worst night of my 5 year career

[zacarias, ASN, RN]

Hey all,

I was called to the carpet by the day shift nurse I gave report to on a person who fell last night. She was suffering from extreme abdominal pain. The morphine wasn't helping and the percocet on its own wasn't helping. I gave morphine and percocet together when I could and while it helped, it only helped a little while. I called the doctor and got an order for increasing morphine and one more percocet. I gave those later when she was in pain. She fell four hours later slipping off the commode.

Her BP was like 65/43. It came up to mid 80s systolic and occasionally went higher but not much. I called the doc and he just said to watch.

Was I wrong to give her percocet and morphine together? She was in severe pain and my thinking was that the morphine could be for immediate pain control while the percocet will stay in her system a little longer, thus she will have longer lasting pain control. Is my thinking wrong?

My other patient developed respiratory problems out of the blue. His pH was 7.13, bicarb is 4.4 and CO2 13.3!!! That is severe metabolic acidosis, but if his co2 is compensating down to the bicarb, why is the pH still off? Is it that the bicarb is so low he can't compensate? He was intubated and they are still working this up.

I had a horrible night and despite me feeling like I did everything I could, I feel upset that the patient fell from the pain meds. Thanks and appreciate your comments.

Zach

[subee, MSN, CRNA]

You did have an awful night! However, with both cases I think you missed the forest because of the trees (or could be that we don't have enough information). Is the severe abdominal pain post-op? With such bad pain, why isn't she in the OR? Severe pain plus narcotics doesn't sound like a recipie for the bathroom. If she was that hypotensive in the BR, prodromal symptoms were missed. Same for the second case - respiratory failure doesn't "come out of the blue." When you've had some sleep and some perspective you'll find that both of these were tough patients with presenting symptoms that were missed. Don't be hard on yourself. Five years isn't that much experience!

[GilaRRT]

The low Co2 is an indication of respiratory compensation. With metabolic acidosis, your respiratory system attempts to correct the PH by blowing off Co2. This in turn, will decrease carbonic acid levels, and cause a shift in the PH. However, it can only compensate so much. So, you can still have acidosis in spite of respiratory compensation. At this point, it actually becomes decompensated metabolic acidosis. Some may argue it is partially compensated; however, in any case, the acidosis cannot be normalized.

As far as the fall, you do what you can. Person howls in pain and hates you for not helping. You give pain meds, patient falls, and still hates you. Sometimes you loose no matter what you do. If her B/P was of great concern, fentanyl may be a medication to consider because you do not hae an associated histamine release with fentanyl like other narcotics such as morphine. However, I have yet to meet many docs that are warm to the idea of using fentanyl.

On a side note: 5 years of nursing experience qualifies you as a senior citizen nurse in this day and age.

[Tweety, BSN, RN]

I'm sure the doc was aware of this severe pain? Did you have an order to administer them both? It's not unusual to give them both together.

Sorry you had a bad night.

[Ruby Vee, BSN]

sounds like you had the night from hell. i'm sorry -- we all have nights like that, and this is a good place to come and vent about it. were you right to give ms and percocet together? i don't know. i wasn't there. but i've given tylox and fentanyl within an hour of each other and it worked out ok, so i won't say you're totally wrong, either.

big hugs! i hope you feel better!

[TiredMD]

Was I wrong to give her percocet and morphine together? She was in severe pain and my thinking was that the morphine could be for immediate pain control while the percocet will stay in her system a little longer, thus she will have longer lasting pain control. Is my thinking wrong?

I see nothing wrong with giving both together, although I would argue that giving both probably didn't do much of anything except add on narcotics. Both are relatively short-acting (half life of morphine IV 2-3hrs, half life of oxycodone 3-4.5hrs).

Regardless, I order both at the same time not infrequently in breakthrough situations.

Though I suppose if she was getting more narcotics than what she was used to, she should have been accompanied to the rest room. But hindsight is 20/20. Don't sweat it, this kind of thing happens all the time.

[pagandeva2000, LPN]

A very similar thing happened to a seasoned nurse a few months ago with the exact same medications. She questioned the doctor because she was uncomfortable administering two narcartics, and because this was a drug addict, the doctor said it was okay to give. The nurse administered the medications and a few hours later, the patient was transfered to ICU because of respiratory failure. The patient got better and has since been discharged, but, the nurse was horrified. Her gut told her this was not a great idea for this specific patient, but, again, as mentioned, many times, these are prescribed together. Nothing happened to the nurse regarding disciplinary action (thank goodness), but she is still bothered. Things happen...this is why medicine is called a 'practice' rather than an exact science. Go home, get some rest, enjoy your holiday (if possible), and pray for patient and guidance.

[SteveNNP, MSN, NP]

I agree with the above posters. I have given two opioids together, with no problems, but it depends on the patient. As far as the blood gas, bicarb levels are VERY slow to respond to acidosis, especially caused by metabolic acidosis to begin with. What was the pt's urinary output?

[caliotter3]

The only thing that I could advise is to carefully monitor patients like this in the future. She should have been accompanied to the BR or offered a bedpan. But even then, sometimes they sneak out on you when you're not watching. Don't be so hard on yourself. You did what you thought was correct under the circumstances and followed the doctor's orders.

[Ahhphoey]

Sorry you had such a bad night. I have given Percocet to patients for breakthrough pain when they are on Morphine PCAs, however, the times I gave it, it was an absolute last resort for post-op pain. These patients were also not allowed to get OOB alone or if out of bed by themselves for any extended period. Like someone else questioned, what was the cause of the abd pain? I would think the doc would have wanted to treat the underlying cause. Either way, you did what you could and what you felt was best and nights like this just happen. Just consider it a learning lesson and take something of value from this night.

[leslie :-D]

i agree w/the others, who state safety precautions should be in place, when administering narcotics.

i encourage bedpan, bsc (w/assist) or assist to br.

risk for falls, is always up there in priorities for me.

for your other pt, i don't know.

i'm not understanding how there weren't s/s leading up to it.

i'm very tired.

and i'm probably way off base here.

hope your day was better today.

leslie

[FireStarterRN, BSN, RN]

I doubt the low BP was caused by an OD of pain meds, which is more likely to cause resp depression first. You don't give enough info as to whether the pt was post op and perhaps suffering internal bleeding leading to volume depletion, or whether they were getting septic. Low BP is a later sign, what about what their heart rate, RR, etc? The cardinal sign of narc OD is resp depression.