What would you have done?

[eileeny21]

So just wondering what you all would have done differently to handle this situation. I received an order from a MD to start a PCA pump for a new surgical admit, the order was for 10mg iv loading dose and then 1-4mg/10min for demand dose. First the pharmacy stated that the medication was pending due to the high loading dose, I called the MD to verify that that was the dose he wanted, he stated that it was. I called the pharmacist who still wasn't sure about it. I called the nurse supervisor and she suggested having the MD talk to the pharmacist. Pharmacist called me back and MD did not want to change a thing also letting me know to have narcan at the ready. The patient at this time had his pain at about a 3, no severe pain and mind you, no history of drug abuse. To make a long story short, I didn't give the loading dose, I just started the PCA pump at 1mg/10min and his pain had been fine. I am a new grad and I guess I am just wondering what you would have done and if I did the right thing. Let me know!

[JB2007, ASN, RN]

I would have done just what you did. The pts pain was not out of control and I would say that the loading dose was not needed at that time. I would start at the 1 mg dose and increase up to the 4 mg dose as needed. The loading dose is not always needed. Depending upon what the medication is 10 mg seems like a bit much. However, you need to take a pts age, size, and overall health into consideration as well.

You never stated what the medication you was giving the pt and that can make a big difference as well.

[eileeny21]

The medication was morphine, and he had was very healthy, the patient also had no history of any drug abuse as well. Thanks :)

[amarilla, RN]

This was a fresh post-op? In my experience, the patient might rate their pain lower following anesthesia and pain relief administered in PACU, but wake up 6-10 hours later in severe pain as it begins to work out of their system, particularly if they have no basal rate and are not pushing the button throughout the night.

I don't know what surgery the patient had, his age or size, but all do impact the effect of the medication. You'll see higher doses for morphine PCAs, though 10mg loading for this patient does seem unwarranted. If the patient's pain was controlled, you did the right thing for your patient, though I'm concerned that you spoke with the MD but did not take this up the chain after not following his (confirmed) orders. You can get your butt chewed in the wrong situation and possibly lose your job for ignoring MD orders, particularly when you've discussed and confirmed them, without the support of your charge / NM / house sup. Make sure they're on board and try to get the doc to change the order or at least agree to change based on your assessment, otherwise, you're leaving yourself open for write up. Good luck.

[nursynurseRN]

I think what you did was right, only thing I would do is tell the patients the doctors plan and see if he agreed with you about the pain and how the pain meds were much more then he needed for the pain level, then if the patient agreed I would chart pt refused just to cover yourself. If the patient wanted the pain med then I would call the doctor and say the pt pain was only 3 and you didn't feel comfortable giving it. Just cause by not giving it and so something happens it will come back to haunt you.

[loriangel14, RN]

I would have given the loading dose if I had clarified with the MD and that is indeed what he wanted.Where I work you would get in hot water for not following an order.

[uRNmyway, ASN, RN]

I agree with Loriangel14. If you disagree with the order, thats fine. We aren't always going to agree with what MDs want. However, you confirmed with him/her that this is the order they wanted. So did the pharmacist. Unless there was a contraindication or possible risk to the patient, you should not just choose to ignore what the MD ordered. My understanding of nursing in the US is that this could definitely get you in trouble in some settings.

[CUMC rn,bsn]

I agree with the past 2 posts. If I question an order I call the resident and talk to them, if the order is out of the ordinary, I will ask them why they want it that way. If they have a good rationale, I will go ahead and give the order. If I still don't agree or am nervous about it, I go up the chain of command to the resident supervisor, then attending, or even the chief of medicine. ( I work at a teaching hospital, so there are always people around to talk to) I also involve the charge nurse or house sup. if needed. It does get quite tricky just ignoring MD's orders. I find that often they will give a large loading dose after surgery since most of the medicine they use in the PACU is very strong, but short acting, and when it wears off, it is harder to play catch up.

[blue heeler]

i would not have given the loading dose.

[RNlmk]

I wouldn't have ignored the order, I would have called the md back stated that had assessed the pt and reviewed w/ my charge & wasn't comfortable giving that dose, could I give 5 or 7 instead and see how they did? If they said no give it I would either ask them to come to the floor or just give it depending on how strongly I felt about it and what my charge thought was appropriate. Most of my pts are not opiate naive so it's not a common problem on our unit.

[sweetiepeas]

I would have talked with the patient about the affects of the medication and my concerns. If they didn't want it, then I could chart that they refused. I'd rather side with caution. Just because they are md's don't make then right all the time. Or you could have just said hey I'm a new nurse can you explain you're rationale for a large loading dose?

[eatmysoxRN, ASN, RN]

If I were the patient and you held my pain medicine and later I had severe pain because of it, I'd be upset. In addition, if you clarified the dose with the doc I would have given it. The only circumstance I would have not given it is if the patients vitals were questionable.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~