Order that says "Don't call MD for pain meds"? Order that says "Don't call MD for pain meds"? - pg.3 | allnurses

Order that says "Don't call MD for pain meds"? - page 3

Hello! I recently took care of a pt with a foot fracture and he only had Tylenol for pain. I don't have any experience yet but I feel that this does nothing for pain of a foot fracture. And the... Read More

  1. Visit  Kooky Korky profile page
    #26 1
    Quote from JBudd
    There was an interesting article a year or so ago in the JEN about the efficacy of one gram IV acetaminophen; on the analgesia scale pts reported the same amount of relief as 2 mg of morphine, with placebo way below. Large scale study. My only problem using it in the ER is that you have to infuse it over an hour.

    Long time ago at a pain management seminar, 650 mg of po tylenol was rated as equivalent to 30 mg of po codeine.

    People just don't want it because it is OTC so it must not be "as strong as I need".
    Are we now giving Tylenol instead of MS04 for MI?

    I would really have to question that study. And I wonder how long Tylenol's pain relief endures for someone with severe pain or even just sub-severe. And how long for the onset of action and of noticeable relief? Again, thinking of severe pain - such as MI, bad fractures, bad burns, and the sickle cell I used to see in ER.

    Codeine - so not equivalent to oxycodone, hydrocodone, oxymorphone, the big guns.

    Perhaps if this whole mess we now face hadn't been couched as Big Brother is going to come down on abusers, with the side effect of negatively impacting ordinary people who do not abuse drugs but who happen to have real and serious pain, either chronic or acute, I would have a more positive attitude.

    Maybe if someone had referenced the study and article you cite here, this latest swing of the pendulum would be a less bitter pill to swallow.

    I guess military in war scenarios will have to love that Tylenol instead of their Morphine. So what if their legs were just blown off? After all, we don't want them to get addicted and abuse the stuff. Sorry, couldn't resist.
  2. Visit  Kooky Korky profile page
    #27 1
    Quote from taivin
    This one sounds like the doc knows his patient. I wouldn't call. I would medicate with Tylenol, elevate leg, ice q 20" or heat (depending on how old the injury is), play some music or put on a good movie, re-wrap/reposition, request diphenhydramine/or similar for sleep (might even be in standing orders). Distraction should be used more often. Also, he could imagine his pain is going away with many types of fantasies. You could also request to stack Tylenol with NSAIDS. I've seen this before as well, and they were always poly substance abusers.

    The forward thinking RN, will upon admission (when seeing there is nothing for pain and the situation calls for pain meds) will request pain meds PRN while writing up the orders/receiving orders. Doesn't mean you have to use them. Then, if there are any issues with the doc/patient you will find out then.
    ...it's a just in case.
    Why are you assuming this pt is an abuser? Or that the admitting nurse is somehow to blame? And of course benadryl works for everyone to have a good 8 hour sleep. Music????? You are dreaming! You must be in-home care or LTC, not acute.

    Imagine his pain going? Yes, imagine is exactly the right word. And she will have to call the doctor anyway for stacking orders because the darling doctor didn't order it.

    Sorry to be testy - this topic just rubs me the wrong way.
  3. Visit  Lev <3 profile page
    #28 3
    Quote from JBudd
    There was an interesting article a year or so ago in the JEN about the efficacy of one gram IV acetaminophen; on the analgesia scale pts reported the same amount of relief as 2 mg of morphine, with placebo way below. Large scale study. My only problem using it in the ER is that you have to infuse it over an hour.

    Long time ago at a pain management seminar, 650 mg of po tylenol was rated as equivalent to 30 mg of po codeine.

    People just don't want it because it is OTC so it must not be "as strong as I need".
    We used to give IV tylenol to the post op ortho patients I worked with. The old ladies with the hip replacements who you didn't want to give narcotics to. It worked wonders. Does drop BP slightly though. We ran it over 15 minutes.
  4. Visit  blondy2061h profile page
    #29 6
    Quote from JBudd
    There was an interesting article a year or so ago in the JEN about the efficacy of one gram IV acetaminophen; on the analgesia scale pts reported the same amount of relief as 2 mg of morphine, with placebo way below. Large scale study. My only problem using it in the ER is that you have to infuse it over an hour.

