Narcotics administration - page 4
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, '12Pain med administration, OH what a subject.
Having been a nurse for 38 years it is quite clear, if it's ordered by the physican, the pt. c/o pain, the proper nursing assesment is made and vitials are WNL I administer the medication as prescribed leaving all personal judgements about addiction aside. It is not or has never been my job to prescribe the medication, therefore I administer as ordered and requested by the patient. If a pt's need for pain medication is questioned, as many times myself and my co-workers have discussed, assessment and documentation are a must.
Many times a pt. will request increasing or decreasing a prescribed dose. As we all know we can educate the pt. reguarding pain med administration and titration then document our findings, this will ultimetly assist the physician in making the decision in what is best for the patient. That is what we all want as medical professionals, that which is best for our patients. For me personally the comfort of my patients is a primary concern, especially in an area of rehab. The more comfortable and pain controlled the patient is, the greater cooperation and recovery. I have even encouraged a pt. to take his/her prescribed pain meds to enhance their participation in therapy, therefore many times expiditing their recovery.
On the other hand I have seen aquaintences, Dr. shop or make unnecessary trips to the ER to obtain pain meds. This ticks me off. Not only are they wasting the medical staffs precious time, but they totally make fools of themselves. The ER staff pretty much know who the frequent flyers are and those who are only there to seek pain meds. I have seen many a pt. leave the ER in a huff when they are not given the meds they wanted when they came in. When the so called patient is in the ER, VS WNL, sitting up, asking for food because they have been there for hours and not given anything to eat then when asked what their pain is on a scale of 1-10, and it is "10" I have to laugh to myself.
But then too communication and documentation is key. The look on their face when nothing is found and they leave the ER with a recommendation for APAP q4 or a script for Motrin is PRICELESS.
In any event, as much as we all hate all the documentation we have to do it and do it well...documentation is our friend, and can protect us in questionable situations!Last edit by Esme12 on Aug 26, '12 : Reason: formatting
Aug 26, '12I agree with most of the replies in this thread. If a patient complains of pain, and the med is due and safe to give, we have to give it. On the other hand, after a few years in mental health, I understand that as nurses, our deep resistance to giving people meds when we know they are drug seekers comes from an aversion to being an enabler. We don't want to enable addicts because we know that is not helping them. Unfortunately, we can't judge a patient's true pain level, so we have to medicate everyone who complains to avoid missing the patient that has true pain that may not be obvious. And for the Press Gainey scores ;-) Sometimes we have to enable peopled with addictions. No way around it.
Aug 26, '12i dont care how much they want. i give it . if they want it more often give them a pca. if the doc prescribed it they can have it. push it fast, sure. if they are trying to get high i document their request and notify the md.
Aug 26, '12Pain, is pain whether it is real or imagined it is still pain. Think about it, Pain is subjective, we ask our patients to give us a number from 1-10 on how much it hurts, we ask them to describe the pain, we ask them how much pain they are willing to live with.
Taking on this 1-10 scale, is all very subjective, and if you have a patient who suffers from Chronic Pain and also Chronic Depression, each diagnosis is fighting the other at times and at others synergizing it, and it isn’t unusual at all, to see such concomitant diagnosis.
While it may seem to the Nursing staff as drug seeking behavior to set ones phone alarm to request the next dose, it can also be explained as keeping on top of the pain margins. If a chronic pain patient does not receive their routine dose of medication at the prescribed time and their pain makes a headway, it goes from extremely difficult to impossible to get their pain back under control, and you may be talking about a patient who has worked for years to achieve just a modicum of control over their pain. Pain control is indeed a funny, and no, I do not mean in the laughable sense, science. Migraines seem to like Nurses, anyone of you suffer from migraine headaches? Then you might have an idea what your patient endures on a daily basis, if they don’t get their medication.
I’ll take it one-step farther, those of you who have had the blessing of childbirth. The pain you went through. How do I know? I’ve had the distinct pleasure of OB/GYN numerous times during all of my licensure pursuits. The main thing I learned during my time there was why G*d chose women for childbirth, if He had left it up to the men, it would have been a one child per family deal, because men are not going to put themselves through that pain and excruciation more than once.
At any rate, my point being, I remember hearing the OB/GYN telling the mothers that they should get ahead of the pain, and take the epidural now or whatever pain control they were going to use, before the pain got too intense, or they would have to use much stronger meds and "ruin the birthing experience." I remember thinking those were a strange choice of words, but to each his own I guess. Being much older now, I can understand where he was coming from, but it would still be that one kid per family deal as far as I'm concerned.
It isn’t up to us as Nurses to second-guess the Physicians ordering the pain control regimen for his or her Patients. If your patient shows mild to moderate s/s of excessive sedation from the medication, you should obviously chart your observation in your notes, and bring it up in your EOS report. That is something that needs to be observed and maybe the meds need to be held or if allowed, modified the next time.
