Administering pain meds to a sleeping pt

Nurses General Nursing

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Specializes in ICU/CCU, Med Surg.

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...

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Specializes in Medical/surgical, ICU.

Personally, I don't like to go in and wake a patient up just to give them prn pain medication.

If something is scheduled for an odd time (say MS Contin or some type of extended release pain medication), I will of course go in and wake them to give them those type of meds.

I find a lot of patients with PCA pumps also have that train of thought..."I fall asleep and wake up in terrible pain, so can you push this for me while I sleep"...or visitors pressing the button while the patient sleeps. With appropriate education, these pt's and their families do seem to come around.

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Specializes in Developmental Disabilites,.

Yes, I have waken sleeping pts to asses their pain. I work ortho so if the pain gets out of control it is very difficult to get back under control. If the pt has been taking 4mg dilaudid po q 3 hrs for the past 2 days, you bet I'm waking them up. I also have a conversation with the pt at the start of the shift in which I ask them do they want me to wake them up. Some people would rather sleep.

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Specializes in Infection prevention and control.

Was it scheduled or PRN?? A patient with a scheduled pain med should be woken up to administer, but if it is a PRN pain med and you assessed her as being comfortable, i.e. sleeping :lol2:, then I would say you did your best. True, just because a patient is sleeping doesn't mean they are NOT in pain. In short, for a PRN pain med NO I would not wake a sleeping patient. For a SCHEDULED pain med, I would.

Don't worry about feeling betrayed...it comes with the job. Don't feel bad about it, nursing judgment takes time to develop. You are a new nurse so you have to give yourself room for error, not that I think this was an error in any way. You have to be able to prioritize and balance your patient load, which also takes time to develop!! Keep your head up opossum!!

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Specializes in ICU/CCU, Med Surg.

Flo, I really like that idea of asking the pt beforehand if it's OK to wake them up.

Also, I just found my report sheet for that night - looks like I gave Dilaudid at 0215 and Vicodin at 0400. So I was doing everything right with the PO PRN meds and probably could have given her more Dilaudid (don't know if it was q1 or q2). But again, I'd feel weird medicating a sleeping pt for breakthrough pain...

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Specializes in ICU, Telemetry.

I don't wake surgical patients up to medicate them for breakthru pain; a big problem a lot of people have is that they think they should experience NO discomfort whatsoever. I had a TAH/BSO, and the first thing I wanted was the pain pump gone and the foley out once I could stand up on my own two feet. I knew enough to know that a) this is gonna hurt, and it's gonna hurt for a while, and b) the last thing I need to do is keep myself so narc'd up I couldn't walk or stay so stoned I killed off my GI motility and then have a nice bowel obstruction thrown into the mix. They actually came and checked the pump because I only used 8cc of dilaudid the entire time (I got the pump yanked the morning after surgery) and took 1 PO pill for the drive home -- after that, it was NSAIDs. I don't like pain, but pain won't kill you. Pneumonia, GI obstructions, PEs, DVTs, and other things associated with someone laying there in a stupor will kill you. My doc told me I had one of the fastest recoveries he'd ever seen, and it's because I made myself move despite pain, not because of all the pain medicine I took.

Having said that, if I've got a terminal CA patient, you bet I dose them around the clock -- you don't want the pain to get on top of them, you want them on top of the pain.

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Specializes in Infection prevention and control.
Also, I just found my report sheet for that night - looks like I gave Dilaudid at 0215 and Vicodin at 0400. So I was doing everything right with the PO PRN meds and probably could have given her more Dilaudid (don't know if it was q1 or q2). But again, I'd feel weird medicating a sleeping pt for breakthrough pain...

See!! I feel weird too, but like nerdtonurse was saying, you really have to take it on a patient by patient basis.

If you haven't already learned this, DOCUMENT DOCUMENT DOCUMENT!!!! Sometimes patients get these crazy ideas in their head and as long as you have the documentation to back yourself up, you are good!! I learned the CYA lesson the very hard way!!!

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Specializes in Family Nurse Practitioner.