    Long time ago at a pain management seminar, 650 mg of po tylenol was rated as equivalent to 30 mg of po codeine.

    People just don't want it because it is OTC so it must not be "as strong as I need".
    You give IV Tylenol over an hour? We do 15 minutes.
  5. Visit  heron profile page
    Quote from Kooky Korky
    Seems like you are assuming a lot, Heron.

    This patient has a foot fracture.
    The pain needs to be assessed and treated properly.

    And even abusers might be having real pain - the foot is fractured, for crying out loud. Don't know if you have ever had a fracture, but I can tell you from personal experience that there is real pain involved.

    So sick of all the people who don't actually have pain telling people on the front lines how to not treat it. People in their ivory towers, their statistics lab, their newsroom, their legislative halls wish to scare doctors on the front lines, threaten them with "DEA is watching your every move".
    Then it's the nurses who have to deal with the patient for hours.

    I hope everyone who is causing patients to suffer needlessly gets some very painful disease/surgery/trauma and gets only Tylenol for it - for weeks and months on end. And their loved ones should have pain, too, so the idiots making these insane rules can endure the suffering of their loved ones. That's the only thing that will open their eyes to the agonies they force upon others.

    This pain frenzy we are now having is just the latest fad. We go through these every now and again.

    OP - call the doctor, call your supervisor, get the appropriate order. Also, neurovascular checks, elevation of the foot, positioning, distraction must all be done.
    The OP provided no information other than the order in question and the diagnosis ... then asked why such an order would be written. How does one not make assumptions?

    My answer to her reflected my experience working with addicts with end-stage AIDS on an inpatient unit during the nineties. That work required that we treat pain effectively and control addiction behaviors at the same time.

    Other posters, with different experience, posted different possibilities.

    I've been fighting for compassionate and effective pain management since the early 70's. What's striking to me is the fact that these discussions always deteriorate into a big, polarized battle, with one side addressing only addiction and the other addressing only pain. The one thing both sides share is self-righteous outrage.

    Of course, the only thing neither side mentions is caring for an active or recovering addict having pain.

    Where is the OP, btw?
    Last edit by heron on Dec 26, '16
  6. Visit  kbrn2002 profile page
    #31 5
    Agree with heron : "Of course, the only thing neither side mentions is caring for an active or recovering addict having pain."

    An unfortunate side effect of the pain debate is the recovering addict that under no circumstances wants to take a potentially habit forming drug. It's much more complicated managing this patients acute or chronic pain when the pharmacological interventions are so limited.

    It took years of escalating pain from psoriatic arthritis before my father in law finally agreed to try tramadol and tylenol when other measures including surgery became less effective. He's a recovering alcoholic and was averse to trying any med with the potential for abuse. He's in his 70's and has been sober for almost 40 years and is still concerned with failing at his sobriety.
    Last edit by kbrn2002 on Dec 26, '16 : Reason: forgot to add quote
  7. Visit  heron profile page
    #32 5
    Indeed, since the OP offered no context whatsoever, the patient in question may well have requested such an order himself.

    I'm actively addicted to nicotine, so I know I'm vulnerable. I also happen to loooove the way opioids make me feel. When I had to seek tx of a dental abcess at an urgent care, I had to restrain the doc from prescribing 30 Percocet. Since I'm not fond of pain, either, I made him cut it back to less than two day's worth (6 tabs) ... just enough to let the abx really kick in. It was still a struggle to keep from indulging.

    Firm limits on behaviors and demands are a powerful safety net for anyone struggling with addiction or addictive tendencies.
  8. Visit  Stepney profile page
    #33 2
    Quote from Kooky Korky
    Seems like you are assuming a lot, Heron.

    This patient has a foot fracture.
    The pain needs to be assessed and treated properly.

    And even abusers might be having real pain - the foot is fractured, for crying out loud. Don't know if you have ever had a fracture, but I can tell you from personal experience that there is real pain involved.

