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.
Dec 1, '12
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