If you are the Nurse Manager for the Pain Control Unit, you already know what you are doing, but it sounds as if some of your staff could use some freshening up. Give your Patients their meds as long as they are due and they don’t show any adverse s/s. At least with all of those I-Phones and Androids going off, your meds will always be on time.Last edit by Esme12 on Aug 26, '12 : Reason: formatting
Aug 26, '12Pain is subjective, therefor, it is hard to say who is really in pain, and who is just med-seeking. That being said, there are people who sincerely need their medication "around-the-clock" so that it stays on board & they arent caught in a situation where they waited too long & get no relief from the med. I have known patients to set alarms for this reason as if they sleep until they awaken (in pain) then the pain is such that the med is ineffective...if I were in the same situation I would prefer the patient to set the alarm than risk having them in pain that I cant relieve with medication, thus also setting myself and my staff up for possible complaints from family members, etc. I am aware that there are those who may not even need the med but use it for habitual purposes, but I am in no position to judge or determine whether someone is having chronic pain or drug-seeking...
Aug 26, '12Quote from Shawn4zI think being a patient helps nurses. Not just the relative of a patient...the actual patient. I know that my current and continuing experience has informed my practice immensely.I wonder how the difference in attitude relates to having been the patient. I have been in severe pain many times with a flare up of a chronic condition and have been eternally grateful to the nurses who were agressive with pain care.
Aug 26, '12Quote from eatmysoxRNThis is only anecdotal evidence, I know, but I'm gonna give it anyway.I just doubt that a patient's pain is 9/10 when they are eating chips and chatting on their cell phones. I understand that pain is subjective, but seriously, if your pain is so bad, you'd show it. You wouldn't desire to eat fried foods and text message your friends. Isn't that an assessment? I've charted it before. "Pt reports pain 9/10. Requests medication and a snack. Patient currently watching television and talking on the phone. No guarding noted...." blah blah.
I am opioid naive. I underwent a 5-hour surgery. Your body WANTS food after surgery (I'm still eating like a pig). I was higher than a kite (brain felt REALLY fuzzy) between the anesthesia still in my body and the pain meds. I was ravenous, and I was on the phone talking to my husband and kids, but I didn't remember much of the conversation until the fuzziness went away and I asked them about it. I still felt pain.
I am not saying that there aren't drug seekers out there. Often, however, patients have a verifiable source of pain r/t hospitalization or r/t medical history, and we still wonder about their pain. I have encountered only one drug-seeking patient in my short stint (+1 year) as a nurse. He wasn't on his phone, didn't eat much, and he acted the part as a pain sufferer. It was verified that he was a drug seeker because of his chest pain admissions with normal diagnostics at multiple hospitals over the past year.
I am also not saying that we don't need to think therapeutically toward discharge. Weaning off the PCA, weaning down the extra meds to match what they normally take at home. That's just common sense and good medical/nursing practice.
Aug 26, '12I have a hard time with the drug seekers like a lot of other nurses. Some things that help me out:
If it is ordered and the patient is requesting it they get it IF it is due. I always go over the pain scale with patients. If they tell me their pain is a 10/10 I correlate that with mild, moderate, severely, extremely severe. I had a patient who kept telling me her pain was a 4 and it turns out she was actually experiencing mild pain. Well that would be a 2 or 3 so it required reeducation on the pain scale.
If a patient has norco and iv pain meds ordered and they are refusing the po I tell the doc. A lot of times that will have the doctor getting rid of the dilaudid/morphine.
If you are taking vicodin/norco at home and you are not in the hospital for an exacerbation of a pain crisis I really don't understand why you are requiring dilaudid just because you are in the hospital. If your pain is at the level it is when it is at home and you are at your goal we are all good.
People who have chronic pain do cry when their pain is so out of control. People who say that doesn't happen...well everyone is different.
Many (not all) patients with chronic pain need limits so they are not monopolizing all of your time. I let them know when there next meds are due. I find it extremely frustrating when they go on the call light 1 hour or more before they know their next pain med is due. I don't understand why they do it and there is nothing I can do about the timing of the pain medication. It is ordered by the doctor and If they are getting their dilaudid every 3 hours well I don't need you to start calling me 1 hour, 45 minutes, 30 minutes, 15 minutes before you can have your dose. I will give it to you 3 hours after you had your last dose because that is then it is ordered. Many of these patients have an extensive psych history and are on multiple psych meds. Sorry but these are things that make me go hmmm. These people need to find other methods of pain control besides iv narcotics. They really need to open their minds to other methods of pain relief.
