i am a new nurse half way through orientation and on the second day with a patient who has chronic pain found myself in a bit of a situation. overnight the pt's hr dropped to the upper 30's and 40's and was remaining there. with the full backing of my preceptor as well as the other nurse on the floor i did not administer the pt's prn oxycodone. i explained the reason why i wasn't giving the med to the pt in various ways several times but the med was still demanded. the pt states she wants to leave so ama paper work is brought to her. a hospitalist that is not treating the pt. explains the consequences of leaving ama and the pt decides to stay because the md said she could have the pain medication. (no new orders were written) hr is now at 38, clinical direction is notified who supports and confirms our decision to not administer the medication. long story short pt leaves ama.
would you have held the oxycodone? what other course of action could i have taken? is there a pain medication that i could have asked the hospitalist to write for that would not send us running with the code cart (that is still the "good stuff" the pt would have accepted)?
i just don't know....i have left the, question every step i make mind set and now am in the question 50% of what i do.
i'm sure anyone reading this can guess there is a ton of back story that i am leaving out.
http://www.immunize.org/birthdose/letter.htm The approximate incidence of bradycardia with oxycodone is 0.78%. Assuming, that is chronic pain patient used to taking opioids there really is not a reason to hold the oxycodone.
The Coreg was probably why the patient was having bradycardia, but if the patient BP was stable and they felt fine then the pulse (assuming that the 12 lead EKG was also ok) just needs to be monitored until the Coreg has time to wear off. The elimination half-life of Coreg is 7-10hrs according to lexi-comp which means it will take 28-50hrs (4-5 half lives) for it to be nearly eliminated from the body.
It's difficult to judge without being there, but if the pt was on tele, the BP was stable, the pt was asymptomatic, we could point to the coreg as at least a possible culprit of the bradycardia, and the hospitalist was aware and on board with giving the pain meds, I would not have held the pain meds.
Thank you for the input everyone!! I think what I'm going to take away from this situation is that 1. My instincts are pretty good 2. I have a lot to learn, and 3. I need to make stronger suggestions to Doc's.
If she was in so much pain wouldn't she have been tachy and hypertensive?
You did the right thing by refusing to give oxy to a pt with a HR of 38.
Next time politely give the med to the MD and say I am not comfortable with giving this.
No, she wouldn't have been tachy or hypertensive, because she was on a beta blocker. Opioids have very little effect on HR uNless the patient is in a lot of pain and tachycardic from pain.
I think you did the right thing. I would have also explained to the patient that it is my duty to keep them safe, and I did not consider it safe to administer the narcotic considering how bradycardic they were. I would have then called the physician and explained what was going on and reported the bradycardia and asked what was being done/going to be done about it. I would have been more concerned about the drop in heart rate than anything else.
You always have every right to refuse giving a medication to a patient if you feel as though it comprises their safety. I have done so on multiple occasions, as have many of my nurse colleagues. Also, don't forget to chart!
I think you did the right thing. I would have also explained to the patient that it is my duty to keep them safe, and I did not consider it safe to administer the narcotic considering how bradycardic they were. I would have then called the physician and explained what was going on and reported the bradycardia and asked what was being done/going to be done about it. I would have been more concerned about the drop in heart rate than anything else.
You always have every right to refuse giving a medication to a patient if you feel as though it comprises their safety. I have done so on multiple occasions, as have many of my nurse colleagues. Also, don't forget to chart!
What exactly was the danger of administering opioids to this patient? Assuming that the only thing wrong with the patient is low heart rate (since they can complain enough and leave AMA the patient must have been doing pretty good) an opioid is going to effect mu receptors which have very little if any effect on directly lowering the heart rate.
H2 antagonists (Zantac etc.) have been know to cause bradycardia too. Would you recommend that these be held also for bradycardic patients? I think if you look at most drugs adverse reactions something will be listed on cardiac side effects.
IMHO this one of the times where you have to look at the whole picture.
Remember the whole picture, HR is just a number. The reason we worry with bradycardia is the resulting potential for poor perfusion. HR is just one part of how end-organ perfusion is determined. HR is one variable in the Cardiac Output/Index. If the CO/CI is not enough to meet metabolic demands then ischemia results, potentially to the point of infarction.
What you need to remember is that pain significantly increases metabolic demand (as does the resulting agitation). So while opiates can directly lower HR (one study quantified it at 2 beats per minute), that doesn't mean that they decrease perfusion. It's quite possible that a patient with a HR of 38 but higher metabolic demand due to pain will experience poorer perfusion than a patient with a HR of 36 but with lower metabolic demand.
Specializes in Med_Surg, Renal, intermediate care.
It's difficult to judge without being there, but if the pt was on tele, the BP was stable, the pt was asymptomatic, we could point to the coreg as at least a possible culprit of the bradycardia, and the hospitalist was aware and on board with giving the pain meds, I would not have held the pain meds.
Specializes in Med-Surg; Telemetry; School Nurse pk-8.
1. You said there's a ton of back story left out. You knew not to post, because that's a HIPPA no-no. Good for you.
2. Holding the med had the support of the other nurses and the Clinical Director -- all of whom, by the way, know the back story that we on AN do not. You knew to ask/get the support of experienced nurses and the "powers that be". Again, I say good job.
3. You asked for other options for pain control. Yes, the patient didn't want to try them and instead wanted to go AMA (that right there tells a lot). You were critically thinking for the patient's best interest.
I am posting, because I wanted you to know, that as a new nurse you did everything you were supposed to do. You thought about what was happening, and whether your inventions were appropriate. Always listen to that little voice in your head that says something about this situation is not right. Will you at times be wrong? Yes. But know that you are never, ever alone. You have a wealth of knowledge working along side you. You will find that the times you have regrets, are the times you didn't stop and think things through before acting.
1. You said there's a ton of back story left out. You knew not to post, because that's a HIPPA no-no. Good for you.
2. Holding the med had the support of the other nurses and the Clinical Director -- all of whom, by the way, know the back story that we on AN do not. You knew to ask/get the support of experienced nurses and the "powers that be". Again, I say good job.
3. You asked for other options for pain control. Yes, the patient didn't want to try them and instead wanted to go AMA (that right there tells a lot). You were critically thinking for the patient's best interest.
I am posting, because I wanted you to know, that as a new nurse you did everything you were supposed to do. You thought about what was happening, and whether your inventions were appropriate. Always listen to that little voice in your head that says something about this situation is not right. Will you at times be wrong? Yes. But know that you are never, ever alone. You have a wealth of knowledge working along side you. You will find that the times you have regrets, are the times you didn't stop and think things through before acting.
So again, I say 'good job'.
There is always more to the story, but sinus brady (if that what the rhythm was) in a obviously stable patient is not a reason in and of itself to hold opioids. This is especially true for a patient on a beta blocker.
There is no research that I could pull up to support holding an opioid for the conditions I specified above.
wtbcrna, MSN, DNP, CRNA
5,128 Posts
http://www.immunize.org/birthdose/letter.htm The approximate incidence of bradycardia with oxycodone is 0.78%. Assuming, that is chronic pain patient used to taking opioids there really is not a reason to hold the oxycodone.
http://www.drugcite.com/indi/?q=Oxycodone&i=BRADYCARDIA
The Coreg was probably why the patient was having bradycardia, but if the patient BP was stable and they felt fine then the pulse (assuming that the 12 lead EKG was also ok) just needs to be monitored until the Coreg has time to wear off. The elimination half-life of Coreg is 7-10hrs according to lexi-comp which means it will take 28-50hrs (4-5 half lives) for it to be nearly eliminated from the body.