Should I tell my NM or not???

[NYnurseatheart]

So, tonight we had a close call in the ER where I work. A patient came in c/o abdominal pain. The charge nurse knew this patient (was an RN who had worked there before I believe) and brought her back quickly from registration where we triaged her at the bedside. The charge nurse inserted an IV, drew labs, while I assessed the patient quickly, and hung a liter of NS. VS were stable. The patient c/o pain, rating it a 10/10. The charge nurse got an order from the doc for pain and nausea meds and gave it to the patient. She gave Dilaudid and a nausea med rapidly (pushed it in as if it were adenosine in 2 seconds or less), and said to the patient "you're going to feel a rush, but it won't last long and you will have relief pretty soon. I simply closed my eyes for a second and bit my tongue. As a nurse for almost 20 years, I NEVER give narcs that rapidly by IV because in my experience, too many bad outcomes occur.

So moving on with my story, our monitors are set to obtain VS every 1/2 hour unless you manually change it. The patient was on SPO2 monitoring so I could tell that her heart rate was baseline and stayed that way. The next BP was lower, but not extremely hypotensive (89/54), so I went in and talked with the patient who stated she felt better. A half hour later her bp was 60's/30's so I ran into the room and she says she feels like she is going to pass out. I grab a doc and drag him into her room. I quickly obtain a second large bore IV site and we hang more fluids....

Long story short, in the next hour and a half we have her on the rapid infuser, hang pressor meds, and blood and get her shipped off to the OR. After she is in the OR I start thinking about how close a call we had. I then realize that after I saw the charge nurse push the narc so quickly, I expected hypotension, so really didn't investigate much (other than talking with the patient) when I saw the initial drop in bp, nor did I increase the frequency of VS because I was monitoring her SPO2 and HR (which both were stable). I never said anything to the charge nurse, but I feel what she did was dangerous and could have had a worse outcome. I don't want to blame her for anything, but what would you have done in my shoes? Would you let your nurse manager know? I realize many of the ER nurses do this, but I am not one of them (pushing narcs rapidly).

Thanks for taking the time to read this!

[Whispera, MSN, RN]

Your first step is to talk to the charge nurse about what you did, and get her rationale. Chain of command states you talk with the "offender" first and try to get it all settled before you go over her head.

[meaganellise]

Considering she had to go to surgery, and had to have pressors and blood I am assuming that the quick administration of the dilaudid was not what caused her pressure to drop so quickly. Did she have some sort of internal bleeding?

[NYnurseatheart]

Your first step is to talk to the charge nurse about what you did, and get her rationale. Chain of command states you talk with the "offender" first and try to get it all settled before you go over her head.

Hi Whispera,

I think I am a little confused by your post. You say I should talk to the charge nurse about what I did. I am assuming you mean talk to her about what she did and get her rationale. The charge nurse is pretty outspoken (she is not always the charge nurse, and has considerably less nursing experience than I do), and becomes very defensive (and argumentative) whenever she is approached/questioned about her behavior. I want to maintain a good working relationship with her, so I guess what I really need is some guidance about how to approach her tactfully.

Thanks for your response.

[NYnurseatheart]

Considering she had to go to surgery, and had to have pressors and blood I am assuming that the quick administration of the dilaudid was not what caused her pressure to drop so quickly. Did she have some sort of internal bleeding?

Hi Meaganellise,

No, I don't believe the dilaudid was to blame for her hypotension and she did indeed have internal bleeding. What concerns me is that the other nurse rapidly pushed a narc, which led me to assume the initial slight hypotension was caused by the rapid narc administration. If I had not witnessed the rapid push, I might have investigated a bit further when the initial drop in BP occurred (or might have increased the frequency of taking the BP).

[meaganellise]

I'm not sure how productive it would be to tell your NM considering your previous response stating that this charge nurse gets very defensive when she feels she is being questioned. I am not sure that will make her change her ways and you also previously stated that many other ER nurses do this. (I have to go off of your references since I work on the floor. :) Also, maybe the NM did or does the same thing when she is in the ER?

I guess I am also worried about how it will affect your relationship with the other nurse. If you speak with anyone about it, I think you should start with your co-worker and then work your way up. At the end of the day, you need to do what you feel is best, regardless of the consequences.

Personally, I wouldn't say anything because the dilaudid was not the cause of her hypotension. I would just remember this the next time I was working with the nurse in question.

[Whispera, MSN, RN]

That's what I meant! Haven't had my coffee yet! talk to her about what SHE did...

If you go to the NM first, your possibility of a good nursing relationship with her is going to go out the window if the NM talks to her and mentions your name as the reporter...

[NYnurseatheart]

I'm not sure how productive it would be to tell your NM considering your previous response stating that this charge nurse gets very defensive when she feels she is being questioned. I am not sure that will make her change her ways and you also previously stated that many other ER nurses do this. (I have to go off of your references since I work on the floor. :) Also, maybe the NM did or does the same thing when she is in the ER?

I guess I am also worried about how it will affect your relationship with the other nurse. If you speak with anyone about it, I think you should start with your co-worker and then work your way up. At the end of the day, you need to do what you feel is best, regardless of the consequences.

Personally, I wouldn't say anything because the dilaudid was not the cause of her hypotension. I would just remember this the next time I was working with the nurse in question.

Maybe you are right. Perhaps I shouldn't say anything to this particular nurse. I don't know exactly how many nurses push narcs that quickly, but I have seen her do it before, and have seen others that do the same thing. I should add that this was not an elderly patient, but a fairly young one - so perhaps the charge nurse felt that it was okay to push the narc so quickly with the antiemetic. I know that all the drug books I have ever looked in say to take 2 minutes (or more) to push Dilaudid in.

[makes needs known]

Is the patient alright? Lots of times I am critical of myself. Perhaps she is also looking at her action. And wondering if she she pushed it too fast. Nursing is a worrisome job.

[NYnurseatheart]

Is the patient alright? Lots of times I am critical of myself. Perhaps she is also looking at her action. And wondering if she she pushed it too fast. Nursing is a worrisome job.

I heard before I left work that she was doing fine now. I know how worrisome nursing is, but this particular nurse does not strike me as someone who is critical of herself.

Has anyone here had a bad experience with pushing a narc too quickly? I do know that all my drug seeking patients would love it if I would push their "vitamin D" as we call it, rapidly, so that they can enjoy the high. Those patients who are in a few times a week wouldn't scare me if given a rapid narc push, because they undoubtedly can handle it. I still will only give a narc (or sedation med) rapidly if the doctor requests it that way (for instance, when a patient is intubated).

[psu_213, BSN, RN]

I doubt that she developed hypotension that long after the dilaudid just because the narc was pushed too fast.

Regardless, I'm not sure what you would tell the NM...if she does approach this other nurse about the senario, then you are likely to get portrayed as a tattle tail, which could damage you with the other nurse and with collegues beyond just her.

[Orange Tree]

It would probably be one of the "silliest" complaints that your nurse manager has ever heard. I vote no.