I believe we as nurses should second guess a pain regimen with a doctor. As nurses we receive much more education than they do. Ordering morphine/dilaudid q6h is ridiculous when it has a short half life. I recently went to a conference and learned doctors are lucky if they get 1 hour of pain education in school.
Aug 26, '12I think nurses need a lot more education regarding pain management and addiction. We recently had a class on this where I work a couple of months ago and it was very helpful. I was an Oncology and Hospice nurse for many years, so I have given a lot of pain medication to patients in my time. I agree, if it's ordered and safe, just give it and withhold the judgement. I have been on the other side, too. I have a history of diverticulosis, first diagnosed about 6 years ago. The first 3 years after I was diagnosed, I had several episodes of diverticulitis, involving pain, fever and very elevated WBC count. I have since learned how to manage the condition and reduce the episodes with diet and early detection of a flare. The last episode I had was 3 yrs ago. I went to an urgent care clinic, seeking antibiotics, nothing else. I told them my history and my symptoms. I told them I was having LLQ abd. pain because that is part of the symptoms of the condition. I was not crying. I did not ask for anything for pain or a prescription for pain meds. I never mentioned pain, other than to tell them that the abd. pain was one of my tell-tale symptoms. I wanted a script for Levaquin or Cipro and then to go home and take care of myself. After examining me, the NP said, "You know, I can't give you anything for pain." I said, "Yes, I know, but you can give me a prescription for an antibiotic, right?" "Yes", he said. I felt like a skid row bum. It's sad when people now are treated like drug seekers when they don't even ask for pain medication, but just admit they have some pain. Pain is part of this condition, but not the biggest part. The biggest part is the 102 fever and 20,000+ wbc count and the possibility that my colon may rupture. That's the part that worries me. People should not be afraid to say they are in pain for fear of being labeled as a drug seeker or an addict.
Aug 26, '12One responder mentioned this, but I think it bears repeating: set a comfort goal with your patient. Research has shown some improvement in managing pain with various types of patients by asking them not one but 2 questions: "what is your pain on a scale from 0-10?" and then "where would you like that number to be (to be able to cough/ambulate/roll over, etc.)?" You can then educate them about pain control and point out that given their surgery or condition, it may not be realistic to get them to a zero, but maybe they would be happy going from an 8 to a 2... or an 8 to a 5. The number system is so subjective, and we can't really know what a 2, 5, or 8 means to individual people. Setting comfort goals helps to illuminate the patients' expectations and gives us something to shoot for. Patients are happy because they are involved with their care, and nurses are happy because they know what the patient wants.
I worked in the PACU as a student, where almost every patient comes out of the OR with orders for pain meds: fentanyl and oral analgesia if they are going home, and often Dilaudid and/or a PCA if they are staying. Our biggest concerns in the PACU are airway (so we don't want to go too heavy on the opioids while they are still waking up) and ability to cough and deep breathe (so pretty much anyone who has had abdominal or thoracic surgery is going to have to learn splinting and take some pain meds). Even when patients are loopy, you can have this conversation with them. Generally, if they can articulate a pain score, they can articulate a comfort goal.
I really think that setting comfort goals has the potential to increase satisfaction with care AND improve pain management. It may still not work for those who are looking to get high, but it might help address the pain needs of chronic pain sufferers and other cases when we just don't know what they are feeling.
Aug 26, '12I generally believe that most patients report pain accurately. I also have noticed some using narcotics for emotional pain or anxiety (and some of them have told me as much). I let the provider know what's going on in such cases.
I dilute narcotics and push slowly. I am shocked that management (as reported here) pressed some nurses to reduce dilution in order to increase patient satisfaction. I think safety should be paramount.
I have trouble with the patient that reports 10/10 pain and when offered the dilaudid, refuses it as the diphenhydramine push is not yet available...wanting to wait until both may be given together a couple hours later. That seems odd to me.
One other comment...for the cancer patient who set her so she could get pain meds through the night... It seems to me that a PCA with a continuous dose would have made her more comfortable... Wonder why the doctor didn't order that.
Aug 26, '12I once had a very wise Nurse Manager on my Orthopedic Unit who said during a staff meeting, "Give pain meds when they are due. We will not make them drug addicts in the 3-4 days they are here and we will not cure them if they are already drug addicts." I have always carried this advice in my mind since she gave it because it is true. I know I have encountered true drug addicts in my 16 yrs as a Nurse, but if they are suffering an acute condition then they are going to require MORE pain meds then the average person. It is not my job to judge but it IS my job to be the patient advocate and to give pain meds in a timely manner. Just Sayin'
Aug 26, '12As others have said, I don't really care if the patient isn't really in pain when they request a PRN narcotic. As long as they can safely handle it and there is a legal order for it, why not? It's not like me witholding a dose they don't really need is going to miraculously cure them of their addiction. You need to pick you battles.