when to give and hold PRN morphine

Nurses General Nursing

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I'm a student nurse--

Recently there was a patient who was only a few hours post-op with a major surgery. The health issue was chronic in nature and I'm thinking the patient had built a tolerance for the pain meds. She had a PCA pump and was in a lot of pain in spite of pushing it every time she could. In fact she had pushed it over 100 times at shift change when it was being checked, and had emptied the entire syringe and was still in a lot of pain. I felt the pain was genuine, especially since the nature of the surgery was a very painful one, and she was not a drug seeker or anything. I noticed that the pt had an order for 2mg morphine IV push every hour PRN for breakthrough pain.

The nurse did not give the pt her PRN morphine. I asked the nurse what was her rationale (politely of course, in the spirit of learning) I was told that the pt had used the PCA so much that she was at risk for depressed respiration with any more morphine. The pt had rapid shallow respirations from the pain, normal HB, slightly elevated bp from her normal, and was mostly alert and oriented except for complaining of pain, had very tense muscles, was sweating, and was unable to ambulate or do cough deep breathe or anything else. I felt like if I were the nurse I would give the PRN morphine as ordered. I don't want to question this very experienced nurse, but I would like to know more about the guidelines of when to hold PRN pain meds and when to give.

I have been taught that resp rate lower than 12 to hold, but this pt was nowhere near that.

First, patients can't get more than the ordered/programmed dose of morphine from a PCA pump, even if they push the button a hundred times (unless someone programmed it wrong). So if a patient is still complaining of pain, VS are stable, and pt is awake and alert, there's no reason not to give the morphine that the doctor ORDERED for just this situation. With nothing more to go on than what you have described here, the RN was wrong to hold the med, in my opinion.

I just remembered that I had a patient on a PCA pump once who kept complaining of pain despite maxing out her programmed doses of morphine. Turned out that the line was leaking and she wasn't getting her meds. Always try to look for equipment failures when you have reason to think that your patient shouldn't be in that much pain while supposedly receiving the prescribed meds.

Specializes in ICU, PICU, School Nursing, Case Mgt.

This is a good catch for you!:yeah:

Adequate pain relief is a "touchy" subject and one that is often not treated appropriately.

You were probably correct in assuming that the patient had built a tolerance for narcotics...that being said, one of the things that is being addressed more and more by the AMA and JACHO and is being hopefully taught is that "the patients pain is what she/he says it is" .

While there is an unfortunate amount of drug seeking going on in hospital today, post op pain is VERY real. It is possible that the PCA basal dose was not set high enough or the bolus dose...or the correct drug.

If the patient is symptomatic for unrelieved pain, which she was (diaphoresis, elevated HR and BP etc) then something was wrong.

Provided the respirations were not depressed and the patient was lucid, I would have given the PRN dose once

and assessed the effect. THen I would have notified the attending or the surgeon or who ever was in charge of pain control and politely suggested a change in orders for the PCA.

I had bilateral knee replacements 5 years ago...and I had also been on a number of analgesics for years...and believe me when I say my tolerance was high.

I spent several hours post op in agony...and then demanded to have an anesthesia consult...they came in shortly and changed everything. Switched from MS to Dilaudid (which freaked me out...but I digress) and increased the basal and bolus amounts and lock out time accordingly. I had to really SPEAK up and stick to my guns. For the most part the nurses were apathetic, except for one who had been an oncology nurse...she understood pain!

Anyway, I think you have the makings of a Wonderful, Sharp and most of all compassionate nurse!:nurse:

Keep up the good work.:up:

s

I also agree with you 100%. I think you read the patient's signs and symptoms well. I also would have given the PRN dose and then taken it from there.

Thank you so much!! I have been bothered by this patient's experience for a couple of weeks now. I am still not very confident in my judgment calls yet and I appreciate the feedback. :-)

My instructors have all taught that it's not our role to judge patients and whether or not they are drug seekers or truly in pain. Our role is to keep them comfortable and safe and promote healing.

My current instructor encouraged us to give the PRN pains around the clock post-op for 24 hours unless there were signs with resp rate and such to hold them. Then after 24 hours wait and assess pain levels before giving the PRN meds.

Specializes in PACU, CARDIAC ICU, TRAUMA, SICU, LTC.

Ohhhh, this is a PET PEEVE of mine! So many times I have seen MDs (residents, interns, PAs, etc) write generic settings for PCA infusions rather than calculating the correct dose for a patient based on body weight. Having had numerous orthopedic procedures in the past, I would calculate the dose for my PCA (I am a former PACU nurse..19years) based on my body weight, and I would give it to the anesthesiologist (of my choice). Most of the time, I was right on the $$, but there were times when the settings had to be changed. I am a staunch believer in Dilaudid analgesia; when I left the PACU, it was the #1 choice for IV analgesia.

It sounds like you made an astute clinical assessment of the patient's pain status; good for you!! Keep up this skill; your patients will thank you for it!!

I absolutely agree about giving the PRN Morphine. If the order is there, the pt's vitals do not reflect too much pain med. administration, then the nurse should of given the PRN dose. At times it's hard not to pass judgment on patients, especially if you have taken care of patients that may have been "pain seekers". After getting a couple of these patients then it kind of hardens you against giving what you may think is alot of pain medications. That might of been what was going on in the head of that one nurse that you followed.

