IV pain meds standards??????

[jbluehorseh]

I have a question. The other night I was taking to my house supervisor about a patient who is a frequent flyer. He is a chronic non compliant patient who always wants the narcs. This hospital doctor hands out the IV morphine and dilaudid like it is candy.

I told her this is not standard practice and she said it was standard. According to our pharmacy, we give more than national average. I told her if the doctors stop handing out the IV narcs then our drug seeking patients would go down to a minimum.

How does your hospital dispense the IV narcs and for what?

I had a patient who was admitted for toe pain (DM) and had a order for dilaudid 2mg q2.

[Wet Noodle]

OP, if you really want to do good, reduce suffering, and save lives, I suggest you take the time you spend worrying about patients' drug-seeking activity and instead ensure that you and your colleagues are vigilant about hand washing.

[Nurse Kyles, BSN, RN]

Q30min pain meds? Can we say PCA?? That just seems undo-able with 4 other patients...

Oh yes... believe me we did ask for PCA. The Doc laughed and said q30min pain meds was doable, so by no means would he order a PCA. Then he just walked off. That doc is a notorious jerk, and really likes to stick it to the nurses.

[Wet Noodle]

Oh yes... believe me we did ask for PCA. The Doc laughed and said q30min pain meds was doable, so by no means would he order a PCA. Then he just walked off. That doc is a notorious jerk, and really likes to stick it to the nurses.

The doctor could just as easily ask you to stand on your head for five minutes q15minutes for the patient's benefit. Is there any recourse at all, through any means? The physician's actions arbitrary and unnecessary actions are diminishing the average level of care in your ward.

[Anna Flaxis, BSN, RN]

I am a nurse of 15 years, and my pain is as adequately controlled as it's ever going to get. I understand venting, I do plenty of it myself. But the standards of pain are pretty straightforward. Pain is what a patient says, period, end of story.

No, not end of story. The nurse is responsible for providing safe care to those with whose care s/he has been entrusted.

I have had patients literally slurring their speech, nodding and snoring while in an upright position, insisting that they needed more pain meds. I've even seen this scenario deteriorate into a code.

Do I doubt the veracity of these patients' complaints of pain? No. But pain never killed anybody; overdoses of opiates have and do.

The nursing process does NOT include blindly following doctors' orders without question. If an order does not seem reasonable, the nurse not only has the right to question it, but a duty to do so.

The nurse is not simply the extension of the doctor. Nursing is a practice distinct from medical practice.

I think this whole "pain is what the patient says it is" thing is a backlash against decades of under treated pain. I think under treated pain is a problem worthy of attention, and that those with chronically painful conditions should not be stigmatized, and further, that they deserve the most effective pain control that can be safely achieved, without judgment and bias.

However, this does not mean that I am willing to forgo the nursing process, abstain from critical thinking, and just blindly follow doctors' orders. We don't do that for diabetes, for hypertension, for heart failure, for infection, but yet we're expected to do it for pain; I'm just supposed to shut off my brain when it comes to pain? That makes no sense to me.

I think nurses should be well educated on pain; the pathophysiology of different types of pain, the pharmacology of various analgesics, and the standards of practice for treating pain. I think we should treat complaints of pain as seriously as any other aspect of nursing care.

But, I do not think patients should be able to just walk into the ED and receive high doses of opiates on demand, without a medical workup, without a nursing assessment, without questions being asked about their pain and whether there might be a better way of managing it than using the ED for that purpose; and, in some cases, without questions regarding whether the person might have an addiction and be better served by addiction treatment services. This is not a character judgment, but rather, addressing a significant public health concern.

[turnforthenurse, MSN, NP]

^^^ Very well said.

I agree that "pain is what the patient says it is" HOWEVER, as Stargazer said, that doesn't mean we blindly follow the MD's orders. If they are slurring their speech, calling out for pain medicine but when I come into the room to assess them they are already asleep or their VS are out of whack, they aren't getting their pain medicine or benzodiazepine or whatever.

