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).
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.
Now I'm not exactly sure what you mean with this...I'll just clarify my position a bit--I don't know that confronting this nurse nor going to the NM is the answer here (both for the OP's reputation and for the good of the unit--why bring up just this one nurse to the NM when educating all the nurses on the unit of how to push narcs may be more beneficial.
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.
My .02. I probably wouldn't say anything to mgmt based what you provided. Unless I missed it, you didn't say what the dilaudid dosage was, what the nausea med pushed was and it's dosage and what her original vitals were -you stated this was not her first encounter, didn't you? Did you see what her vitals were like on the previous one or look for a baseline? Did I miss the time between the readings when you noted the first drop? Where was the ED physician and was he made aware of her vital changes? that'd be good to know before pontificating further. If the push you described is accurate by all means say something to the other nurse, tho I'm guessing she already realizes her mistake.
Specializes in Peds, Tele, ICU, ER, Orthopedics, Psych,.
firstly, if sev'l nurses are slamming narcs in, it warrants attn, period.
yes, it's not necessary for those who do it correctly, but the goal is to prevent a bad pt outcome...
so this inservice is needed for the greater good of the pts.
how to approach this nurse?
since she is defensive and argumentative, avoid asking her why she pushed it in quickly.
as suggested, do bring up that pt w/internal bleeding...
and then tell her you noticed how quickly she pushed it in,
and that she's taking a huge risk when she must know it is contraindicated.
then nod your head and walk away.
end of discussion.
you have planted the idea in her head, she doesn't have anyone to argue with, and you've said what you had to.
we cannot look the other way when we observe dangerous practice.
if she gives you the cold shoulder, ignore it.
continue your work and your treatment of her, as you have all along.
you did what you had to.
much luck.
leslie
Thanks Leslie. I think there must be a way to bring this issue to light without singling out the charge nurse in this incident. I think that there are way too many newer/less experienced nurses in our ER who will witness this behavior and consider it safe to do. Perhaps in many cases it is safe (like I mentioned earlier, the drug seekers who ask for their med to be pushed rapidly, and complain if you dilute it or push it slowly). After having worked in many different hospitals as an ICU/CVICU traveler, I have seen the down side to pushing narcs rapidly. Narcs are also not the only drugs I have seen pushed rapidly by this particular RN. I believe we have guidelines for a reason, to protect the patients safety.
I have been thinking about the way you suggest to approach her. I am not so certain that it would work well, but on the other hand I think it is an issue that should be addressed and not shoved under the rug. I believe she served in Army (or some branch of the armed forces) prior to becoming an RN. She is probably 10 years younger than me also. She is a confrontational type of person, very direct, but also very dismissive of others at times. I have heard her say "whatever" and walk away when someone complains to her, which leads me to believe I might be getting no where by saying something to her.
I agree. The dilaudid was not the cause of her hypotension. She I think the bleeding and abdominal pain were.
I agree, you shouldn't push a narc like dilaudid too fast..... but BP should rebound after that. However bleeding, abdominal pain and a fast track tot he OR would drop BP.
I wouldn't take it to the nurse manager, but you may want to talk to the CN in a non-offending way.
Specializes in Trauma Surgery, Nursing Management.
Judging from your latest post (#27), my feeling is that you should approach her with kid gloves, as distasteful as that may seem. I would go about it this way:
"Hey Nurse X. I have been thinking about the pt that we took care of on Monday, you know, Mrs. X. I was really concerned that her BP dropped so quickly, and I wonder what your thoughts are regarding this. I know that you wanted to give her some pain relief because she was REALLY having pain, as you know. We also know that she did have some hemorrhaging. In your opinion, do you think that the combo of the rapid IV narc push AND the hemorrhaging led to the rapid decline in BP? The only reason I ask is because I know you have seen this scenario a lot and I wanted to get your opinion."
This puts her into the role of "teacher"...again I state that this is not the most comfortable situation to broach...but it WILL diffuse any sort of conflict that may result from your asking her. Does that make sense? (Forgive me, I am so tired from soooo many traumas in the OR today.) I work almost daily with a passive aggressive doc, and I have learned to approach her in a way that puts her mindset into an "educational" role instead of a "blaming" role.
Specializes in Peds, Tele, ICU, ER, Orthopedics, Psych,.
My .02. I probably wouldn't say anything to mgmt based what you provided. Unless I missed it, you didn't say what the dilaudid dosage was, what the nausea med pushed was and it's dosage and what her original vitals were -you stated this was not her first encounter, didn't you? Did you see what her vitals were like on the previous one or look for a baseline? Did I miss the time between the readings when you noted the first drop? Where was the ED physician and was he made aware of her vital changes? that'd be good to know before pontificating further. If the push you described is accurate by all means say something to the other nurse, tho I'm guessing she already realizes her mistake.
I can answer some of these questions. First the dose of dilaudid was 1 mg, and the nausea med was zofran 4 mg (both in the same syringe and slammed in). The patient's initial VS were 110's/60's, and HR 60's. The patient was familiar to the charge nurse because the patient had worked at our hospital in the past (not in the ER, but on the floor with the charge nurse before she came to the ER). The patient had only had one other visit to our ER, and her VS were pretty comparable (except that her HR was in the 80 - 90 range then), and that had been more than 6 years before.
