you were acting as pt advocate and perhaps saved the pt from a respiratory arrest or at the very least some respiratory distress. I do agree, however, that the medications should have been staggered somewhat. I know that the pt requested pain meds + ativan but seeing as they both depress respirations, I would have started with pain coverage then given anxiolytics afterwards. Either way, you did the right thing and it's all a lesson learned.

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