Administering pain meds to a sleeping pt

[opossum]

I'm a new nurse and recently received my first "negative" comment on a patient survey.

Pt was a young woman s/p lap appendectomy; she complained that I "must have forgotten" about her pain meds and claimed that I medicated her once at 11pm and that she woke up in severe pain at 6am...saying it was too long to go without pain meds. According to a note I wrote in my documentation, I medicated her twice during my 11pm-7a shift...I didn't go back and consult the MAR, which would definitely have a more accurate record of when I gave the meds.

I can't help but feel bad about all this...I almost feel betrayed in a weird way, since I felt I had a good rapport with her. I remember being concerned about her pain, explaining that the PO meds were "long-acting" and that IV Dilaudid would be for breakthrough pain. I remember checking in on her a couple of times and she was asleep. I had other pts that were less stable, and figured if she's sleeping, she's relatively "OK'.

I *now* realize that just because a pt is sleeping, that does not mean they are not experiencing pain. I can't remember what the orders were, but I'm guessing the PO was q4 hrs...and if what she says is correct, that I medicated her at 11pm (actually unlikely, given that my shift starts at 11pm and by the time I finish taking report and looking over charts, I don't start rounding until closer to midnight), then I probably could have given her another PO around 4am, which I must have missed.

But would you wake a sleeping pt to give them a PO pain med? I guess that's my big question here...I feel a little weird giving any pain med to a sleeping pt (unless they are on a vent, sedated, etc.) - not because I think they are pain-free while asleep, but because I don't want to disturb their much-needed sleep and jostle them awake just so they can focus on their pain again - does that make sense? Or am I talking crazy here...

Any thoughts/advice on this is appreciated...

[linearthinker, DNP, RN]

It's never appropriate? Any particular rationale behind that?

The OP asked:

"But would you wake a sleeping pt to give them a PO pain med?" She didn't ask is it ever apppropriate, she asked would you. I stand by my response. I have no idea what has transpired since the OP.

[carolmaccas66, BSN, RN]

As Flo says, in many units I've worked in, u must wake people up.

The doctors who perform the ops also annoy me, cos they tell people 'you will have pain relief and will have NO pain', which is inaccurate. They should be saying we will control your pain the best we can, so that you are comfortable'. Some patients don't respond well to any pain meds, pumps or whatever.

I wouldn't wake them for a prn med either. I would wait for them to ring the call bell. If they couldn't (dementia or whatever), I would give all meds as charted.

If meds aren't prn, they get woken whether they like it or not and get given them medication.

Patients will always find something to complain about, especially when they have pain. She is just blaming u for having pain. Why didn't she ring her call bell for something - did u ask her - or couldn't she be bothered.

We are not mind readers, and generally, if people are sleeping comfortably, I do not wake them for prn meds.

Just say something like: My crystal ball wasn't working that night!

I reckon u did the right thing - she is just whingeing and whining (as usual with these types of patients), & just wants someone to blame.

[Mgrn123]

Happens to the best of us. Chart chart and chart. In this situation check her Bp pulse etc.... Tell her u do it at night while she is awake so u don't scare her. Check her hx of meds administered if she has been there a while and based on that judge if she needs pain meds. low Bp hr etc don't do it abnormal hr Bp etc she may be in pain. Hope this helps!

[LouisVRN, RN]

I will ask the patient on my first round, if they are taking pain medication, if they want me to wake them up for it. If they say yes, I wake them up every time they are due for it, if they say no, I tell them to call me if they want anything. I document their response.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Once had the opposite problem. Patient only had IM Demerol ordered and was terribly afraid of needles. This pt had run himself over with his skimobile (never would tell me how he did that) and had multiple rib fractures. I went to check on him during the night. Couldn't see him breathing, so I turned on the room lights. His respirations were so shallow to avoid pain he had circumoral cyanosis. I put him on 2 LPM via nasal canula, then gave him the Demerol ventrogluteal (often works well with ortho patients) anyway. An hour later his call bell came on and he thanked me for giving him the Demerol (phew! what a relief).

