Is following a doctor's order "too many" narcs?

  1. I'm a new grad and I'm about 2 months into orientation on a med-surg unit. Sometimes I get patients with histories of painful conditions such as cancer or sickle cell anemia, with a doctor's order for a narcotic pain medication PRN Q4H, Q6H, etc. Sometimes the patients don't report any pain so I leave it at that, but sometimes the patients report pain "always" and want their medication Q4H or Q6H around the clock. So on my shift, I reassess the pain throughout the day, ask "are you having any pain" at the Q4H mark, and if they say yes with a number rating of 4+ I ask if they feel they need the pain medication. If they say yes, I give it, but have noticed on MAR's a few times that other nurses are giving narcs less frequently. Could I get in trouble for giving too many narcs if a pattern develops? Another nurse told me not to give them unless the patient asks for it without me suggesting. But if the patient has cancer and pain is a 10, should I ask them explicitly if they want the med? Maybe they forgot what's on their MAR? Yet another nurse said the patient would "get high" with the ordered Percocet 2 tablets Q4H for pain. High? The patient's vitals are fine and he's up and walking around (now that his pain is controlled), he doesn't look "high" to me. Again, I am never giving more than the order, and this is by far not every patient with a narcotic order. Maybe the patient just happened to have pain on that particular day? I'm day shift, so it makes more sense they'd feel pain and ask for it while awake than on night shift. I just want to make sure I'm doing the right thing and walking that fine line between 'leaving patients in pain' and 'drug pusher' (either of which could get me in trouble).
  2. 13 Comments

  3. by   xtxrn
    If you are following the orders, and the patient complains of pain and no lethargy/abnormally low vital signs (from the patient's baseline), you're fine I asked with my assessments if people had pain. What other nurses do is their problem As long as you don't give something too often, or too many, you're ok !

    Don't worry about pain meds giving someone a "high".... if it's used as directed, and treats the pain- the patient may look more calm since the pain is better.

    Do a search (upper right part of page) for pain medication (this has been discussed a LOT) and you might find some good answers there
  4. by   Sanuk
    Agree with xtxrn; if the patient is awake, telling you they have pain, and is able to have pain medication based on the orders, why wouldn't you give it? Now, I have had to wake patients up for VS and had them tell me their pain is 10 and then fall asleep while I'm still doing their BP. On those patients, I hold the narcs. When they wake up and stay up on their own, they can have them.
  5. by   33762FL
    I think I might work with a few T-Totallers on my floor, or at the very least, people with culturally different ideas about pain and narc use?
  6. by   AJPV
    Pain management is a very big deal to the JC. They track hospitals to see how compliant they are with reassessing pain within the requierd time window after medication dosing and documenting that reassessment. I would be curious if the nurse who is skimping on pain meds is also skipping the reassessment because the reassessment would likely reveal that the pt is still in pain (and would therefore require further interventions).
  7. by   Sanuk
    Haha. I'm a teetotaler all the way. Don't drink anything but water and iced tea, quit smoking, no pain meds stronger than advil - my drug of choice! Still, it's not my pain it's theirs. I look at it if they're awake and hurting, VSS, order is written and they're within time limit, how can I justify not giving it?
  8. by   mazy
    If the dr. orders Q4, then it's acceptable to give Q4. If the patient looks calm and is walking around and is asking for pain meds, the first thing to think about is that the Q4 pain meds are managing the patient's pain adequately enough that she/he can have some kind of good quality of life. Why mess with that? Why wait until the patient is in agony before giving the med?

    Nurses who make judgements about pain management make me stabby. Please don't let them derail you, you're doing the right thing by following dr's. orders.
  9. by   MunoRN
    If the patient meets the indications for the PRN (pain) and doesn't have any of the contraindications (over-sedation), then it is appropriate to give it.

    You will hear Nurses claim that patient's have to ask for prn medications, which is a ridiculously ignorant statement for a Nurse to make. As Nurses, it's our responsibility to assess, which includes assessing for pain. We are also responsible for assessing at appropriate intervals, which for short acting pain medications would require re-assessing 3-4 hours after the pain med was given since this is when it's likely to no longer be effective. It's not the patient's responsibility to ask to be assessed.

    The reasons why some Nurses are stingy with pain meds seems to vary. For some it seems to be a way of establishing their control over a patient, for others it seems to be just based on myths or assumptions that all patients are drug seekers. The thing to remember, is that pain medication is not just for patient comfort, adequate pain control significantly improves patient outcomes and actually decreases total opiate usage in the long term.
  10. by   BluegrassRN
    Yes, you should always try to treat pain. Just do it with a thoughtful approach.

    It's important to know what the pt's history is, and what the plan of care is. If the patient is supposed to go home tomorrow (presumably on po pain meds) and you've given four doses of IV pain meds, that's no good and you need to explore this more. The po pain meds may not be cutting it, the pt may be playing you for the IV meds, or you may not be giving the best med for the pain. Sure, IV fentanyl works fast, but it doesn't last more than 45 minutes. Those two percocet may not provide instant relief, but it provides LONGER relief, and it may be more appropriate.

