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

  1. 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.
    Last edit by VegRN on Nov 29, '12
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  3. by   VICEDRN
    I have to say that I think we are obligated to give the patient the iv med. pain medications have been reviewed by patient and md. We have no right to deny people what is on their mar as a general rule of thumb. I say this as a patient as well. I recently had a baby and sat through six different nurses "theories" on relieving post op pain in new mothers regardless of what I wanted or the doctor ordered. It's frustrating and it's really not our business under most ordinary circumstances.On to your specifics here...what you described sounds like a reason to withhold all pain meds given the concerns for sedation. Further, if a patient is clearly abusing meds, I wouldn't administer meds either but would rather talk to md.
  4. by   RNperdiem
    Where I work, we usually start post-op patients on IV meds, and then transition them over to oral meds. I work in ICU, so we are well familiar with IV meds. My approach is give the oral first, and you have the IV available for breakthrough pain between doses if you need it.
    Your judgement sounds fine to me.
  5. by   tnbutterfly
    Moved to Nursing and Patient Medications for more response.
  6. by   PediLove2147
    Same as RNperdiem. I would have given the PO first and if the patient was still complaining I would then give the IV.
  7. by   eatmysoxRN
    In this wonderful world of surveys I would suspect my job would be jeprodized if I denied IV pain meds. I always encourage PO first. I also give iv meds slowly on patients who refuse PO meds because they are also the ones who ask for a certain way of administration. I think pain is extremely subjective but sometimes it is ridiculous what patients do while simultaneously requesting pain meds.
  8. by   sapphire18
    If a patient is too sedated for IV meds, then they are too sedated for PO meds too. If vitals are fine though, including resp rate, you still need to treat the pain. IMO, you should give the patient the form they ask for...the MD can decide whether to d/c the med if they want. This is why I like "med A for pain level 1-3, med B for pain level 4-6" etc.
  9. by   Rhi007
    As a patient I have only ever gotten IV pain relief twice: when I had appendicitis I got IV morphine 2.5mg PRN and post op shunt placement in recovery 5mg of fent and that lasted all night then I was on 5mg oxycodone PO PRN. I guess I'm one of those compliant patients which nursing staff love
  10. by   itsnowornever
    We only have iv/im meds to give so my replies are kinda off, but as a patient I prefer to tolerate pain. With both c-sections I hade a pca pump, never pushed it, instead asked for Tylenol. I have dealt with torn disks and ignored my Percocet for Tylenol. I don't like the effect of stronger meds. I guess a nurse would love me also. LOL. Just give me my Tylenol and we will have a great day!
  11. by   sapphire18
    Quote from Rhi007
    As a patient I have only ever gotten IV pain relief twice: when I had appendicitis I got IV morphine 2.5mg PRN and post op shunt placement in recovery 5mg of fent and that lasted all night then I was on 5mg oxycodone PO PRN. I guess I'm one of those compliant patients which nursing staff love
    Just because someone requires more medication to adequately manage their pain, does not make them noncompliant. And I'm guessing you meant 50mg of fentanyl? I've never seen lower than 25 given.
  12. by   psu_213
    It depends on the situation. If the pt is tolerating PO and IV is not ordered, I'm not going to call the doctor for an IV order just because the pt wants it (if the PO is otherwise controlling his pain). If the IV is ordered, I would most likely give it, particularly if the PO is not working.

    When I worked on a step down floor, pts. would come with IV pain meds. Eventually they were written for PO. That way it could be seen if the PO controlled their postop pain since they would sent home with PO meds. If they still were in severe pain, I would give them IV if they requested it. If the PO was doing a decent job of controlling pain, I would stick with that. There is no way their pain will be 0/10 days after major surgery....even with IV meds.
  13. by   SwansonRN
    Fentanyl is dosed in mcg. 50mg of fentanyl sounds pretty scary!
  14. by   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.
    Last edit by NRSKarenRN on Dec 2, '12 : Reason: Added link title