Pain Medication Inquiry

nightmare, RN · Jan 20, 2008

Do your patients not have a main painkiller and another for breakthrough pain?

kukukajoo, LPN · Jan 20, 2008

Okay, so this woman is no longer your preceptor. You asked for another one. Where there problems with her precepting you? Animosity now?

I don't think she had the right to yell at you at all! I am thinking she is trying to exert more control over you and intimidate you. You can't let this happen.

I would talk to your charge nurse and get the scoop on whatever your hospital policies state and a clairfication on everything you mentioned.

It is one thing trying to help & teach a new nurse, it is totally another thing to use intimidation and agression on a new nurse.

gospursgo07 · Jan 20, 2008

Well, I work on a med-surg floor. Typically, post-op patients have IV meds for pain or PCA pumps. IMO this is due to the recent surgery and given amout of pain as well as advancing pt's diet (many pt's get sick when PO meds are given on an empty stomach).

In my hospital, the transition to PO pain meds (typically Vicodin, Norco, etc) comes a couple days post-op, but with IV pain meds still available for BREAKTHROUGH pain. **This is not with every pt, of course as there are always exceptions to the rules, some pt's pain requires longer and more aggressive treatment. ***

A typical example would be a pt post op day 3 from a tib/fib fx: he is given Vicodin as needed to cover his pain, but I may give him an extra IVP of morphine say, after working with PT or ambulating.

I try to encourage pt's to use the IV meds only for breakthrough pain, as they will not be able to have these meds available once d/c'd from the hospital. MOST pt's want to go home, and understand this concept in preparation for their d/c.

In response to your question, If the IV meds are available and the PO meds are not effective, I would def administer them. that is what they are there for after all,esp pain scale 9/10. (Just my opinion) :redbeathe

PMHNP10 · Jan 20, 2008

I was just starting to feel comfortable in my new job when another nurse, (who used to be my preceptor, until I asked for a new one) went into my patient's Pyxis med of removed meds. She called me into the med room and her and this other nurse cornered me. She told me I couldn't give my patient IV pain medication after she had been on PO. The patient had pain level of 9/10, excruicating pain which wasn't being managed by PO meds. I was going to give the patient PO Dilaudid until I thought about switching her back to IV, so I had not had not returned the PO Dilaudid yet. The nurse flipped her lid & started yelling at me, you need to return pain meds right away, you can't just keep them in your COW, (computer on wheels), you need to be more careful, you're nursing license is on the line. My stomach is upset, my weekend off has been consumed by this "confrontation".
I talked to other experienced nurses on the unit and they said it's ok to switch a patient back to the IV form of a pain medication, if POs not cutting it.
The confrontation has raised other questions for me, since I've been dwelling on it. For instance, say that the patient has two pain medications that they can have, i.e. Flexeril & MSIR, MSIR is not working on their back pain & another dose is not due for another hour, can I give the Flexeril or should I call the doctor & get a one time order? What are people's thoughts on this situation?
The nurse that yelled @ me gave a fresh post-op ventral hernia repair Motrin for pain because she wasn't due for another PO pain medication, what do you think of this?
Also, if I have a patient who is not due for another dose of PO dilaudid for another hour can I give them IV Dilaudid 1 mg which they can have every 2 hours? Is it possible to give a patient a dose of IV pain med to get their pain under control & switch them back to PO later. I realize they are two separate orders w/ different directions I feel that I should call the doctor to be on the safe side and say, "So and sos pain medication regimen is not cutting it..." Advice?

As a rule of thumb you wouldn't start a patient back on an IV pain med after being placed on PO meds (i.e., it's not an ideal scenario), but if there is a valid order, I don't see the problem. But here is where it gets tricky...what sometimes happens is a doc will write an order for a PO med and assume that the new pain med will cancel out the IV or IM med. Did you know you were supposed to be a mindreader...didn't teach you that in school. This especially becomes an issue when 2 or 3 docs are dippin their hand into the jar.

Probably the best thing to do if you see a new order which is similar to a previous order (whether it's an apparent switch from a IV/IM to PO or change in dose) is get a clarification on whether the old order is dc'd if the new order doesn't already clarify.

The other nurse certainly should not have yelled, but without knowing all the details I can't know if the nurse was accurate in their concern.

