What would you do in this case?

[al7139, ASN, RN]

Hi all,

New to nursing and to cardiac care. I have just started my fourth week at work. I had a patient tonight who was very frustrating for me.

This is an older retired radiologist, who was admitted several weeks ago for acute mental status change, dx: encephalitis, and has a long history of other medical issues including HTN, RA, DM. He was admitted to ICU and spent several weeks there before coming to our unit.

His history is not very clear, but it appears that he was treating himself without the advice of his Physician, and this is what landed him in the hospital. He was using a long list of drugs esp NSAIDS, and his body couldn't handle it. He has lots of problems as a result of his self treatment.

He has been bedridden, and just started working with PT. Has gotten OOB a couple times to sit in the geri-chair, but is non-ambulatory.

I actually feel sorry for him in a way, but after tonight, I wanted to strangle him!

My shift (3-11) started with report. He had Morphine 2mg at 1230, then flexaril and ativan at 1500. His start of shift b/p was 100/72. I withheld his dilitiazem as per protocol. He c/o pain in his neck and back later on (he does have cspine problems), and I gave him another flexaril since enough time had elapsed. He was getting some anxiety about 1 hour after that, so I gave him ativan as scheduled. At about 9pm, I was doing his skin med regimen, and he asked for 6mg of morphine for neck and shoulder pain of 9/10. I had just checked his b/p for lopressor, and it was 93/68 ( witheld lopressor). I told him that I did not feel comfortable giving him 6mgs since his b/p was low. He was not happy about that at all. I told him I would give him 2 mgs, and suggested position changes and applying his K-Pad to help alleviate some of his pain with non-med interventions. (BTW, my preceptor agreed with my plan) He refused repositioning, and heat application, and agreed to the 2mg, but wanted me to call his MD, stating that he always runs low b/p's (this is true, but I still did not want to give him his full dose and bottom him out). I gave him 2mg, and told him I would check his b/p in an hour. If there was no change, I would give him the rest of his dose (4mg). Well, I checked, and it was down to 83/56. No way was I giving him 4 more mgs of morphine! Boy was he pissed! I went to my preceptor, who again agreed with my gut feeling about this (the MD had rx'd 2-6 mg q2hrs prn pain, but I doubt he would have wanted to hear his pt had bottomed out). I again explained to him why we did not feel safe to give him his morphine, but he wouldn't listen to reason. Later, at change of shift, the vitals were checked, and his b/p was up to 98/72. He asked for ambien for sleep. I checked the drug reference to see what effect it had on b/p. It can affect it with an OD, but in a normal dose the change is not significant. My preceptor agreed he could have it. Got the med, and went to give it to him. He said if I could give him ambien, I could give him morphine, and refused the ambien and insisted on 6mg of morphine. Again tried to explain to him how each drug affects b/p. Not listening, just wants his morphine. I went to my preceptor and said that even with his b/p up I felt very uncomfortable giving him the morphine. She told me it was a judgement call on my part. I said that if another RN felt ok about it they could do it, but I wasn't going to give him the med. Again, she agreed with me, and commended me for going with my gut feeling on this. We gave report to the oncoming RN. I explained what was going on with him, and told the oncoming RN that I was sorry I was passing this problem along to her, but that I just did not feel comfortable giving this med with such a low b/p, even though that was his trend. I also did not want to leave the oncoming nurse with a patient who had recieved 6mgs and bottomed out or coded on her. She was very cool about it, and said she agreed with us, since the RNs who have worked with him are concerned about his possible addiction, and he apparently tries to bully the nurses into giving him his narcs.

Anyway, sorry this is such a long story, but I was just wondering if any experienced RNs would have treated this issue differently than we did? I really felt torn, because I obviously want to be able to alleviate any pain my patients are having, but I want to keep them safe and not hurt them in doing so. I feel I handled the situation appropriately, but would appreciate some feedback since I am so new.

One other point, my preceptor did not feel calling the MD was necessary in this case, since this is apparently an ongoing issue with this patient.

Thanks,

Amy

[All_Smiles_RN]

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.

[al7139, ASN, RN]

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

[al7139, ASN, RN]

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!

[Kymmi]

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.

[bigsyis]

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.

[al7139, ASN, RN]

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

[al7139, ASN, RN]

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

[maolin]

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.

[Sabby_NC]

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??

[al7139, ASN, RN]

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

[RVMI73]

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..