    So sick of all the people who don't actually have pain telling people on the front lines how to not treat it. People in their ivory towers, their statistics lab, their newsroom, their legislative halls wish to scare doctors on the front lines, threaten them with "DEA is watching your every move".
    Then it's the nurses who have to deal with the patient for hours.

    I hope everyone who is causing patients to suffer needlessly gets some very painful disease/surgery/trauma and gets only Tylenol for it - for weeks and months on end. And their loved ones should have pain, too, so the idiots making these insane rules can endure the suffering of their loved ones. That's the only thing that will open their eyes to the agonies they force upon others.

    This pain frenzy we are now having is just the latest fad. We go through these every now and again.

    OP - call the doctor, call your supervisor, get the appropriate order. Also, neurovascular checks, elevation of the foot, positioning, distraction must all be done.
    Thank you for saying so eloquently what I could not say, as I was just shaking reading some of the comments. The OP said foot fracture. Who cares what their history was. A fracture is an acute problem, and proper pain management may include strong medications for only a few days, followed by OTC. I have had fractures and they hurt. It is not up to anyone to tell me about my pain. The OP needs to call the ortho and next time the nurse accepting the patient should make sure adequate pain meds have been ordered. Adequate pain management at the onset contributes to proper healing and recovery.
  9. Visit  heron profile page
    #34 9
    As I noted: self-righteous outrage.

    No one has suggested that the patient's pain is non-existent or that it be ignored. Indeed, the wide range of possible scenarios - which is what we've been discussing - points to the need for further assessment, which is something on which everyone has agreed.

    Different contexts suggest different avenues of approach. Disregarding the order to call a single provider might well be the right thing to do. On the other hand, it might not.

    Pain control is too complex for a "one size fits all" solution.

    Given the paucity of information in the OP, the only realistic advice is to call the primary provider and discuss the situation. Everything else has been pure speculation - and hardly something to get all thin in the nose about.
  10. Visit  azzgirlRN profile page
    #35 2
    I have had several instances where drug seeking behavior has ended up with the pt being unable to obtain anything stronger than Tylenol or ibuprofen. They have ED'd themselves right out of being able to obtain anything stronger at ED's across the city, and sometimes elsewhere. That being said, the best thing is to clarify the order so you do not feel that you have not advocated for this patient, it is all you can do and then you will know the answer to your question. All questions are good questions if unsure, BTW, new or not.
    Last edit by azzgirlRN on Dec 26, '16 : Reason: spelling
  11. Visit  Tenebrae profile page
    #36 1
    Quote from heron
    Indeed, since the OP offered no context whatsoever, the patient in question may well have requested such an order himself.
    .
    This actually makes sense

    I had an addiction to temazepam (same family as valium). Any time i get a new doctor I make a point of telling them under no circumstances should they prescribe me any benzodiazapine, I do it when things are fine so should things not be fine temptation cant even enter into it

    It actually paid off several years ago when a doctor tried to prescribe me some valium as a muscle relaxant following a back injury.
  12. Visit  BostonFNP profile page
    #37 9
    I have written similar orders in the past, and in doing so, I was aware I might be getting a phone call instead of the on-call. I can say that when a note like that is written, it is done for a reason; providers aren't just monsters that want people to suffer and perhaps the short-term pain from a foot fracture is less damaging to a patient than getting re-exposed to pills they previously suffered with.
  13. Visit  Boomer MS, RN profile page
    #38 2
    Quote from BostonFNP
    I have written similar orders in the past, and in doing so, I was aware I might be getting a phone call instead of the on-call. I can say that when a note like that is written, it is done for a reason; providers aren't just monsters that want people to suffer and perhaps the short-term pain from a foot fracture is less damaging to a patient than getting re-exposed to pills they previously suffered with.
    If this is one possibility, the issue could easily have been clarified by the MD speaking with the RN taking care of the patient. That would have saved a call to the MD asking for clarification. During subsequent reports, the information could be passed on. It is an unusual order, IMO, but perhaps not without merit.

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