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).
Specializes in Peds, Tele, ICU, ER, Orthopedics, Psych,.
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.
Maybe I should edit my original post. I am not suggesting that the profound hypotension she developed was because of the dilaudid, but that because the dilaudid was pushed quickly, I expected hypotension. So, when the patient did develop hypotension, I did not look for another cause (which was shock from blood loss).
Also, to clarify, I would want to tell my NM because I find the practice of pushing narcs quickly to be unsafe, and if it is a common practice where I work, maybe some of the nurses need to be reminded that doing things quickly (even though policy is to push no faster than 1 mg over 2 min) can have unintended consequences. I would not want the NM to single out the charge nurse I am referring to, but perhaps have the issue addressed as an education topic or something.
Personally I would say nothing but if someone brought this to my attention as the manager I would also be looking into the nurse who ignored hypotension as well as the nurse who pushed the drugs
Specializes in psych, addictions, hospice, education.
Personally, I think the NM would single out the nurse you are talking about rather than having a unit-wide inservice. Also, personally, I HATE having to sit through an inservice on a topic someone else flubbed-up when I'm doing it correctly. It's punishment for the whole crew rather than confronting the one or few who need re-education.
Maybe you're telling yourself to remember to not assume a symptom is from the obvious, for future reference in a similar situation?
I guarantee that if you tell the NM about this, it will get back to the other nurse that it was you who made the report. I stand by my idea of talking to the other nurse first. Might it be possible that she has pushed dilaudid quickly for so long that she doesn't remember it should be pushed more slowly? Tell her your concerns and your rationale for having those concerns. If you see her doing it again, THEN tell the NM (or not).
I think people jump to "reporting" people way to quickly when a more upfront, personal discussion can do the same job, and might even develop some sense of being a team.
Maybe I should edit my original post. I am not suggesting that the profound hypotension she developed was because of the dilaudid, but that because the dilaudid was pushed quickly, I expected hypotension. So, when the patient did develop hypotension, I did not look for another cause (which was shock from blood loss).
Also, to clarify, I would want to tell my NM because I find the practice of pushing narcs quickly to be unsafe, and if it is a common practice where I work, maybe some of the nurses need to be reminded that doing things quickly (even though policy is to push no faster than 1 mg over 2 min) can have unintended consequences. I would not want the NM to single out the charge nurse I am referring to, but perhaps have the issue addressed as an education topic or something.
If you have observed many nurses doing this incorrectly, then, yes it should be brought up. Again, I would not bring it up to you manager in the context of this specific incident, but more in a general sense. Also, rather than taking this to the manager, it might be best to start with your unit's professional practice committee, EBP committee, education committee, etc. (if you unit has one of these groups).
Specializes in Peds, Tele, ICU, ER, Orthopedics, Psych,.
If you have observed many nurses doing this incorrectly, then, yes it should be brought up. Again, I would not bring it up to you manager in the context of this specific incident, but more in a general sense. Also, rather than taking this to the manager, it might be best to start with your unit's professional practice committee, EBP committee, education committee, etc. (if you unit has one of these groups).
I believe we have a ED focus committee as well as an education committee. I would talk to the nurse who did it, especially if I thought it would do any good. Unfortunately we are not scheduled to work together for another week. If I do bring it up to her, do you have any suggestions on how I can tactfully state my concerns without making her feel like I am attacking her or doubting her judgement?
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.
Now there's a 3rd nurse. This is like "Telephone". It is absolutely amazing how easy it is to be misunderstood.
I don't mean to sound critical of you, psu, I just am always amazed when this happens. And scared.
I believe we have a ED focus committee as well as an education committee. I would talk to the nurse who did it, especially if I thought it would do any good. Unfortunately we are not scheduled to work together for another week. If I do bring it up to her, do you have any suggestions on how I can tactfully state my concerns without making her feel like I am attacking her or doubting her judgement?
Thanks for your post!
Yes, if there is such a thing as a unit meeting, a journal club, something like this could be a great topic of discussion.
If you want to address her directly, start by asking how Nurse ______ is doing. Mention that it sort of scared you when her pressure dropped and see where it goes from there. I don't know. Just a thought.
Have you reviewed proper IV admin of narcs? You can see what they say regarding rate/rapidity of administration, perhaps bring this gently into the conversation?
I wish we could just say openly, directly what we want to say and not worry about where the fallout, if any, falls.
Specializes in Peds, Tele, ICU, ER, Orthopedics, Psych,.
Personally I would say nothing but if someone brought this to my attention as the manager I would also be looking into the nurse who ignored hypotension as well as the nurse who pushed the drugs
It might very well be that I end up saying nothing and simply take this away as a learning experience. However, as I think I mentioned in my original post, I did go in to talk with the patient immediately after the first hypotensive reading (80's/50's), and believed that because the patients heart rate remained in the 60's (baseline), and the patient reported feeling better, that the hypotension was simply a side effect from pushing the narcotic too quickly. It was with the next BP reading (1/2 hour later, 60's/30's) that I realized the hypotension was NOT due to the narcotic, but a symptom of shock from the patients internal bleeding. I am very grateful for the patients good outcome though.
Specializes in Peds, Tele, ICU, ER, Orthopedics, Psych,.
I am a little confused, a patient with those symptoms should have been assessed by a DR right away, and OR called for stand by...
The patient was seen by a PA initially. It wasn't until she became extremely hypotensive that everything jumped into high gear (stat portable US, rapid infuser, Levophed, Surgeons called in, etc). As soon as we had her ready and stable enough to transport her to the OR she went, they were on standby as soon as she became very hypotensive.
Specializes in Mental Health, Medical Research, Periop.
I noticed in your original post you said youre not blaming her, so Im trying to figure out why you are going to the NM. If other nurses on the unit are doing this then you can suggest an inservice BUT to go to the NM about this one person based on an incident you witness and didnt question immediatly - I say no, not worth it.
NYnurseatheart
57 Posts
Maybe I should edit my original post. I am not suggesting that the profound hypotension she developed was because of the dilaudid, but that because the dilaudid was pushed quickly, I expected hypotension. So, when the patient did develop hypotension, I did not look for another cause (which was shock from blood loss).
Also, to clarify, I would want to tell my NM because I find the practice of pushing narcs quickly to be unsafe, and if it is a common practice where I work, maybe some of the nurses need to be reminded that doing things quickly (even though policy is to push no faster than 1 mg over 2 min) can have unintended consequences. I would not want the NM to single out the charge nurse I am referring to, but perhaps have the issue addressed as an education topic or something.