I always explain the difference between scheduled and PRN. I also will not wake someone up for pain medicine. If you can sleep you are not in agony....People tend to believe that we will just show up every 4 hrs or whatever without understanding if it is prn they have to ask:twocents:

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Specializes in ICU/CCU, Med Surg.
I don't wake surgical patients up to medicate them for breakthru pain; a big problem a lot of people have is that they think they should experience NO discomfort whatsoever. I had a TAH/BSO, and the first thing I wanted was the pain pump gone and the foley out once I could stand up on my own two feet. I knew enough to know that a) this is gonna hurt, and it's gonna hurt for a while, and b) the last thing I need to do is keep myself so narc'd up I couldn't walk or stay so stoned I killed off my GI motility and then have a nice bowel obstruction thrown into the mix. They actually came and checked the pump because I only used 8cc of dilaudid the entire time (I got the pump yanked the morning after surgery) and took 1 PO pill for the drive home -- after that, it was NSAIDs. I don't like pain, but pain won't kill you. Pneumonia, GI obstructions, PEs, DVTs, and other things associated with someone laying there in a stupor will kill you. My doc told me I had one of the fastest recoveries he'd ever seen, and it's because I made myself move despite pain, not because of all the pain medicine I took.

Having said that, if I've got a terminal CA patient, you bet I dose them around the clock -- you don't want the pain to get on top of them, you want them on top of the pain.

Absolutely - if they're terminal or on a vent, I would definitely keep those pain meds going...but this girl was young, athletic, and just had an appendectomy. She even walked herself around the unit; I praised her and encouraged her to do that, as that would make a more rapid recovery. Whenever a pt c/o pain, I do at least think to myself 'When did they last get pain meds? What can I give them to help keep it manageable?' So I'm assuming I did all that with her and then to get this stupid survey brought to my attention that implies I "must have forgotten" about her pain meds?? I'm appalled!

NoAverageLPN - these are all PRN I'm talking about. I would definitely wake them up for scheduled pain meds :)

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Specializes in Oncology; medical specialty website.

I would, so they don't wake up in out of control pain. Then you have to play "catch up" trying to get them comfortable again.

Sleep is an escape mechanism from pain. It does not equal "comfort."

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Specializes in Oncology; medical specialty website.
I don't wake surgical patients up to medicate them for breakthru pain; a big problem a lot of people have is that they think they should experience NO discomfort whatsoever. I had a TAH/BSO, and the first thing I wanted was the pain pump gone and the foley out once I could stand up on my own two feet. I knew enough to know that a) this is gonna hurt, and it's gonna hurt for a while, and b) the last thing I need to do is keep myself so narc'd up I couldn't walk or stay so stoned I killed off my GI motility and then have a nice bowel obstruction thrown into the mix. They actually came and checked the pump because I only used 8cc of dilaudid the entire time (I got the pump yanked the morning after surgery) and took 1 PO pill for the drive home -- after that, it was NSAIDs. I don't like pain, but pain won't kill you. Pneumonia, GI obstructions, PEs, DVTs, and other things associated with someone laying there in a stupor will kill you. My doc told me I had one of the fastest recoveries he'd ever seen, and it's because I made myself move despite pain, not because of all the pain medicine I took.

Having said that, if I've got a terminal CA patient, you bet I dose them around the clock -- you don't want the pain to get on top of them, you want them on top of the pain.

Pain can kill you. If your pt is in pain and isn't moving because of the discomfort, he can get a DVT, pneumonia, etc. Not everyone is going to just "suck it up" and move. Inadequate pain control impairs the healing process.

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I agree with Flo and ONCRN63.....w/Flo.- look at the day or so previous to your shift, and talk to the patient when you do your first assessment. With both, I agree that pain is better dealt with in a proactive manner- catching up is horrible, and in the process limits the patients ability to do what he/she needs to do to increase mobility.

http://www.worldwidewounds.com/2001/march/Pediani/Pain-relief-surgical-wounds.html

http://my.clevelandclinic.org/services/Pain_Management/hic_Pain_Control_after_Surgery.aspx

Also, scheduled pain meds are reason to awaken.

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