Medication Management
Is there anything we can give the patient for sleep?
Go-tos: MELATONIN!, atarax or benadryl (careful in elderly patients, trazodone, low dose seroquel or zyprexa
- Generally avoid benzodiazepines unless indicated for another problem (ie alcohol withdrawal)
Patient is sustaining bradycardia to 40s
1. Review vital signs trends, assess for underlying causes, review old ECGs (if available). Obtain a repeat ECG
3. See patient and assess symptoms
4. If asymptomatic, only HR monitoring is needed
5. Symptomatic --> ACLS bradycardia algorithm
Patient has some pain in his knee after coming up from the OR for a knee surgery
Post-op pain - multimodal approach but typically will involve opioids for severe pain
Patient wants to leave AMA
- Go see patient to assess capacity and sign AMA paperwork
Patient's blood glucose is 40.
2. Assess symptoms, vital signs, recent insulin administration to determine underlying cause
3. Repeat POC glucose in 1 hour, if still trending low consider D5 or D10 gtt
Patient's bedtime blood glucose is 96, should I hold their Lantus?
Depends, but typically the answer is NO and dose-reduce instead.
- For a T1DM patient: NEVER hold the lantus (even if the patient is NPO), consider dose reduction
Patient is hypertensive 180/105
1. Review vital sign trends
2. Assess for underlying causes (holding home meds?, acute pain, withdrawal, etc.)
3. Assess symptoms
4. If no symptoms > monitor, no need to treat! (with some important exceptions, ex: ICH, recent major surgery (bleeding risk), aortic dissection, etc.
Patient has a headache
1. New headache? Hx of headaches?
2. See patient, assess symptoms, VS trends (hypertensive, tachy?), GOOD neuro exam
3. If benign exam and features of headache, migraine cocktail, NSAIDs are good options
Patient has nausea and itching after starting IV cefepime infusion
- Hold infusion
- Go see patient and assess symptoms and VS
- Consider calling Pharmacy to see if it can be run at slower rate OR pre-medicate
- If concern for severe reaction, alert Pharmacy, add to allergy list, consider steroids or benadryl (epi for anaphylaxis!)
Patient fell while walking to the bathroom.
2. On blood thinners? they may need imaging
3. Document in a note, discuss why this happened with nursing (do they need sitter?, fall alarm off? etc)
Patient's blood pressure is 93/55, am I ok to give the IV lasix?
Depends, but typically the answer is YES.
- Lasix typically will only cause symptomatic hypotension if the patient is or becomes hypovolemic from diuresis.
Patient is febrile to 101.1 F
1. Assess fever curve, vital sign trends, recent labs (WBC, prior infectious work-up), reason for hospitalization (ie are they here for bacteremia, or neutropenic fever etc.)
2. Give Tylenol!
3. Repeat basic infectious work-up usually CXR, UA, CBC w/ diff, BCX, and consider ABX
Patient is reporting 10/10 back pain which is a chronic problem for them
Optimize multimodal pain regimen, try muscle relaxers, lidocaine patches, diclofenac gel, NSAIDs (if safe to do so)
- Provide education to patient (and nursing) that chronic pain is often not an indication for IV or PO opioid pain meds
Patient is agitated and ran out of the unit.
2. Involve security, nursing supervisor and charge RN
3. Sometimes requires involvement of Cincy PD (esp if patient was on a med hold)
Patient is very sleepy, not really waking up...
1. The scariest page!!!! Go see immediately and usually call Rapid.
2. STAT vitals, neuro exam... GSC <8 = intubate!
3. Labs including VBG, RFP, CBC, lactate etc. imaging
4. Consider MEDS as etiology -- always pretty safe to give a dose of IV narcan
Patient is going down to the OR for surgery in 30 minutes, am I ok to give morning meds?
- Ask WHICH meds! Typical meds that are held prior to the OR are: ACE/ARBs/ARNIs, diuretics, ASA, plavix, DOAC, therapeutic AC, scheduled mealtime insulin (NPO), etc.
- Always give beta-blockers and statins if the patient is already on them prior to the OR (mortality benefit!)
Patient is hypoxic 86%, needing 2L O2 nasal cannula to return to 95% O2 saturation.
2. See patient and assess symptoms.
3. Consider CXR, bronchodilators, diuretics depending on pathology. Typically don't need a VBG unless they are also more confused/lethargic but an ABG can be helpful to see if they are 'truly' hypoxic.
Patient here for cancer related pain is reporting breakthrough pain after getting his scheduled PO oxycodone.
Multiple ways to address this
- Consider giving next PO dose early or spot dosing IV or PO
- Add multimodal meds if not already on board
Patient had three large volume bouts of melena, with blood pressure of 90/60.
1. See patient ASAP, assess symptoms, repeat VS
2. STAT type and screen, 2 large bore IVFs
3. Start IVFs if waiting for blood products. Don't delay ordering blood to be prepared waiting for a CBC... if you see blood, they're losing blood!
4. Consider STAT CT A/P w/ contrast (GIB protocol) and call IR (often more important than GI in these acute settings)
Patient is too sleepy and I don't feel comfortable giving oral medications. Can I hold them?
1. Figure out why the patient is so sleepy! Look for organic causes (VBG, CTH, etc)
2. Consider obtaining enteral access (NGT placement)
3. Switch meds to IV as able. Call pharmacy for help!
Patient is tachycardic to 107
1. Assess VS trends
2. ECG
3. Treat underlying cause: consider fluid bolus, holding any meds? (beta blockers), pain?, withdrawal?
Patient is reporting 10/10 abdominal pain, your sign out says... "patient is being treated for SBO, ACS following, call with any abdominal pain"
Go see the patient!! Don't call the surgeons without a good abdominal exam.
- Labs can be useful, check CBC (bleeding?), renal (acute renal failure?), LFTs, lipase (biliary pathology), lactate (bowel ischemia)
- Consider STAT abdominal imaging with any concerns for perforation or ischemic bowel
Elderly patient is confused and starting to hallucinate.
Likely delirium, determine underlying cause
-Pain? Bowel/Bladder concerns? Recent medication administration? Withdrawal?
- Lost hearing aids or glasses? Sleep-wake cycles altered?
- Metabolic/Toxic or structural cause? Do a good Neuro exam
Patient is tachycardic to 170
1. Assess symptoms, go see patient ASAP, check other vital signs
2. ECG, hook up patient to Zoll.. what's the rhythm?
3. ACLS tachycardia algorithm