PRN narcotics for patients who cant request it?

[EMYrn2011]

I recently started working on a subacute unit; majority of the patients are unable to verbalize needs. Many of these patients have PRN narcotics and anti-anxiety meds. At this facility the LVN gives all the PO meds, and injections; as an RN I am not to give them. I work on the night shift so I'm the only RN and basically in charge. There have been several times where I noticed that two of my patients are visibly agitated, and appear to be in distress. I have been asking the LVN on my shift to give the prn meds as often as they can ex: MS PRN q1hr. They would give it every hr. However, there is one LVN who refuses to give the narc until the patients are visibly agitated. I feel that the med should be given before this happens, to keep the pain in control and to prevent it from increasing to the point where the dose is not enough. Am I right in this case or is the LVN? If so how should I handle this situation? In this facility it is very clear that the LVNs act as if they are above the RNs and often try to tell us what to do...

[Assailants]

Why isn't this Pt getting ATC PO pain meds? Giving morphine q every hour anit going to help with long term pain relief.

[tewdles, RN]

So the bottom line is this, the RN is the better trained of the clinicians.

The judgment of the LPN will default to the judgment of the RN. The LPN always has the right to refuse the RNs direction.

For a painful patient who is not able to ask for their prns we are responsible to observe and assess them regularly for signs and symptoms of discomfort. We act upon those signs to intervene to reduce discomfort. The goal is to medicate before the discomfort it too great. If agitation is an early sign of discomfort for this patient he should be treated with his prn asap while taking other nursing steps (repositioning, etc) to improve comfort.

[EMYrn2011]

I get what your saying, but the pt is on hospice. They are an ex-addict, in fact they overdosed which is why they need to be in our facility. This pt also had a sore, that was poorly amputated by a MD who is known to chop limbs off a little bit at a time to get more money. The wound is clearly infected and slowly taking over. Because he's on hospice there's not much we can do but medicated. This pt is regularly agitated, to the point where they swing their arms around none stop, bc the LVN waits until that happens, the does is often not enough to help... It's been an issue of under medicating, which is why I ask my LVN how many time they were medicated, not just on my shift but the other shifts as well. That's where the real problem is. When we come on this pt is so agitated, I don't think there's anything wrong with communicating this problem in rapport.

[EMYrn2011]

Well, to play the devil's advocate here, I'm not going to just give PRN Ativan/Morphine/whatever in anticipation that the pt might become agitated. I'm going to wait until the pt actualy presents with some symptoms. Especially if we're talking about q1hr PRN morphine. That's a lot of morphine. Is this pt actively dying or something?

Frankly, if this facility is staffed like 99.9% of skilled units, this LVN sees this pt far more than you do. Unless she's totally lazy and/or incompetent shouldn't you assume she knows how to assess pain/agitation? Why do you want all these pts to receive as many doses of their PRN meds as they possibly can? If the situation is such that they really need q1hr morphine, isn't there something far more serious going on? I mean, yikes, that's a ton of narcotics. Does the doctor need to be called for order changes?

I'm sorry, I'm not going to give a PRN just because a RN tells me to. Nothing in the nurse practice act dictates that I have to do that, any more than you have to blindly do what a physician tells you.....

I get what your saying, but the pt is on hospice. They are an ex-addict, in fact they overdosed which is why they need to be in our facility. This pt also had a sore, that was poorly amputated by a MD who is known to chop limbs off a little bit at a time to get more money. The wound is clearly infected and slowly taking over. Because he's on hospice there's not much we can do but medicated. This pt is regularly agitated, to the point where they swing their arms around none stop, bc the LVN waits until that happens, the does is often not enough to help... It's been an issue of under medicating, which is why I ask my LVN how many time they were medicated, not just on my shift but the other shifts as well. That's where the real problem is. When we come on this pt is so agitated, I don't think there's anything wrong with communicating this problem in rapport.

[EMYrn2011]

When I worked on the trauma floor, if a pt required intervention for pain more often than q 2hrs (especially with IV medication) then their pain was not considered 'controlled' I would definitely see about changing up the meds if they are needing morphine every hour consistently. Also about the whole LVN education thing, what is her reasoning? Has she been burned in the past after over medicating someone? And as the RN in charge of the pt's care, why are you not allowed to give a medication? (Not saying that you should have to... Just wondering why the RN's aren't allowed to give pain meds. Is it so 2 people aren't potentially giving the same med twice?)

I can give it, but for some reason the facility prefers for the LVNs to do it, if I believe correct they do this to help with the work load. I was told that RNs don't give the po meds, but have been told by several RNs that there are times when they do it bc the LVN won't. Which is what I've started to do.

[tewdles, RN]

Please speak to the hospice nurse about this.

If the LVNs in you facility are not going to medicate this patient at intervals then the patient needs a change in plan to include better long acting control.

Also ask about lidocaine or morphine for the wound edges, this may improve his comfort.

Is he on a low air loss mattress? If not, he should be.

It is crucial to the hospice goals of care that this patient receive his medication according to the plan. Failure to do that will result in a poor hospice patient outcome.

Talk to the hospice nurse...asap.

[leslie :-D]

i very much agree with tewdles, that you need to contact hospice nurse stat.

and to ensure the (new) poc reflects fewer prns and longer acting, more powerful meds.

it doesn't matter if he is an addict or not...not in hospice.

his pain needs to be addressed.

i am hoping this isn't being turned into a power play betw lpn and rn.

furthermore, i know plenty of rn's that hesitate in giving mso4.

lots and lots of education and inservices needed with nurses in gen'l.

this frustrates me to no end, when i see a pt suffer because the nurse doesn't understand pain mgmt.

and ftr, if you look at a pt's med'l hx, one should be able to see why narcs are indicated...

and waiting for symptoms to appear is one of the worst ways to manage it.

we need to anticipate it and treat it accordingly.

you DON"T wait until pt is agitated or restless.

it is that much harder to try and catch up to it.

preventing it is key.

again, please talk to hospice nurse.

the hospice nurse then needs to have a meeting with the DON or nurses, to ensure this pt is being adequately managed.

gah!

this stuff really frustrates me. ;p

op, thanks for being his advocate.

leslie