[Wet Noodle]

However, this does not mean that I am willing to forgo the nursing process, abstain from critical thinking, and just blindly follow doctors' orders. We don't do that for diabetes, for hypertension, for heart failure, for infection, but yet we're expected to do it for pain; I'm just supposed to shut off my brain when it comes to pain? That makes no sense to me.

i don't dispute most of what you said, but for hypertension you can measure blood pressure; for heart failure there's the EKG, and now, measurable biomarkers; for infection there is WBC count, sed rate, and temperature; what is the objective measure for a patient's pain? Do you take a blood sample and measure the cortisol level? Is there something you can do with brainwaves?

When it comes to a claim of pain, you have nothing to go by but what the patient says.

Overdosing on opoids is a different matter, and for that, there are subjective and objective tests (such as blood pressure).

[Anna Flaxis, BSN, RN]

When it comes to a claim of pain, you have nothing to go by but what the patient says.

Not exactly. I agree that each person's experience of pain is indeed subjective. Some people can handle tremendous amounts of pain and won't even take a Tylenol. Some people are so pain sensitive that a hangnail rates 12/10 on the numerical pain scale. And, of course, each individual's emotional response to the pain experience plays a huge role.

However, we do know a lot about pain from a scientific standpoint. It's important to understand the cause of the pain. For example, the pain related to trigeminal neuralgia has a different etiology and requires a different treatment than the pain related to pericarditis. The pain related to bone metastases has a different etiology and requires a different treatment than the pain related to acute myocardial infarction.

Understanding the etiology of the pain and the pathophysiology related to it is really important when it comes to treating the pain effectively.

If a physician orders opiates for neurogenic pain when there are no contraindications to antidepressants, anticonvulsants, and topicals, I think it's completely reasonable to question that. How effectively is this person's pain being addressed? What are the ethical implications for the nurse who keeps her/his patient snowed on Dilaudid all day "because the doctor ordered it" and the patient wanted it, and oh heck, it's just easier to give it?

According to the ANA, "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations."

It seems to me that advocating for safe, effective pain control falls well within that definition.

Even with pain, the nursing process needs to be followed, and if something doesn't add up, the nurse has a duty as a patient advocate to ask questions.

If it turns out that the patient is addicted to opiates and has no intention of changing that, then giving the opiates to prevent withdrawals falls within alleviating suffering, and the nurse should do so without bias since addiction is a health issue and not a moral one, in my opinion. Giving the opiate would be harm reduction, since the potential for greater harm exists by withholding the drug.

However, I don't think it's helpful at all to turn a blind eye to the public health problem of opiate addiction, and be forbidden by social mores from ever even questioning a report of pain as a possible ploy to obtain opiates. Drug seeking does happen, and preventing health care providers from being able to even utter the words puts a restriction on how holistically we're able to treat people. That being said, I want to reiterate that I see opiate addiction as a public health issue, not a moral one, and that's how I think it should be framed within the health care community.

[tokebi]

I have been "lurking" out here for quite awhile, but felt compelled to share my personal experience on frequent fliers who use a lot of IV narc's. This pt. repeatedly admitted for abd pain, had every workup known to modern medicine, including exp. surgery. No source of pain could ever be found. Always prescribed Dilaudid 2mg Q2 hr. IVP, then begging & screaming for it early. As Nurses we always dreaded her arrival, knowing we weren't helping her. She was non-compliant & would "sneak off" the unit after getting her Dilaudid, go outside & smoke until time for the next dose. We were told to document everytime she did that & we faithfully did so. The MD refused to listen to our concerns & angrily (!) told myself & another Charge RN to "just give it to her". In 10 months time, she was admitted 16 times. The last admit, she was found dead in a visitors bathroom, off the main lobby, about 45 min. after her last dose of IV Dilaudid. Her toxicology report was + for opoids, diazepenes & THC, & an old pill bottle with lots of different pills in it was found in her personal belongings. I was off duty when this happened, but the family is now engaged in litigation against the hospital & the MD.

If the hospital is guilty of anything, I think it should be the failure of getting her the help for her psychological/social/addiction issues, not because of giving her the med she stated she needed.

I think we often get so focused on dealing with physical ailments that other aspects of illness that addicts may have, end up getting ignored. They might not appear sick and have nasty attitude but they also need help.