Managing pain question- best advice - pg.2 | allnurses

Managing pain question- best advice - page 3

:nurse: My situation is this.... I recently medicated a pt with IVP Dilaudid 2mg (as ordered) for a pain scale of 10/10, at the same time I also gave 2 Percocet 5/325. The pt had an ACDF two days... Read More

  1. Visit  newrngrad profile page
    0
    I forgot to say I agreed with u for rationale and especially knowing peak times! Kudos!

    But- I would have started out . 5mg dilaudid........ 2mg of dil. Is a lot!
  2. Visit  alwayskatiek profile page
    1
    I don't like to give IV/PO at the same time, but it depends on my pt load too. If I have 8 pt's that night, I would give the Dilaudid, check back in 30 mins and give the po. If I only have 4-5 pt's, I may give them at the same time. Also it helps if you know the pt. if you have seem that the 2 mg isn't going to touch him, I would add the po Meds at the same time. Is the pt on a heart monitor? I may be a bit more aggressive there too, because I'll be able to hear the alarms at the desk going off, giving me another way to check on him. There are so many factors to consider, and that is part of what experience teaches you. Follow your heart and gut, they will lead you in the right direction. PS. If you will be going off shift during the peak action times, PLEASE be more conserative!!! I had to narcan more than a couple of pt's as I came on shift because the previous shift over medicated them.
    JulieL likes this.
  3. Visit  moonlitfirefly profile page
    0
    Quote from moonlitfirefly
    Pain control is imperative to allow a patient to progress and participate in their treatment. The astute nurse should assess, plan, implement, and evaluate. There is no substitution for good nursing judgment! And there is no contraindication to give PO narcotics with a breakthrough IVpush narcotic...unless their respirations are below 12-15, SaO2 is <90-92%, hypotensive, bradycardic, their mentation is other than alert and oriented x2-3, and or their age and history proves otherwise. Keeping a pulse oximeter or capnography machine on continuous monitoring and no less than hourly checks for patients at high risk is imperative. If the medications are ineffective in managing the pain or the medication dosage is too high, immediately notify the attending, resident, or NP/PA, and your Charge nurse...and even better if you have a resource such as a Pain Management Team available get in touch with them! The appropriate pain management regimen for the right patient, as well as administering the treatment appropriately can make all the difference!!
    correction: SaO2 is <90-92%
  4. Visit  morte profile page
    0
    Range orders are not acceptable "on the floor". order for 2 mg, is 2 mg.....and, to the OP
    8 months and you have a grasp of critical thinking, congrats.
    Quote from newrngrad
    I forgot to say I agreed with u for rationale and especially knowing peak times! Kudos!

    But- I would have started out . 5mg dilaudid........ 2mg of dil. Is a lot!
  5. Visit  Perpetual Student profile page
    1
    Range orders are not acceptable "on the floor".
    According to whom? Policy in your place?

    Range orders certainly are appropriate--and best practice. Nurses using their judgment to appropriately medicate based upon patient pain rating, tolerance, level of sedation, and so on is key to effective, safe pain management.

    http://www.ampainsoc.org/advocacy/pdf/range.pdf
    DalmatiaRN likes this.
  6. Visit  morte profile page
    0
    it needs to be a specific med for a specific thing...ie pain of 1-5 1 tab of vicodin, pain of 6-10, 2 tabs. not 1-2 tabs for pain.
    Quote from Perpetual Student
    According to whom? Policy in your place?

    Range orders certainly are appropriate--and best practice. Nurses using their judgment to appropriately medicate based upon patient pain rating, tolerance, level of sedation, and so on is key to effective, safe pain management.

    http://www.ampainsoc.org/advocacy/pdf/range.pdf
  7. Visit  Perpetual Student profile page
    3
    Quote from morte
    it needs to be a specific med for a specific thing...ie pain of 1-5 1 tab of vicodin, pain of 6-10, 2 tabs. not 1-2 tabs for pain.
    That also is incorrect and not best practice. I realize that some of the regulatory types (e.g. JoCo) advocated such things, but they are not consistent with a sound understanding of pain management. I've heard leaders in pain management (e.g. C. Pasero) completely denounce that practice and advocate having any policy endorsing rating-based pain medication dosing changed.

    The role of the nurse is to assess the patient's pain, respiratory status, medication tolerance, and so on and titrate to keep the patient comfortable and safe. I often see patients who're "10" out of 10 in pain, but their respiratory rate is 8 and they're snoozing until I stimulate 'em. We could have a little robot that goes from patient to patient popping out drugs based merely upon numerical rating, but I'd rather have a nurse with professional judgment tailoring the care to the individual patient.

    Suppose a patient who just arrived from the PACU a half hour ago has pain that is now 5/10. He received 350 mcg of fentanyl in the PACU over 90 minutes (as well as some intraop, but you rarely hear about that). He's A/Ox4, vss, joking with you, been drinking and munched some crackers in the PACU. Do you think that giving him one Vicodin is going to keep his pain under control, which is what you would have to give if you had such a range order? Or would he be better served by receiving two based upon the professional nurse's assessment of his pain,tolerance, and the fact that the fentanyl is going to rapidly wear off?

    FWIW, our hospital does have range orders that read something like "Percocet 5/325 1-2 tablets every 4 hours PRN pain" and we passed our recent JoCo survey easily.
    wooh, DalmatiaRN, and iCare24 like this.
  8. Visit  P_RN profile page
    1
    Other than being not narcotic naive, what other co-morbidities does he have? I have had people in sickle cell crisis have 8-12 mg (per hour-2 hours) of Dilaudid ordered while they were munching cookies and talking on the phone. This is while they say it is 10/10. Before the meperidine back off, these same people would get 100-150 mg an hour.

    Is your patient an addict? Is the doctor aware? Doing the oral plus the IV I'd really worry about the APAP excess if you are giving it around the clock.
    wooh likes this.
  9. Visit  WeepingAngel profile page
    0
    I've had good success with around-the-clock medication for pain. Such as, staying on top of those 2 Percocet Q4H. I used to give EVERYbody Dilaudid, and ended up with a lot of nauseous, puking, hypotensive patients... but now my rule of thumb is Dilaudid for pain greater than 7, so I will medicate my patients with a PO med ASAP after surgery to get a baseline, reassess them, and if their pain is not relieved, medicate with Dilaudid. Of course there are always exceptions, and each patient is a unique individual!
  10. Visit  wooh profile page
    1
    Quote from suanna
    With appropriate assessment your patient was in no danger and most likely grateful for your pain management.
    100% agree with suanna's post.

    I think nurses tend to overly fear oversedating patients. Especially if the patient isn't opiate naive. Patients shouldn't suffer because a nurse is too nervous to give adequate medication to relieve pain.
    I'd have done exactly what you did with the exact same rationale.
    Last edit by wooh on Mar 25, '12
    workingmama77 likes this.
  11. Visit  wooh profile page
    0
    Quote from Perpetual Student
    FWIW, our hospital does have range orders that read something like "Percocet 5/325 1-2 tablets every 4 hours PRN pain" and we passed our recent JoCo survey easily.
    Agree, what you cannot have is two ranges in the same order. So that order is good. "Percocet 5/325 1-2 tablets every 4-6 hours PRN pain" is not.


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