What would you do in this case?

In a future case like this where you are deciding to give a med or not, check his BP trends. If he is always 90-100 / 50-70, then check and see what other nurses have done. If a dose of morphine 6mg was given, see what his vitals were before and after. if he seems to handle it, you probably can give him a small dose. I definitely would not give 6mg with a BP like that, good call on your part! Maybe 2 or 3 depending on how he's handled it before.

Same with insulin. If you think the dose is too high, check back on previous days/shifts and see what was given and the accu-checks before and after.

Each person's body will handle things differently. Watch how they trend. I think you handled the situation well. Keep up the good work.

Thanks All Smiles for your feedback! It makes me feel better to know that my gut instinct was on track in this case. Being so new, it's hard to tell whether I am right or wrong sometimes. I felt bad, because I don't ever want to have the attitude that a patient is "drug seeking", or their pain is not valid, but I really felt that it was unsafe to give 6mg of morphine in this case.

Amy

By the way All Smiles,

I don't know that any of this patients nurses ever did a before and after check on him when getting Morphine...But I will definitely do it on all my patients receiving narcs, as well as check resp and pulse.

Again Thanks!

I agree with checking the trends of his B/P however I dont think I'd have given all 6 mg with a B/P less than 100 systolic. I might have given him another 2 mg in place of the ambien. I think the only thing I would have done differently is I would have notified the MD with his B/P and his constant request for morphine. I would have let the MD know that you gave him the 2 mg and that did not control his pain however you felt the B/P too low to give any additional. The MD then might have ordered something else p.o that might not have had has much effect on his B/P...my only train of thought on that is that way you've covered yourself for c/o uncontrolled pain issues even though it was a ongoing problem it was still a problem for you. I am just thinking that that way on one can come back and say you ignored his pain issues.

I agree that keeping the patient safe is your first priority and withholding the morphine was a wise decision.

So many times it is very difficult to manage a patient that has a history of taking alot of pain meds because the body develops a tolerance and what might knock me or you on our butts doesnt touch the person we're treating and given that all patients deserve adequate pain control and it is such a subjective symptom it always concerns me as to whether they will come back and say that nurses refused to give meds and they didnt have relief from their stated pain issues. Documentation will be the best defense for you if that ever happens. If you can document the reason that pain med wasnt given ie b/p, mental status changes, etc---then that will justify your decision but if you do that then you must also document other relief efforts such as what you tried --the heating pad , etc---however if no relief still obtained then I feel you must have documentation of MD notification of inadequate pain control so that the issue falls into the MD's hands on how to manage the issue.

I think you did the right thing, and I am happy for you that you had the support and encouragement of your preceptor. Since the pt "self-medicated himself for years," there is no real way to know what he may, or may not, have taken or administered to himself. Therefore, he may, or again, may not, already have a tolerance for, or addiction to pain meds. Unless he offered up this information, you would have no way of knowing any of this. It sounds to me as though you used good nursing (and gut) judgement, and I am proud of you.

Thanks Bigsyis for your reply...It's always so hard for me to know if I am making the right call being so new. I only graduated this May, and it was a real shock to start work, and realize how little I really know even after all we learned in school! I am glad that you and the other nurses who replied to my thread agree with my decision. I guess there is something to be said for going with your gut feeling. Glad to know my gut is working. I really had a bad feeling about this, and am sure that if I had given this man the full 6mg of morphine, something very bad would have happened, and I never want to be responsible for causing harm to my patients. I didn't want to downplay his pain, and am sure he was in pain, but could not justify the danger of the med vs his relief. I did all I could to offer alternative, non narc options to help relieve it, but he just would not consider any other option but morphine, which makes me wonder if he was using morphine prior to hospitalization, and did not tell us. I am wondering if a PCA in this case would be warranted, since it can be set to low doses, and gives a sense of control to the pt. I believe alot of his issues (including his pain) come from a feeling that he has no control over his health issues. I wonder if being able to use a PCA would give him the feeling that he is controlling his meds and his pain issues, and help him feel better. It would certainly be safer for him to only be able to get 1mg every 10minutes, instead of 6mg in one dose. Of course, he has not really expressed any responsibility for his actions that landed him in the hospital in the first place, so mabye he does have some addiction issues that he is in denial about.

Any thoughts? I'm really curious, since he will be with us for a while longer, and I am likely to work with him again at some point.

Amy

By the way...

I consider myself so very lucky to work on a floor where the nurses and the rest of the staff are so supportive of new team members and nursing students. I did two clinical rotations here, and before I graduated, turned in a resume to the unit manager. I knew without a doubt that I wanted to work here. So many clinical rotations in school, my experience with the RN's were negative. Students were treated like an inconvenience and a burden. I felt like the nurses had totally forgotten that they were once terrified and nervous students also. On this unit we were encouraged to ask lots of questions, do everything we were allowed to do as students, and they would even make a point of seeking us out if a patient we weren't working with needed something (iv, foley, PICC dressing , etc). How very cool, and wonderful to know that they really sincerely enjoyed having us there. It was a real confidence builder to have that kind of encouragement. That has not stopped since I started working there either. I look forward to being able to do that for other students in the future, because it made all the difference in the world to me.

Amy

Good call on holding back on the morphine - at least you had some parameters to work with and he was able to get some pain relief - it wasn't a 6mg or nothing. I'm curious, did he have any PO med options as well? I might have considered that as an adjunct to the morphine - a nice slower onset, less drastric bp effect and longer action.

Just an idea here but if this gentleman is having so much pain why not suggest to the MD to commence this man on a 12 ER medication or Fentanl Pain Patch to give him better long term pain management with a break through morph dose?

A patient with good pain control will be a happy more compliant patient yes??

I agree with the last two posts. In fact, I believe that that is what was done for him in the end since he was running so low.

Amy

Fair play to you..you handled the situation very well..in the cases like this just always listen to ur own judgement ..at the end of the day its your own signature who are at stake in drug kardex...the court will see that just in case something will happen..good judgement..