[breastfeedingRN]

we have one doc that at 24 hours writes new orders that differ from the standard c-section orders that would come into effect at that time since the epidural orders end at 24 hours. all the other docs use the standard orders which allows 400-800 mg of ibuprofen q 6-8 hours prn and 1-2 percocet or 1-2 tylenol/codeine q 3-4 hours prn.

this doc though writes for motrin 600 q 6 hours prn and percocet 1 q 4-6 hours prn. luckily the doc doesn't have too many that deliver there that i have run into, but the ones that i have had aren't doing to well in the pain management area, especially that first 24 hours after the epidural pain orders are off.

i had one the last night i worked that got to a point where she was really in pain and it was a little less than an hour till the percocet could be given again. she had had motrin and 1 percocet at 2030 and it was like 2345. she was rating her pain at a 9 and was trying hard not to cry. her hubby was even surprised at her pain level. she was about 36 hours post section. our standard orders call for morphine 2-10mg IV for pain management, so i gave her 2 mg thinking if i could at least get her pain down then the ordered doses would maybe keep her under control if we got her back to a happy place first. her pain was incisional and cramping from breastfeeding, she said it wasn't gas pain.

the morphine worked, then i gave her the percocet q 4 the rest of the night and the motrin q6. at 0715, she was in a lot of pain again, had been up walking and breastfeeding all night, pain was 8-9 and she wasn't due for anything again until 0830. i asked the charge if i should give her morphine again or not and she said that it was too far out for that. that day shift could ask doctor to change med doses.

i had already told the patient that they should talk to the doc in the am about getting her orders for more frequent pain medication or different doses since it wasn't working. the husband was going to talk to the doc as soon as she got there because he said his wife normally wouldn't complain about pain and that she was. i also passed it on to the day nurse that she was due at 0830 and that i thought she maybe needed new orders. she agreed.

i put a warm blanket on her abdoment to help with cramps and she was fine with it as doc had been there early the day before and most of our docs are there early during the week.

what else should i have done? i now think i should have woken the doc up for new orders since it was only almost midnight. i think it is ridiculous to write those orders for someone so fresh after a c-section. maybe for going home, but not that soon.

[tntrn]

Our routine P/O c/s pain meds are for Motrin 600 q 6 prn and Percocet 1-2 q 3-4 prn. We can begin to give the PO meds 12 hours after the epidural was administered, and we will start with both the Motrin and the Percocet given together. Then the patient can have something about every 3 hours. Maybe it's a placebo of sorts, but when they know they can have something more often, it works. Rarely do we have anyone who needs more than that after we get the routine started. During the immediate post op recovery period we have some IV meds that can be given but after 2 hours post op, if the Duramorph isn't kicking in, we call the anesthesiologist and usually we'll get an order for IM Demerol. And I might add, we call regardless of the time of day. Waiting for Day Shift to call is babying your docs.

Our 0700 and 1200 section patients are usually, at the very least, up at the bedside by 1700 and most of them will already have ambulated to the bathroom for peri care or to the sink to wash face and hands.

[Jolie]

I agree that this doc's orders sound a little skimpy, but why would you not call immediately for a patient who is having pain rated at 8-9-10?

Whether it is 11:45pm or 7:15am, your patient deserves better than, "The next shift will see what they can do to get your pain meds changed." Your duty is to provide appropriate care (including sufficient pain relief) to your patient, not to worry about interrupting the doc's sleep.

Also, in the doc's defense, if he doesn't hear from you that the order is insufficient, how is he to know that his patient needs more pain meds?

Don't be afraid to advocate for your patients!

[breastfeedingRN]

I totally agree that my job is to advocate for my patient's. Being a new nurse I sometimes am not sure of what I am supposed to do, etc. I probably should have called at midnight, but I really thought that if I got her over the hump with the Morphine, that maybe the pain meds that were ordered would be sufficient. She had just been up walking, was breastfeeding and cramping and I thought maybe it had all just hit her and getting it down would help her.

I don't want to baby any doc, I know that the nurses at our hospital do tend to do that though. I have called docs for orders late before, but since she had an order for something IV, I gave that.

I learn from all my mistakes and next time I will stay late and call the doc myself to get a new order because I felt bad knowing the patient needed medication and it would have to wait till at least 0830 for medication.

[Spidey's mom]

We have the Motrin 600 mg, Tyl #3, Vicodin, and the CRNA has orders for morphine 2-4mg q30min . . .

I work in a small rural hospital so I can always wake up the ER doc . ..

steph

[dansamy]

OMG! That's barbaric. Thank god my doctor gave me a PCA for post-delivery.

[dcampbell]

Just wondering....As an inactive RN for 13 yrs., why aren't PCA's used anymore for fresh post-op c/s's? I remember "back in the day" how effective the PCA's seemed. The pts seemed happy and comfortable and best of all "low maintenance" as far as pain went. With the exception of the situation we are discussing, are pts on this new drug protocol happier, or have better pain control, or are more ambulatory....what? Thanks.

[Spidey's mom]

Originally Posted by dcampbell

Just wondering....As an inactive RN for 13 yrs., why aren't PCA's used anymore for fresh post-op c/s's? I remember "back in the day" how effective the PCA's seemed. The pts seemed happy and comfortable and best of all "low maintenance" as far as pain went. With the exception of the situation we are discussing, are pts on this new drug protocol happier, or have better pain control, or are more ambulatory....what? Thanks.

It probably depends on where . . . . . I had my last child 6 years ago by cesarean and had a PCA. It was great.

We never do PCA's at the rural hospital where I work though.

steph