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With narcotics, avoid potentially fatal mistake
ED nurses gave 2 mg of intravenous (IV) hydromorphone to a 40-year-old man with severe throat pain. After two additional doses were given in an inpatient unit, the man suffered respiratory arrest. He was resuscitated, but sustained permanent central nervous system impairment and died.1
High initial doses of opiates might be appropriate for cancer patients; patients who use high-dose narcotics at home; chronic pain patients; and patients with acute fractures, dislocation, or trauma, says Leigh Ann Schmidt, RN, BSN, nurse manager of the ED at Hospital of the University of Pennsylvania in Philadelphia. However, some patients are at higher risk for problems. These patient at risk include those with allergies to analgesics such as morphine, hydromorphone, and meperidine, says Ramazan Bahar, RN, an ED nurse at St. Joseph's Regional Medical Center in Paterson, NJ.
"The elderly are at high risk, due to other chronic medical problems which alters the body's ability to metabolize the medication. Also, polypharmacy may cause reactions with IV analgesics," says Bahar. "Narcotics should be used with caution in patients with severe asthma, chronic obstructive pulmonary disorder, and hepatic dysfunction." To reduce risks of IV pain medications:
• Ask the right questions.
Before giving narcotics, Schmidt says to ask these two questions: Does the patient have any allergies? And if the patient had this situation before, what helped with the pain previously?
Also ask if your patient has a history of drug addiction. Colleen Claffey, RN-BC, MSN, CEN, CPEN, an ED nurse educator at Jackson North Medical Center in North Miami Beach, FL, says, "That would indicate an individual may have a high tolerance to opiates. Patients with chronic medical issues such as sickle cell disease or significant injuries may also warrant large doses of pain medications."
• Before giving an IV pain medication, ask if the patient has ever taken that particular drug in the past.
Bahar says, "If so, ask the patient to identify how they reacted and if there were any complications. This gives you a good baseline to work from."
• Be ready for an emergency.
Knowing where the crash cart is located and its application are essential. Claffey says. "Providing supplemental oxygen or bag valve mask maneuvers may be indicated," she says. "Certainly, knowledge of the opiate reversal [naloxone] and its implications is critical."
• Perform frequent reassessments.
Schmidt says, "Guard against breakthrough pain by keeping a schedule of reassessment of pain and medication administration."
Achieving a pain score of zero might not be a realistic goal. You might have to settle for achieving a level of pain that is acceptable to the patient, particularly for patients with longstanding pain issues, Claffey says.
• Don't hesitate to question orders.
At Jackson North's ED, a resident wrote an order for 10 mg of morphine for a 7-year-old child, instead of 1.0 mg. "Fortunately, the nurse questioned the order, and the patient was not harmed. Clearly, this was a near miss," says Claffey. "Depending upon the condition of the child, a sentinel event may have resulted if proper monitoring had not occurred. If something doesn't sound right, don't do it."
• Monitor your patient closely.
Watch for respiratory depression, nausea/vomiting, change in mental status, and hypotension, as well as local reactions such as phlebitis at the injection site or generalized urticaria, after administering IV pain medications, Bahar says.
"During administration, place the patient on a cardiac monitor along with pulse ox and noninvasive blood pressure monitoring," he says. "Monitor the patient's reaction for up to five minutes. Do a full set of vitals post-administration." (See related stories on transdermal pain patches, pain assessments, initial interventions for pain, and IV pain medications, below.)
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Look for transdermal patches on patients
Due to a change in mental status, a patient was sent to St. Joseph's Regional Medical Center's ED in Paterson, NJ, from a local skilled rehabilitation center with a blood pressure of 70/40, a heart rate of 48, and a respiratory rate of 9. The triage nurse noted that the patient had multiple comorbidities and was obese. Also, the man was on several pain medications, including a transdermal pain patch.
"The case was immediately brought to the attention of the ED attending physician, as the patient's baseline vitals were starting to fall," reports Ramazan Bahar, RN, an ED nurse at the hospital. "The ED nurse immediately removed the transdermal patch and suggested to the attending that the patient may have overdosed on analgesia." After the appropriate dose of naloxone was administered by the ED nurse, the patient's vitals improved.
"The patient's condition was monitored for a few more hours, with another dose of naloxone administered," says Bahar. "The patient's condition improved greatly. He was discharged back to the transferring health care facility."