In the end, it's just best to clarify because unless it's stated explicitly in the order, you can NEVER really know what the MD wants. And even when you're more familiar with the ways of the docs, it's still better to clarify because I suspect in times of legal proceedings due to those orders, the story will change, and you don't want to be hung out to dry.

nrsang97, BSN, RN · Jan 20, 2008

If the PO meds weren't cutting it then giving a dose of IVP dilaudid which was still ordered for 9/10 pain is fine. As long is the IVP med order is still valid. As gospursgo07 stated. So why was the other nurse mad at you? She wasn't your preceptor anymore and as long as you ran it by your preceptor then what gives.

I really don't think you did anything wrong. Especially if the IVP med wasn't ever written to be d/c'd.

caliotter3 · Jan 21, 2008

You need to talk about this to your charge nurse. Do not let this person intimidate you because she is holding something personal against you. It does not even matter if she were 100% right. The manner in which she went about this, with the other nurse present, tells me that her intention was not a friendly helping hand, but an attempt to put you on the defensive and to put you down, right or wrong. This tactic, intimidation, is often used by co-workers who are trying to gain control over another in order to maintain their own status within the unit. Don't let it happen. Go to the charge nurse. And talk to the charge nurse about the manner in which she confronted you. You have a right to be treated with respect.

GrumpyRN63, ADN, RN · Jan 21, 2008

First things first, your ex-preceptor really had no business to check up on your work! What was she do ing, printing out all your 'meds given' on ALL your patients, looking for some descrepancy?? Who the H does she think she is?, and to ambush you w/another nurse to confront you? I hope you spoke w/ your preceptor or another senior staff member. That is inappropriate, I would be pretty ******.As far as the meds go.. I think many different factors are involved in evaluating po vs iv narcs.If the pt had been on po from iv and now the po wasn't cutting it, I just wouldn't switch them back to iv. Unless their condition changed ie. N/V, NPO and it warranted IV, you would always try to go in the po direction, unless something occurred ie. very painful procedure or dsg change and they needed extra to get back on track, then yes of course you can give them the IV and get their pain back under control.If po dose and frequency was working and now it's not, you would want the md/HO whoever to be aware as they should probably be reassessed. They also my want to reassess the regimen and increase the dose and/or decrease the interval instead of just chasing w/ IV for breakthru. Also depends on what type of pain, acute ,chronic ,surgical,medical, so each case if different. I think you have your patients' best interests in mind and are using good thought processess , As far as your back pain pt, sure I would certaintly give the Flexeril and see if that helped.agree w/her . As far as the Ventral hernia pt, My first question would be why doesn't the pt have a PCA 2) If they are taking po and are on po pain meds it is ok to give an NSAID as an adjunct to narcs, works well w/ a lot of pts, I usually recommend it by day 2 once they are eating ( or whenever they are eating), usually FRESH would get Toradol as adjunct, but those pts are on IV-- usually PCA,

morte, LPN, LVN · Jan 21, 2008

unless this nurse was charge on the day of this occurence, (s)he had no right to be accessing this patients info, this would be an HIPAA violation.....good luck

kukukajoo, LPN · Jan 21, 2008

I think the OP says that although the other nurse that reamed her thought the pt had po meds, it had not yet been switched from IV to PO and she was actually jumping the gun with the ream out.

The hospital I do clinicals at stops IV but leaves in the saline lock in case the meds need to be started up again. I thought this was common practice?

OncNewbie · Jan 21, 2008

Thank you all for responding to my inquiry. Alittle more information... The patient in question was a day one post-op ventral hernia repair w/ a 2 wk prior cholecystectomy. I was wondering myself why she wasn't on a PCA, the patient was wondering why she wasn't on a PCA. Anyhow, the nurse that bullied me was day shift charge nurse & I was coming onto a 7p to 7a shift. I told the 7P-11P charge nurse the situation and she listened to me w/ a sympathetic ear. The nurse I had issues w/ has a history of belittling and being rude to other staff members; she even does this to other experienced nurses.

I did learn from this experience but there was no need for her behavior. I do need to be more careful & seek clarification. Why was this 4 hr post ventral hernia repair being given PO pain meds in the first place? This was the 7P to 11P charge nurse's first question.

Anyhow thank you all for your support.:icon_roll

OncNewbie:)

GrumpyRN63, ADN, RN · Jan 23, 2008

At 4 hrs fresh p op, I would have definitely put her on the IV narcs for the noc, and then days could decide if she could switch to po w/ advancement of her diet... you were correct, she was wrong on all fronts