Do we have to give IV pain meds if patient requests when PO meds are ordered?

[VegRN]

I am an experienced nurse and am curious as to what you all think about this. If a patient is complaining of pain and they are specifically requesting IV pain meds but they are tolerating PO and have oral meds ordered, what do you do?

If you don't want to read the whole post, long story short, are we required as nurses to treat the pain based on what we think is appropriate given our professional judgement or are we required to give them the specific pain medication they ask for? I tend to think it is the former but in the absense of safety concerns, I will do the latter.

Had a patient last week that complained of knee pain, was admitted for an unrelated reason. Hx of sleep apnea, was supposed to wear CPAP at night and during all naps and refused. Pt received IV pain meds just prior to me coming on and was sleeping soundly for the first 4 hours of shift, woke during assessment, drowsy and fell back asleep, sleeping through machines beeping, staff coming into the room to fix them, per report often falling asleep during conversation when doctors are in room. VSS but this is when patient is woken, I wouldn't be surprised if he was desatting during periods of sleep.

Midway through shift, resting comfortably when I walked by room and dramatic display of pain when I entered room to assess. I gave him PO pain meds when he asked for IV pain medication because he was tolerating PO, they last longer and I was concerned about his level of sedation, I explained all of this to him. He was not happy about this and complained to the charge nurse about it. I kept titrating up his oral pain meds through shift, reevaled him every 30-45 minutes and he was comfortable and sleeping though waking much more easily than with IV pain meds.

I got the impression that the charge nurse wanted me to just give the IV meds to make him happy despite my concerns with his sedation level. I let her know that I didn't think it was the safest approach given previous level of sedation, hx sleep apnea and refusal to wear CPAP and that if she felt it was appropriate that she was free to give him IV medication. She did not.

When there are no safety concerns and patients request IV pain meds over po, I strongly encourage them to take the PO because it will provide longer lasting pain relief and generally most of them are going home in the next day or two and need to make sure their pain is controlled with PO pain meds. If they want IV pain meds, I will give them a dose now and closely monitor pain through the shift and titrate up oral pain meds so they are satisfied with their level of pain control.

I appreciate your thoughts on this, thanks so much.

[nopainNurse]

A patient falling asleep mid conversation is overly sedated. Passero has a opioid sedation scale that is really useful --

Assessment of Sedation During Opioid Administration for Pain Management

I would not give any dose of opioid to a patient who is that sedated, especially with sleep apnea. If patient still in pain, then would try alternative non sedating meds (NSAIDS, acetaminophen) and contact MD.

Once sedation decreases, I would then assess and give an opioid, however less than what was given last time as I don't want to re sedate the patient. As for IV/ PO question, it would depend on the order. If I have both a PO and IV order, would be a discussion with the patient. Ultimately if patient is taking PO, my go to would be PO, but does depend a bit on the situation. If patient in severe pain then would consider the IV to get on top of it fast.

That being said, I unfortunately often see "bad" orders, where the IV and PO opioids doses are the same. When this happens, it is obvious that the IV will be "better", as IV/SC opioids are considered 100% bioavailable, but PO opioids are only about 50% bioavailable. When I see this, if the patient is in pain I give the IV and contact the MD for an increase in the PO, and then encourage the patient to try PO with the next dose.

[sapphire18]

Fentanyl is dosed in mcg. 50mg of fentanyl sounds pretty scary!

Haha yup you're totally right...50mcgs...never heard of 5.

[somenurse]

I see both sides of this one, but, some wonderful replies above.

Also, worth noting, our minds are super powerful, (thus, the placebo effect, and yeah, when i was young new nurse, we used to give actual placebos, and yes, these placebos often actually worked, IF we presented the placebo with right words)

my point there is,

if the patient is demanding IV meds, if the patient feels only the IV med will work,

there is a chance, that the patient will only be satisfied with the IV med. One also has to take care, it does not seem a power struggle, too, which is always upsetting to many patients. (not that THIS was, but, sometimes, there can be a whiff of that power struggle/control thing, in similar types of scenarios, even if it is not part of THIS scene at all).

Yes, if you do have a serious and valid concern, about the patient's ability to tolerate opioids, your concern should also include giving PO pain meds, too, i'd think. It's also tough, when a particular patient's normal baseline Sao2 is not that great, and we nurses want to keep that patient at top levels, when they never are at top levels. (doesn't really apply here, though, but, those pts often get denied pain meds, too).

sometimes, a few nurses, seem to resent medicating pain that does not seem 'real' or strong enough to the nurse, with IV pain meds, unrelated to the patient's vital sign status. Not that this applies to THIS situation, nope, AND EACH PARTICULAR CASE IS DIFFERENT, (LIKE, we are trying to wean the pt off in anticipation of d/c home, or for whatever other valid reasons, each case IS different.)

but, i have seen and used to be one of those nurses.......i now hang my head. (that was long ago).