Don't ignore these factors in your pain assessment
Until the underlying cause of your patient's pain is clear, it can be dangerous to give escalating doses of narcotics, warns Lisa Wolf, RN, CEN, clinical assistant professor at University of Massachusetts — Amherst's School of Nursing and former nurse educator for the ED at South Nassau Communities Hospital in Oceanside, NY.
Wolf says to ask these questions: Is the pain acute or chronic? What is the location? Is it radiating? Is the pain increasing, or was it maximal at the onset?
"It makes no sense to treat the pain as separate from the underlying cause," says Wolf. "Focusing solely on relieving the pain rather than discovering its cause can lead to a delay in diagnosis and definitive treatment." Here are three other factors to consider:
• Vital signs.
This gives you an indication of potential problems and a baseline to monitor physiologic signs of pain and its resolution. "If hypertension and tachycardia are the physiologic reaction to pain, then as pain is managed, these vital signs should come back closer to expected parameters," says Wolf.
• Body size.
Patients who are morbidly obese must be medicated based on ideal body weight and watched carefully for signs of respiratory distress. "The morbidly obese patient may also lose their airway faster and be a more difficult intubation because of the soft tissue in the neck area," says Wolf. "It is critical to monitor the patient who is morbidly obese with appropriately sized equipment. Blood pressure measures are very important, and so a large cuff is needed."
• Your patient's age.
"The very old and the very young are particularly susceptible to overdose," warns Wolf. Because pediatric patients are medicated by weight, you must double check any medication given to a pediatric patient, she says. "Pull out your calculator and do the math, then have another nurse repeat the calculation," Wolf says. "The consequences of a missed decimal point in this population are catastrophic."
Impaired renal and hepatic function in older patients can cause medication to be metabolized more slowly, says Wolf, so look for clinical signs of renal impairment such as edema, oliguria, and a history of taking erythropoietin. "The patient may give a history of end stage renal disease, renal insufficiency, diabetes, or tell you he or she is on dialysis," she adds.
Consequences of inefficient drug metabolism can include a toxic buildup of the drug, says Wolf. "Adjustments usually include using smaller, less frequent doses of medications," she says.
Consider these drugs for initial intervention
When deciding on an initial intervention for pain management, consider the following about these options, says Lisa Wolf, RN, CEN, former nurse educator for the ED at South Nassau Communities Hospital in Oceanside, NY:
• A nonsteroidal anti-inflammatory drug (NSAID).
An NSAID might make pain manageable until more definitive treatment is available or before moving to opiates, especially if the pain is migraine-like or suspected renal colic. However, Wolf notes that NSAIDs can increase bleeding, "so understand the etiology of your patient's pain."
"If narcotic pain medication is ordered, morphine administered intravenously in doses of 2 to 4 mg is inexpensive and effective," says Wolf. Morphine is now dispensed in "carpu-jets" of 2 mg, 4 mg, and 10 mg per 1 mL, so double-check the dosage as you remove the medication from its dispenser, she notes.
"Morphine can cause significant respiratory depression," warns Wolf. "Patients given frequent or larger doses should be carefully monitored for both respiratory rate and effort, as well as expired carbon dioxide."
Morphine also can cause a "histamine flush," which can be frightening for the patient, and can drop blood pressure, she says. "This common side effect is why it is very important to have baseline vital signs prior to administration," says Wolf. "For example, if the nurse is medicating a patient for pain associated with a myocardial infarction, depending on the location of the cardiac injury the patient can be hypotensive."
"This has distinct advantages for use in the emergency department," says Wolf. The drug's short half-life allows for frequent re-evaluations between doses, and it causes almost no increase in histamine release and minimal drop in blood pressure, she explains.
"Meperidine has been the traditional opioid of choice in biliary tract disease because it causes less sphincter of Oddi spasm," notes Wolf. "However, the incidence of adverse central nervous system effects, including seizures, have led many to caution against its use under any circumstance. It is not often used anymore."
Start with low dose of IV pain meds
When in doubt, begin with a lower dose of intravenous pain medications, says Colleen Claffey, RN-BC, MSN, CEN, CPEN, ED nurse educator at Jackson North Medical Center in North Miami Beach, FL.
"For instance, an emaciated, elderly patient may have an order for 2 mg of morphine. But starting with 1 mg is a good approach," Claffey says. "Remember that you can always give more, but you cannot take away."