Specializes in ICU, PICU, School Nursing, Case Mgt.
Thank you so much!! I have been bothered by this patient's experience for a couple of weeks now. I am still not very confident in my judgment calls yet and I appreciate the feedback. :-)

My instructors have all taught that it's not our role to judge patients and whether or not they are drug seekers or truly in pain. Our role is to keep them comfortable and safe and promote healing.

My current instructor encouraged us to give the PRN pains around the clock post-op for 24 hours unless there were signs with resp rate and such to hold them. Then after 24 hours wait and assess pain levels before giving the PRN meds.

THe last part is ok, however, if the patient already had a PCA pump going, my thought is that the pump could be reprogrammed without waiting for the 24 hours of running in to the room to medicate the pt every two hours.

THat is time consuming, can disturb the patient and is not intelligent use of time management.:yawn:

You should have enough information after a few doses of prn/ie "breakthrough" meds in order to make an informed judgement. I think your instructor may be giving the "textbook" answer or at least the conservative answer.

That works if you don't have 4 or 5 other post op patients you are doing it for and on a med surg floor-you will.

The PCA can be reprogrammed and a different med such as dilaudid, infused if needed so the patient can control her own pain. That is the purpose for a PCA and it has been well documented that when the meds and doses are correct, the patient will use less analgesia than if asking for meds from the nurse.

If you are brave, you may want to run that past your instructor, it would show that you are thinking not only about patient comfort but time management skills as well...then again maybe not:lol2:

The other really important aspect of pain control to consider is this: you do not want your patients pain level to creep up so that they really need the PRN dose...you want to keep them comfortable at all times if possible. It takes more medication to bring down a "10" on the pain scale, then to maintain a "2 or 3"...or what ever number the patient is content with.

I also have had my share of surgeries (bilateral hips in addition to the knees) but I also have worked for many years in ICU, PICU and in house Hospice...you really get an education in pain management there.

Again, your judgement is sound so far...keep up the good work...:up:

oh yeah, in my opinion,

The nurse that held the prn meds was either 1. lazy, 2. cruel or 3. ignorant!

s

Specializes in ER and Med-Surg.

With those symptoms,you give the medication and if the breakthrough Morphine still doesn't help, call the surgeon and possibly get her PCA or breakthrough switched to Dilaudid. Pain is subjective. It would be different if the pt had been half-asleep, groggy, had low respirations or low BP. The nurse before you, while experienced, was either on a power trip or too lazy to medicate the patient that often.

I really enjoy your concern and your question. When I was a Med aide, I had to give roxanol, ativan and atropine. What is often called the "hospice cocktail." It was heart breaking for me to give the last dose of a patient whom I took care of for a year. I could not feel her pulse, I could not manually take her BP, her respiration was 8/min. We tried the electronic BP. It would not read.

I don't think that you are talking of a hospice situation. I can perfectly understand your RN holding the morphine. There are other pain meds that can be offered. Morphine is wonderful, but does slow down the respiration.

At this point I think with the tolerance of pain and the genuine pain. It would be appropriate to consult with the physician with this concern. Be adamant about your concern. It is genuine. You mentioned that the patient had rapid respiration because of the pain. That is subjective and you cannot diagnose the cause of rapid respiration, you are not a doctor. It is out of your scope of practice. I really enjoyed your question. I know you will be a good nurse, from an objective point of view.

Great question! There is no secrete that we undermedicate for pain. This is a real problem. I would agreee with the previous posts. You are a patient advocate and you cannot assume what the patient really feels (pain is what the patient tells you it is).

Now, I would have medicated for breakthrough pain and monitored for adverse effects. It gives you more leverage when speaking with your M.D. or M.D.'s as to the effectiveness of analgesia for your particular patient.

Another thing to consider is having a consult with pain management team (some facilities have Anesthesia Dept. in charge of that).

Specializes in ICU, PICU, School Nursing, Case Mgt.

" You mentioned that the patient had rapid respiration because of the pain. That is subjective and you cannot diagnose the cause of rapid respiration, you are not a doctor. It is out of your scope of practice."

posted by "neutrophil"....

UH,

I kind of have to take issue with this statement.

Part of our assessment as RNs is the taking and interpretation of vital signs...ie respirations...if the patient does not have any known underlying respiratory conditions that would cause tachypnea and she has just had major surgery and she is not febrile or scared or anxious....then it is a pretty good nursing assumption that she is in pain. Unrelieved pain is a major cause of rapid breathing.

It could be written as a nursing diagnosis..."tachypnea as related to unrelieved pain"...and it would be acceptable to call an MD and state that the patient has a rr of 24 or whatever....I believe she is in pain, Doctor....

Just saying, it sounds like you are selling us short...are you a nurse now? You stated in your post that you were a Med Aide in hospice. I worked in house hospice and only RNs could give narcotics...at least where I worked. Please don't take my statement the wrong way, it is not ment to upset you, I just felt that the statement was rather odd if coming from a nurse.

To the OP, you will have to assess and reassess and reassess patients and make your "nursing" diagnosis based on the information you have gathered. Then call the MD if needed with your informed input!:nurse:

s

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