SL Nitro Error...How is this possible?

Hi all,

No, it was not my error, but I got the patient at start of shift.

Ok, here is the situation:

There was a new admit to the unit who came in for CP. Per my charge, he had active 10/10 pain on arrival to the room. The nurse who had him is a floater who sometimes works in our ER as well. Our protocol in the hospital is NTG SL x3 doses max q5 min, with vitals before each tablet. we also do a 12 lead EKG, and call the MD. If 3 NTG don't work, we get further orders. We stop giving NTG if the SBP goes below 90.

Anyway, this nurse actually gave the patient the WHOLE bottle (25 tabs) of NTG! The only way we found out about this is because the Clin II went to help her, and saw the pills in the patients mouth.

When questioned about this, the nurse said she had always done it that way. I have to wonder how many patients she has done this to. Scary!

Anyway, I got this patient, and was all over him since I was expecting his B/P to crash, and was prepared for a transfer to ICU or Stepdown. Amazingly, the lowest his B/P got was 98 systolic. He was a little tachy, but not alarming. I had my CNA checking vitals every 5 minutes, and basically spent the first few hours of my shift in the patients room. Patient was fine, never a problem....how is this possible? BTW, his pain did go away, and he never even got a headache! I know some people never get a change in their B/P with NTG, but I have never seen a pt recieve so much at one time...

Any thoughts?

BTW, I am sure the nurse is in serious trouble for this, she is VERY lucky she didn't kill this guy.

Amy:eek: