new nightshift nurse

  1. Hello.. i am a new rn to a med/surg floor. I am orienting to my
    new shift 7p-7a. I have a situation that i would like some advice for. I had a pt who was receiving demerol q6 with placebo inbetween. She received the placebo at 0130. The rest of the night when I checked on her, she was resting or sleeping. the next day she told the day shift that she hadnt received any pain medication all night and she was in agony. The charge nurse the next nite questioned why I hadnt given her anything since 0130. She never called for any pain med at all. so my question is do
    we wake pt up q3-4 hours for their prn pain med or do you wait til it is requested.
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  2. 8 Comments

  3. by   Helori
    I usually ask the patient when I am settling them at hs "Do you want me to wake you through the night for pain meds or will you call me if you are awake and need it?". Also, it always helps to document in your charting that the pt slept comfortably through the night.

    Question though, why was she getting a placebo along with her prn's?
  4. by   finallyRN
    I usually inform patients of how often they can get thier pain meds. I tell them they can call me after that time for more but that I will not bring it if they do not ask for it. I also agree make sure it is documented that they were sleeping through the night. If someone can sleep throught the night their pain can not be that bad.
  5. by   Ted
    I guess I'm having a little problem with the "placebo" thing. Can such an order exist? Is it even ethical for an doctor to order a "placebo"?

    With regards to pain management during the night shift, I also tell the patient the frequency the prn pain meds can be given. I also make a point on how important it is to tell the nurse when the pain is above the certain number (0 to 5) and to ask for the pain medication no matter what time of night or day they may experience pain.

    Many patients seem to be more than reluctant to tell the nurse that they are in pain. They are afraid of addiction or of being over medicated; they don't want to bother the nurse. . . . or they just sometimes believe that experiencing pain is normal and "should" be tolerated. Somepeople even believe that experiencing pain is their "lot in life" . . . and they're sometimes the hardest to teach about effective pain management.

    Well, pain may be normal after an operation or when experiencing metastatic bone cancer, but it doesn't have to be tolerated. My experience with effective pain management is that patients generally have a more positive outlook towards their situation and can do more things to help prevent complications (cough and deep-breathing breathing exercises, ambulating, etc. . .) Pain management education is the key, of course!


    Interestingly, people can sleep through their pain as well. . . although usually fitfully. It's a shame because with effective pain management, they may experience a needed good night's sleep.

    I've learned my lessons through working with dozens of cancer patients. I guess I'm rather agressive with pain management. I will advocate for PCA's. Did so last night when one of my ICU/CCU patients (who is a DNR/DNI) was receiving MSO4 q 1/2 to 1 hour with minimal results. The doctor actually took my advice and ordered a PCA!!!!! Here's the clincher, though. . . the f***ing hospital didn't have any spare PCA pumps to spare!!! ARGHHHH!

    Oh well. . . I just gave the MSO4 all night long as stated above. . . and it seemed to help him sleep. . . at times.

    Ted
  6. by   pebbles
    I discuss it with the pt while they are awake. I ask them "What would you like me to do for your pain overnight? Would you like me to wake you up and ask you if you want a painkiller? Or would you rather I wait and you can just ask me for it when you are ready for painkiller?" I use this as an opportunity to teach about pain control strategy, to find out what people's needs are, what their understanding is of the meds and pain control issues. I also like to ask these questions while the family is still there, because they can help me obtain information from the pt about the real level of her pain, and it reassures them that yes, I will be making sure the pt is not in pain overnight... families worry a lot about neglect and pain control is very important.

    Everybody is different. Personally I would rather be bugging someone a bit too much than have a pt lie there in pain. If I know that somebody has had a lot of pain in the past few days, or if they just had surgery or something that would LIKELY cause them to have bad pain, I would err on the side of caution and wake them up anyway. It is not a hotel -people are there to get good symptom management and care, not to sleep undisturbed. Why should I feel apologetic to wake someone up if waking them up is part of giving them better pain management.

    I do have a big issue with the placebo thing. This is unethical ,and in most places ILLEGAL unless the pt is knowingly part of a controlled drug study. Do you chart that the pt was getting a placebo, or does it get signed off on the regular demerol sheet? This is lying to the pt and it is very very wrong. It violates informed consent laws, it destroys pt/caregiver trust and it does not do the pt any good in the long term. Why would you give a placebo, why not use other techniques to deal with the pt's pain and other needs? I would suggest that all the caregivers on your unit need to address the issue of placebos and honesty in care provision, more than you need to worry about whether to wake someone up at night.

    Also, if this pt has chronic pain -it could well be that she slept all night but was still uncomfortable... keep in mind the adaptation that occurs with cronic pain.
    Last edit by pebbles on Sep 25, '02
  7. by   Rustyhammer
    If the patient says they are in pain then who are we to doubt this pain. People exhibit their pain differently and have different thresholds.
    Placebo pain meds?
    I don't like the sound of that at all.
    -Russell
  8. by   shygirl
    You know when I was in nursing school, they always taught us "If a patient says they are in pain-then they are in pain".

    We have several patients that say they are in pain, request a prn and then are asleep by the time we go back in the room to give it to them. Do I wake them up? Sometimes I do if I know the etiology. Sometimes I don't wake them if they have shown to be a narc seeking person. I always go check the ones I didn't wake to see if they are still asleep or if they still need it. I work with a lot of dementia persons also who don't remember asking, but they know how to say vicodin or ultram!
    Shygirl
  9. by   MollyMo
    With your initial assessment, discuss the plan of care with the patient. Nothing fancy. Just tell them what meds they have coming, when vitals will be taken. Ask when was the last time they had pain meds and did it work. Let them know that it is available and to ask for it. If you don't want to wake them for a prn med, tell them that so they will know to ask. DOCUMENT,DOCUMENT,DOCUMENT! If they're resting quietly or if you hear snoring respirations or whatever chart it. No longer think that they are asleep. We don't know that. No longer think that if they're asleep they can't be in pain. Sleep is a good way to dodge pain for a while but a poor indicator of whether or not pain exists.
  10. by   nursenet
    thank you all for your replies it helps me greatly. i too was taught that pain is pain. since im still on orientation i did ? giving the
    placebo, i was very uncomfortable with it. i was kinda given the
    runaround as too why we were doing it, but didnt want to make any waves. i learned a new lesson.

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