Narcotics administration - page 2
I work on a med-Surg floor where dilaudid is prescribed excessively. Especially to chronic drug seeking pts. We have joked that we think some of the pts are setting an alarm to wake themselves up so... Read More
Aug 26, '12Everyone remember what we learned about the ways chronic and acute pain are expressed?
People with chronic, opioid managed pain usually do not seem to be in pain. Pain for them is part of being alive.
Maybe I am naive, but it seems to me that while seekers do exist, we need to be very, very careful in judging them as such.
On this one I am with Sun0408.
Aug 26, '12Quote from TheCommuterThis, this and this. Pain is whatever the patient says it is. I find it really hard to believe a patient is c/o 10/10 pain when they are sitting in bed, laughing and talking on the phone, but what am I to judge? As TheCommuter said, as long as their vitals are okay, they are not overly sedated and they are due for their next dose, I will go ahead and medicate them.In this day and age of healthcare where so-called 'customer service' overrules patient care, I've resigned myself to giving patients whatever they request to avoid having any petty complaints lodged against me.
As long as their respiratory rate is at or above a certain threshold and they are not overly sedated, I do not care if they are really in pain. They're getting their narcotics as long as it is time for the next PRN dose.
The nurse is in a no-win situation here. If a patient complains that the nurse did not give the Dilaudid promptly, management blames the nurse for creating a 'poor patient experience' and providing bad 'customer service.'
The whole "customer service overrules patient care" initiative is a bunch of crap, IMO. I recently made a post regarding this. We have had "higher ups" ridicule nurses for not giving pain medication when it is due because the patient was overly sedated. They basically told this nurse, "even if the patient is somnolent, if their pain medication is due you give it to them" because it is better for their Press Ganey scores. It's outrageous. This issue was also discussed in a recent issue of AJN which I thought was interesting. Pain management is one of things measured on the HCAHPS survey but it's a bad measurement tool because sometimes pain control cannot be effectively measured. Look at the chronic pain patients who are sometimes on MULTIPLE narcotics/other sedating meds at once. Sometimes the doctors are to blame - there are some that I have worked with who seem to be afraid to go up on the pain meds for patients who really need them. The article mentioned that a study should be done that shows a positive correlation between increased patient satisfaction and patient safety.
I'm not saying patients shouldn't be satisfied with their "experience." They should be, but safety should trump that, IMO...
Aug 26, '12Quote from AnoetosI'll go one further. Patients who are opioid naive with no chronic pain issues may not seem to be in pain, depending on their personalities and pain tolerance. I am one of them. Post-op, I was ordered morphine 2 mg q2h (refused it most of the time), slept between admin times, and woke up in pain (my fault, not the nurses, due to my refusal) My HR and BP never went above my baseline. Pain was 5/10 at rest and 8-9/10 with movement. The morphine took the edge off, but that was it.People with chronic, opioid managed pain usually do not seem to be in pain. Pain for them is part of being alive.
My pain tolerance is very, very high. My post-op pain experience has taught me to S-T-F-U and push the meds. Pain is what the patient says it is.
Aug 26, '12Quote from schoolmackI don't think it's lost. You mentioned SCC and CA patients. They live with pain and pain exacerbations and are frightened to death of letting their pain get out of control.The concern regarding my first thread is being lost on the dosages of medicine mentioned. I struggle to continue to administer medication to pts setting alarm clocks to receive it vs those that are suffering and apprehensive to take meds.
Aug 26, '12your point was not lost. You struggle with this because you are putting a value judgement on this, and you are also probably feeling a bit used by the pt as they wait until they can get the next bit of medicine. But thing is it is really hard to tell who is in pain or not. And you don't really need to. I do not waste energy on trying to decided who "deserves" pain meds, or who is actually in pain. As long as it is safe to give and I have an order, I give the medication. I find that I feel a lot less aggravation this way.
Aug 26, '12Here is what I know. I have both chronic - diabetic neuropathy - and acute pain. I do what I can to keep my pain at bay. Gabapentin 600 mg q8hr will help me if I LOOK AT THE CLOCK and take it q8. If I am distracted and it gets to be 10 hrs, then my lower legs start burning and pinging, and another 1/2 hour goes by before the med helps.
Muscular and joint pains abound as well, and Ibu 800, or norco 5/325 will be my drug of choice depending on the time of day. And when I was in the hospital I waited 2 hours at one point to get my prescribed meds. My anger didn't help my pain, either.
I sometimes cry at home alone.
Aug 26, '12If a person says they have pain, I don't know if they really do or not, some hide pain, some exaggerate pain, I am not a mind reader.
If you have respirations adequate enough to have a dose, no sleepiness, adequate BP, etc., and are due for a dose, sure.
