Please Help my narcotic situation

Ok so I had a scare tonight when administering a new narctotic order. HX. Resiedent has broken femur and pre existing MS. Sent to Er where we are told in the ltc facilty that they will no be treating the fracture. Pain is 10/10 at all times since readmission. Nurse practioner calls doctor on my behalf to increase medications. Currently the resident in on 20 mg oxycontin BID with dilaudid 1mg 1 to 2 tabs q 4 hr for breakthrough pain. The NP nad doc decide that they should streamline the meds and switch the oxycontin to hydromorph contin 9mg with the dilaudid (being the same med class). I come in on Evening, resident received the first dose of 9mg in the monrnign and I ask what her pain scale is ( at 10/10) so I give the extended release as ordered and give prn .

Residnet is very snowed and scaring me. O2 sat 90% and resp 12. Doctor comes in and suggests we reduce the meds tomorrow and monitor. Rn charge nurse comes up and assessed the resident as not needing narcan though she is mostly unreponsive. I monitor the remainder of my shift with no change.

I left feeling a bit uncomfortable with the situation....but I followed orders and wanted to only help her. What would you have done
Narcan rescue is not without its risk. At my work we give it based on resp status not on LOC. So if RR >8 and o2 sat >88 then no narcan. Just let them sleep it off. I would apply O2, cont pulse ox and monitor frequently.

I would need a little more Hx but with 10/10 pain, RR 12 and SpO2 @90% doesn't really sound that bad. I would like to hear what others have to say. This sounds like a difficult situation for you and the pt. I'm so sorry

My setting is hospice so I am coming from probably a different mindset but here goes. I would give the pain meds as ordered. She has an unrepaired fractured femur and is uncontrolled pain. Every time she is turned for repositioning or peri care she is in pain whether she is awake or not. If the MD wants to back off the Dilaudid is up to him of course and may be wise if she is previously opiate naive. I would request a non-narcotic pain med as an adjunct such as Trilisate which is very effective for bone pain.

Yeah. Would love to see some Toradol for this... we used it post op for hip ORIF, and many of the patients never wanted PRN meds.

mmm...I will question orders from now on...I was so scared tonight

Toradol is nice, but not for long term. And if they aren't fixing the fracture, this is going to be long term. I'm thinking something muscle relaxing to stop the quads from spasming around that fracture.Why are they not fixing the fracture? That's just inhumane.I wouldn't narcan, and I wouldn't worry about the respiratory depression. My RR right now is 12 and I'm WIDE awake. And 90% while asleep? That's fine too.

The argument is that she is non ambulatory before #. However she had an electric scooter that kept her a little independent. We are taking all independece away and its likely she wont get in her chair anytime soon with no tx. So you its inhumane in my opinion.

Why are they not fixing the fx? He would feel much better after the surgery. I think it would help if they went back to the Oxycontin and upped that dose. We usually try to get coverage from several types of narcs. If dilaudid is not working for him why not try norco or percocet? People react differently to pain meds its all about finding the right combo for him. I totally agree with wooh, get some muscle relaxants and that should help big time.

Quote from woohToradol is nice, but not for long term. And if they aren't fixing the fracture, this is going to be long term. I'm thinking something muscle relaxing to stop the quads from spasming around that fracture.Why are they not fixing the fracture? That's just inhumane.I wouldn't narcan, and I wouldn't worry about the respiratory depression. My RR right now is 12 and I'm WIDE awake. And 90% while asleep? That's fine too.

Resps of 12 are fine. Let her sleep. And Narcan not only reverses narcotics, it also shuts down the body's natural endorphins and she will awaken in incredible pain.Is the resident now at least comfort care?

Quote from AngelofLTCThe argument is that she is non ambulatory before #. However she had an electric scooter that kept her a little independent. We are taking all independece away and its likely she wont get in her chair anytime soon with no tx. So you its inhumane in my opinion.

With the MS, I was guessing it was the non-ambulatory rather than 100 years old and too risky for surgery. I have a family member that's non-ambulatory. Didn't mean her femur fracture didn't require surgery (and had to fight to get it for her too, ergh!) As said above, that's the only real fix for the pain. And if she's 10/10, she needs the fix, poor thing. (Like said above, not aimed at OP, aimed at whoever thought she didn't need the surgery. I'm sure I'm preaching to the choir with that one.)Whatever you do, avoid the narcan. I remember a cancer patient that was full code except for narcan. He wanted everything done, EXCEPT narcan. He'd gotten that once (after a tech had been pushing his PCA button while he was sleeping) and NEVER wanted it again. Full code, but if it was narcan or die? He'd take death.If I had a femur fracture, you'd have to give me some sort of cocktail that included a clonidine patch, a fentanyl patch, some darvocet stolen from an old person's cabinet since it's no longer available, a dilaudid PCA and probably an epidural PCA to go along with it, and of course the muscle relaxants. And I almost forgot, traction to keep it stretched out. Of course, then I'd go crazy being stuck in the bed all day, so you'd have to add some anti-psychotics to the list.I'm a wuss. I ever fracture something, EMS should just wheel me straight on into surgery.