[NurseKatie08, MSN]

For me it depends on the patient...diagnosis plays a role as well. I work in a geriatric rehab, so often once my patients start working in depth with therapy, they are really hurting (especially the orthos). Often I notice I have to encourage my patients to utilize their PRNs (many of them don't want to be a bother, then there are the stoic old men as well). I also get to know my patients very well (since I have them for weeks at a time) so I can often predict when so-and-so will want some tylenol, etc. Every patient is different. As an example I have one patient --we'll call her A (post op hip hemiarthoplasty) who received a total on 30mg PO Oxycodone during my shift to control her pain, but have a patient (we'll call her B) in her mid-nineties s/p fall at home with multiple compression fxs (most old, one new) who completely denied pain throughout and wanted nothing more than her scheduled Lidoderm patch which she said helped just fine. You'd better believe if I was working 11-7 I'd be waking up patient A. Would round on B, but definitely wouldn't wake her up unless something seemed amiss.

ETA: Then again, IV pain meds don't come in to the mix in my setting as we only give PO, topical or IM (rarely) narcotics. Only time I've administered meds to a sleeping patient is SL Roxanol to hospice patients, which is a totally different ball of wax.

[RLeeRN]

Yeah, sometimes it sounds like we get bonus points for every PRN med we don't give. With that in mind, we surely wouldn't want to bring the subject up. And if a call bell goes off and someone actually asks for one, dang! there go those points.

It'd be funny if there weren't nurses who actually function like this. I know, because I've had some of them. And so have family members.

We ARE supposed to bring up the subject and assess, with the patient, whether additional meds are needed or not. That's a big part of our job!

You nailed it! Assess don't assume.........PRN Meds are there for a tool to use to help the patient, not to play keep away.

[Aurora77]

I ask my pt what they would prefer when I do their assessment. Some patients want to be woken up when it's time for PRN pain meds, others want to ask for them. It seems to work out for me. Or, at least I haven't gotten any negatives about pain control yet.

[OCNRN63, RN]

Happens to the best of us. Chart chart and chart. In this situation check her Bp pulse etc.... Tell her u do it at night while she is awake so u don't scare her. Check her hx of meds administered if she has been there a while and based on that judge if she needs pain meds. low Bp hr etc don't do it abnormal hr Bp etc she may be in pain. Hope this helps!

Vital signs are an inappropriate gauge for whether or not to medicate for pain. This is basic information that you can find in most pain management educational materials.

[xtxrn, ASN, RN]

Vital signs are an inappropriate gauge for whether or not to medicate for pain. This is basic information that you can find in most pain management educational materials.

Very true, and if the pain becomes out of control, they can have vasovagal reactions, and drop their BP significantly-- then you've got someone in horrendous pain, who isn't safe to medicate because of waiting too long. It's the overall assessment- the whole person, diagnosis, history- chronic vs acute pain (chronic pain patients take a lot more because they're used to a higher 'start point' for pain)....and what the patient says is pain- not what is assumed. :)

http://heartdisease.about.com/cs/arrhythmias/a/Syncope2_2.htm

http://www.medicinenet.com/fainting/page4.htm

[Esme12, ASN, BSN, RN]

I am big with education. My surgical patients are usually observation and would be dc'd the next day. I make sure they are aware that I will not wake them but if they want pain med to ask since they are not scheduled. Also I try hard to stick with PO overnight before they go home with the usual, "you can't go home on IV meds" When I check on pt's, usually if they are hurting they stir enough to be able to let me know they want pain meds or I ask if I notice they are not fully asleep.

If the pt is admitted for an extensive time then my approach would be a little different and more proactive. But I still will not wake a pt and will educate them in advance so there is no confusion.

We do not get ortho pt's.

I see what you are saying. My only issue with this is that those observation patients are in overnight and they are denied the pain relief available/ordered because ....they "can't go home on IV meds".......but if the Doc felt they could go home on PO meds.....they would have gone home, wouldn't they? Instead the Doc felt there was a need to spend the overnight for pain control and observation.

It's tough to know for sure but I agree if they are sleeping.......I don't wake them unless pre-decided I would.:)

[LPNnowRN]

I agree with nerdtonurse? about dosing CA patients--I have had a patient with bone cancer with a pump programmed for base rate and up to four additional doses MS per hour. Patient NOT in control of pump, nurses were, and if he was sleeping you bet I pushed the button to keep his pain under control. Never saw a human being in so much pain--very sad.