With the initial hypotension (80's/50's) I immediately told the PA who initially saw her. She already had NS infusing, but I made sure it was w/o (which is what the PA suggested). I also layed the patient flat, and stayed with her for a few minutes (assessing her). The patient reported feeling better, denied dizziness, and continued to have a HR in the 60's. I scanned the patients bladder because she had been unable to void but she had less than 100 cc according to the scanner. We were testing a serum HCG, but really wanted a faster urine pregnancy test. In hindsight I should have changed the monitor settings to recheck her bp sooner. I don't think it would have changed much though - other than perhaps allerting us 15 minutes sooner that we needed to intervene quickly. If I had given the meds, instead of the charge nurse, I would have been more suspicious of her lower BP and increased the frequency of the VS. I don't think I am blameless, but I feel what the charge nurse is doing (slamming IV meds) can have some very real potential for patient harm.
As for the charge nurse realizing what she did was dangerous - I am not so sure. I have seen her slam in many meds, especially narcs.
My .02. I probably wouldn't say anything to mgmt based what you provided. Unless I missed it, you didn't say what the dilaudid dosage was, what the nausea med pushed was and it's dosage and what her original vitals were -you stated this was not her first encounter, didn't you? Did you see what her vitals were like on the previous one or look for a baseline? Did I miss the time between the readings when you noted the first drop? Where was the ED physician and was he made aware of her vital changes? that'd be good to know before pontificating further. If the push you described is accurate by all means say something to the other nurse, tho I'm guessing she already realizes her mistake.
I think a young healthy patient with a 30pt drop in systolic BP warrants further investigation, more frequent VS, MD eval, etc. Of course she was feeling better--she had narcs! I think you are in the wrong just as much as she is. But, she didn't actually harm the pt. You potentially delayed her diagnosis by 30mins.
I think we've pretty much established that the while the initial drop in bp may have been due to the rapid push of dilaudid, the extreme hypotension was the result of an abdominal bleed.
Here are several other things to consider. One reason we don't push dilaudid fast is to head off the aforementioned drop in bp. But another reason I've heard many times is that we don't want to give drug seekers the reward of a "rush" in addition to the fix they are after.
Could it be that because the nurse in question knew the patient (may indeed have worked with her in the past), that she viewed her as someone who was not a drug seeker and therefore took a chance on pushing the dilaudid quickly so she'd get faster relief?
This may not be something she does regularly, but rather an action she viewed as doing a favor for a friend who is young enough and healthy enough to bounce back from a momentary drop in pressure.
Of course, the trip to the OR proved that the patient was not really healthy at the time, and the short term pressure drop from the quick push actually obscured the downward trend.
If your coworker made an exception to the normal slow administration because she thought of it as putting a buddy on the fast track to pain relief, she may have had a few freaked-out moments herself (without telling you, of course) between the time when the blood pressure started heading south and the abdominal bleed was discovered.
No matter what the reasoning was, one of you should have increased the frequency of the vitals. The fact that you were concerned and didn't do that shows a pretty big lapse on your part.
If you bring this situation up to anyone, I suggest you do it in a general way so that everyone gets a reminder to push narcs slowly. And maybe it would be good to just keep it under your hat unless you see this or any other nurse do it again.
Specializes in Clinical Research, Outpt Women's Health.
Honestly? Without going into the right or wrong and all this second guessing?
I would give my coworker the benefit of the doubt and keep my mouth shut. I would never have a BP drop like that again where I did not increase the frequency of my vital sign monitoring "'just in case".
I've seen blood pressure bottom out after giving narcs slowly, too. I guess I wouldn't attribute a drop in BP to the administration method of the narc, but rather the fact that a narc is on board.
Sure, your coworker shouldn't have pushed it fast, and I'd probably straight up address that with her. It doesn't have to be a knock down, drag out fight. Simply tell her you noticed her pushing the narc fast, and did she realize it's to be given over a minute or two? That way she knows someone is paying attention, you know that you've addressed it, and you know that now she knows exactly how fast to push it. She can get as defensive as she wants after your statement, but your message has already been delivered.
However, you simply messed up by attributing a significant drop in blood pressure to a narc. You were concerned enough to implement the other interventions, but not recheck BP sooner? Regardless of whether the drop was due to narc administration or the reason she presented in the ED, it's still an issue of perfusion, and you should have followed up on it sooner instead of dismissing it. Lesson learned. Take responsibility for it, learn from it, and move on. From your info, you have a lot of experience. You've been in situations like this before where later you've thought, Hmmm, I should have done x, y, z instead. This sounds like one of those situations.
psu_213, BSN, RN
3,878 Posts
Now I'm not exactly sure what you mean with this...I'll just clarify my position a bit--I don't know that confronting this nurse nor going to the NM is the answer here (both for the OP's reputation and for the good of the unit--why bring up just this one nurse to the NM when educating all the nurses on the unit of how to push narcs may be more beneficial.