I think, somewhere in my formative years, i was mentored by one too many nurses who scoffed at patients complaints of pain, or felt IV meds were going to lead to addiction, or were being given for "fun" of the patient, or that patients who have low pain tolerance, were wussies, or similar attitudes,

or that patients should display actual anguish to earn IV pain meds (sad if a patient thinks they DO need to put on act to deserve a strong pain med, as some pts can be in pain, and fairly stoic, but, they've learned, "This nurse, needs to SEE pain displays, or else, i'm getting tylenol..." and these pts feel some need to perform displays to get what they want when the nurse enters.... which is degrading and sad, imo)

anyway,

-------------sometimes, i think, these kind of thoughts from nurses mentoring me

poisoned my attitudes about strong pain meds, in the old days.

but, luckily for me, i did later, come to a better understanding of pain control, and of being more accepting of the vast array of coping skills and pain tolerance (or lack there of) amongst patients.

My goal and attitude, changed, rather dramatically, too.

Now, my attitude is way way more to "If it makes my patient happy, and if it is not harmful, i'll do it." Pain and stress, and not feeling cared about, are harmful, too.

(of course, normal caveats apply there, so far as standards of good nursing, doctors orders, status of patient, etc)

but, that is my starting point for many decisions. Once i began to use that as my starting point,

nursing became a bit less stressful for me. (obviously, that idea does not apply in any way at all, to this here scenario, at all). but, after i changed,

after i grew, it was only then, that i could look back, and realize, i did have a bit of wrong mindset initially, about medicating pain.

maybe that does not make complete sense,

and it is off topic to THIS scenario, but, it came to my mind when i read some of this. In my old ways, i could always come up with some rationale, to withhold the stronger pain meds, too, evne when the same pt had tolerated the IV meds well in previous shifts, etc, the old me, could find some reason to sometimes avoid IV meds that were ordered by doc.

i have no words to express how much i regret i was ever that way, and how much easier my job became, once i learned a better way to think, my previous 'power struggle' kind of thinking, was exhausting mentally, and harmful to me, and to my patients. SO GLAD to be rid of it. AHhhhh.

i know this is kinda off topic, and probably not explained well, either. Maybe some ppl will know what i mean, and others won't at all.

sorry if too "off topic".

[Sunnysidegirl]

We all need to use critical thinking and nursing judgment based on fact not just because the order is there and the pt insists.Those reasons alone will not hold up in court if something should happen to the pt.

The pt obviously had received a hefty dose of pain meds prior to your shift. Falling asleep mid sentence?

In your case if you suspected the pt was having apneic periods and the pt refused CPAP I would NOT give the IV pain med and would call the M.D. That way you are addressing the pt's need for IV pain meds but also addressing the pt's breathing status. Perhaps the pt's pain meds needed an overall like putting the pt on a long acting PO med.

Your decision was sound.You were trying to protect the pt's ability to breath. I just would have called the Dr. about the issue.I'm willing to bet the Dr. would of appreciated your concern.

[corky1272RN]

I had a pt that had PO and IV pain meds ordered PRN. The order comment included by the MD was "only give if pain not relieved by PO". So when the pt asked only for the IV, I informed him that the PO had to be given first then the pain would be reassessed in 1 hr. He wasn't that happy, but accepted it (I guess he really had no choice). However the nurse that I relieved that day was coming back the next day, we got to talking about the order the next day. She was just like "I don't care I just give it" , basically she just gave the IV not the PO then the IV. That was her decision but the MD did write that order comment as a type of parameter.

[Sadala, ADN, RN]

I don't get why you would opt to give only PO meds if the physician has IV meds ordered and this is what the patient requests. In my view, if the physician and patient make the decision to move the pt to PO meds only as recovery progresses, that's one thing. But not giving something the patient has ordered in spite of the pt's request seems weird to me.

[Vespertinas]

Often, our orders are written specifically stating that IV mediation is for BREAKTHROUGH pain. So I try as much as possible to follow that. It becomes many times harder though when I follow numerous shifts that have been doing otherwise.

[morte, LPN, LVN]

Technically, that nurse was commiting a med error...

I had a pt that had PO and IV pain meds ordered PRN. The order comment included by the MD was "only give if pain not relieved by PO". So when the pt asked only for the IV, I informed him that the PO had to be given first then the pain would be reassessed in 1 hr. He wasn't that happy, but accepted it (I guess he really had no choice). However the nurse that I relieved that day was coming back the next day, we got to talking about the order the next day. She was just like "I don't care I just give it" , basically she just gave the IV not the PO then the IV. That was her decision but the MD did write that order comment as a type of parameter.