If you yell at me and demand more or to not dilute or change orders, NO. I will give you what is written and you can discuss with the doctor when they come to see you. Not my job to prescribe or change orders. If someone is in pain and I feel it's legitimate and they ask me like I am a human being and not a slave and a servant, I will call and get orders changed, but this is rarely the situation.
I'm not gonna deny pain meds to someone who says they have pain and who are able to have another dose, both within the order's time frame and physically (respirations, somnolence level, etc).
I also am not gonna be at someone's beck and call for their next fix. You are totally nodding off and have respirations of 9 and your blood pressure is 89/60.. no pain medicine until you wake up, your bp comes up, and you start breathing again, I'll be back to reassess shortly.
If you yell at me and treat me with disrespect though I am not gonna make you first on my pain med rounds (q4 or 6) when I assess pain levels for my patients.
I deserve respect just as I respect my patients and care for their safety, well-being, and about their pain levels. If a patient is honest, respectful, and needs and can have the meds, I give them. If they can't tolerate a dose because of their safety, I hold.
I'm not going to harm a patient to get them high. I'm not going to risk my license for a drug-seeker. I am not going to leave a patient in pain unreasonably if they can have pain medicine.
Aug 26, '12The "I'm not giving pain medication" even goes to the smallest of patients.
I had a baby once that was 24 hours post-op from major abdominal surgery. The baby was grunting at every breath and I looked at the chart and the nurse hadn't given the baby any pain medication in 12 hours. "She didn't feel it was necessary". Well, it's important to note that this woman's husband is an alcoholic and has a problem with recreational drug use. The baby's vital signs were kinda normal (slightly elevated) but it was obvious this baby was in pain.
The mother wanted to know why the baby was grunting...I didn't want to make the situation worse and tell the mother the baby was in pain, plus she was the type that wouldn't leave the baby to rest, which didn't help either. When I saw her change the baby's diaper I was horrified that she was never shown how to do it to minimize pain to the infant.
So I started the baby on Q4 morphine (which was already ordered) and just let the baby sleep for the next 12 hours and got an order that only the nurses were to do the diaper changes (tried to teach mother, but she wasn't following directions)..the baby stopped grunting after a couple of hours and seemed to be in peace. We continued that for 48 hours before we moved to pain meds Q6 and then tapered off. Kid did WAY better.
But that is how far-reaching that the biased towards opiates can be...you would never do that to an adult that can talk.
Aug 26, '12I have worked almost my entire career in settings with a large number of patients who are not ... *opiate naive*. I have worked through the intellectual, emotional, and philosophic difficulties you are describing in regard to being responsible for narcotic med administration with these patients.
I have let it go, and I gently suggest that you work on doing the same. Especially in an acute care setting -- there is not time to even begin to change a person's lifelong coping mechanisms / lifestyle / worldview / approach to living. I educate, assess, and give meds as prescribed as long as my assessment doesn't give me a reason to withhold meds. I communicate with providers about patients' presentations. I am fortunate to work in an environment in which customer service does not generally interfere with common sense; nor do I routinely work with providers who I think prescribe excessively.
I also encourage you to reflect on pain management in patients with chronic illness -- i.e., cancer and sickle cell. With the intellectual understanding of their disease processes and the effects of long-term exposure to opioids ... what do you gain as a nurse, or what is gained by the patient, from overly-cautious med administration?
I have seen nurses burn out and derail careers over this issue.
Wishing you peace.
Aug 26, '12I crack up at my job with one doc who always orders 0.4mg dilaudid every 4 hours and these are ortho patients. He is a fantastic surgeon and if I ever need him you can believe I will have a chat on med orders. Another doc writes 0.5-1.0 mg morphine. I always think that most of that is left in the syringe space.
Aug 26, '12I'm just a student, but they've already taught us that pain is what the patient says it is.
I remember as a patient, when I had my c-sections, the nurses emphasized to me the importance of staying AHEAD of paid-- that once the pain starts getting bad, it's harder to get it under control so taking medications on schedule is preferred... perhaps that is what is concerning patients??
Aug 26, '12A friend of mine just lost his license because of another nurse that refused to give pain meds to a drug addict and the mess that ensued after that. They restrained the patient on doc orders and got a ua for a drug screen..krazy the pain med should have just been given
Aug 26, '12It's sad to see SSC patients labeled as drug seekers once again. Nurses have no business projecting what their idea of what a person's pain SHOULD be. Valuing a patient report of pain as more valid if the patient is apprehensive about taking meds is ridiculous. It flies in the face of all we've learned about chronic pain and tolerance. The reason that these patients set alarms is because they are aware that their pain will return and want to avoid that.
Patient report of pain is not all that matters. Ask your patient to report a tolerable level of pain and medicate to that. If it's zero, medicate so that your patient will report "zero" when pain is assessed. Patient care is ALL about the patient, after all. Not the nurse's expectations of how the patient should feel...