    I've had pts request the IV pain meds over po, and when we've discussed it, it's because they want to sleep. Well, I've something else that can help with that, and will be more appropriate. Or they just think that IV is always better. No, no it's not. That's why you're waking up ever 2 hours in excruciating pain, because your IV fentanyl isn't providing you with long term relief. You're pain is a 6? We're going to be doing some po meds.

    Some pts just want the instant relief (understandably). But they don't have that option at home, and they need to work on finding what will work for them before discharge, particularly if they're going home on a combination of medication (muscle relaxant, narcotic, etc).

    If we're in the early stages of pain control, I'm typically not worried about iv vs po, but I always choose po first unless the pain is terribly acute and we've been treating exclusively with iv, there is nausea or there isn't any po ordered. I do always discuss with the pt that the goal will be to go to po, so they know what to expect. I always make sure they understand that po provides longer relief, and that it is also what they will be going home on. They also need to understand that they shouldn't wait until their pain is at an 8 or 9 to ask for the meds.

    Another thought: always consider the non-narcotics. We have some nurses who give a narc for EVERYTHING. Pt has a headache? Give lortab. Pt feels achy because of fever? Lortab, dilaudid, or maybe some iv morphine. HELLO! What about that plain old tylenol or ibuprofen? Just because those aren't the big guns doesn't mean they won't provide adequate pain control.

    And while I'm on a pain control rant, toradol is WAY underused as a pain medication. I've seen plenty of patients c/o pain uncontrolled by a pca of dilaudid, morphine, or fentanyl get better pain control with intermittent prn iv or po narcs and scheduled toradol. Particularly pts with some sort of abscess or soft tissue pain (peritonsillar abscess comes to mind).

    Sorry, I know this is a disorganized post. Mainly my point is, be thoughtful of the entire scheme of things when you are giving prn meds. What is the pt's history, what do they take at home, where are they in the discharge process, what are they taking the pain meds for, what is the most appropriate medication for their overall situation, and what does the physician plan to do with them tomorrow? Do they really need that much prn pain meds? Maybe their scheduled pain meds need to be adjusted, maybe the type of prn pain meds need to be adjusted (lortab 7.5 instead of lortab 5, for example), or maybe we aren't giving them what they take at home, so of course they need a lot of prn pain meds. Oftentimes you will need to consult with the physician, and don't be afraid to do that.
  11. by   PunkBenRN
    My cynical answer: Put simply, Doctors will not write an order that they think may at one point jeopardize the patient (keyword: think). Many view nursing by the lowest common denominator and assume if the PRN orders are written they will all be given. For example, call a doctor and say "This patient is still in a lot of pain but I am afraid of these side-effects. They have not been observed, but I don't want to put this patient in danger. Could we adjust the pain meds?"

    You know what many doctors will say? "I am a doctor, I wrote the order, if they are still in pain give the f***in pain meds!!"

    Yes, this has happened to me a few times

    You have to remember, if they are on all these pain meds for a legitimate condition (i.e., cancer), it is likely that they may have developed a tolerance and can handle all of this pain medicine. If you don't feel that they could or are uncomfortable with giving multiple pain meds to a patient you just met, start low and slow and work your way up until you find what combination works. Also look back and see what they have been receiving all along, could set you down the right track.

    Just to clarify though, not all doctors are obtuse as stated above. It just seems like when you need a doctor, you end up with the person above on the other end of the phone
    Last edit by PunkBenRN on Dec 4, '11 : Reason: typo
  12. by   turnforthenurse
    As long as you are following the order (giving Q4H or Q6H or whatever) and the patient looks okay and VS are stable, you will be fine.

    And with chronic pain, it is better to give meds around the clock versus waiting for it to become agonizing. Much harder to get it down to an acceptable level for the patient that way (harder to control) if that makes sense.
  13. by   leslie :-D
    Quote from BluegrassRN
    And while I'm on a pain control rant, toradol is WAY underused as a pain medication. I've seen plenty of patients c/o pain uncontrolled by a pca of dilaudid, morphine, or fentanyl get better pain control with intermittent prn iv or po narcs and scheduled toradol. Particularly pts with some sort of abscess or soft tissue pain (peritonsillar abscess comes to mind).
    last spring, i had some lesions surgically removed from my lung.
    i was on iv fentanyl, dilaudid and morphine - none of them were helping my pain.
    then the nurse offered me toradol - it took my pain from a 7 to a 0.
    that's all i wanted afterwards.
    i would do a commercial for that drug.

    bluegrass, great post btw.
    pts with cancer and sickle cell, the implications are there for strong pain mgmt.
    but you want to mimic their regimen, to what they'll be using at home, to extent possible.

    as for prn dosing, i am huge on staying ahead of pain.
    you just don't wait until the pt starts complaining.
    op, keep on doing your assessments, keeping in mind - that their pain (real or potential) is valid and warrants addressing.

  14. by   HeartsOpenWide
    Everyones pain is different. I always ask what the pain level is, then ask them if they need pain meds. If they want it, and it is due, I give it. It not my place to judge if they are in pain or not; pain is subjective, not objective. If they say 2-3 and say they want pain meds, I will some times suggest Ibuprofen and tell them that after 45 mins if it has not worked we can try a narcotic (my patients always have IBU ordered post partum unless they are already on Tordol). I usually have to talk my patients into taking pain meds because they are paranoid with breastfeeding...its easier to stay ahead of the pain than to treat it