ortho pain control

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    Any opinion on this? New nurse from LTC facility joins ortho, has been there for about 6 months now...carries own patient load, has a total knee patient who had not been medicated for 10 hours, poor woman gets up to potty in the tail end of the shift , barely able to ambulate to BRP, almost falls due to pain....I check her last med for pain and find it was ten hours ago......what would you do?/how would you handle it? Tell the nurse to medicate her? Medicate the patient yourself? Share the info with the supervisor so the "problem" can be corrected?

    OK....same nurse provided care to another patient the previous day. I get the patient next evening and the adult child of the patient complains to me about the same nurse and how she never medicated her mother during her shift. Mother had a total hip. What would you do?/how would you handle it?

    BTW, this nurse never asks questions about providing care to ortho patients. Isn't part of ortho "selling" the patient on pain control so they have an easier rehab? Yes, some patients have less pain than others but total knees take the cake as far as pain goes and should be medicated to get optimal flexion and extension early on. Also every nurse on this unit is extremely helpful in answering questions about patient care, pain control, anything without making any nurse feel inferior. After 26 years of nursing experience I still ask questions of my co-workers.
    Last edit by Mary Austin on Apr 1, '09 : Reason: time adjustment
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    All I know is that joint commission and the state want people checked for pain. If the nurse is not asking about pain levels the standard of care is not being met. It is hard to decide what to do because if you bring it up to her she may take the hint or may be one of those people that just bristle at the suggestion. Maybe it is time to clue in management because if joint commission ever gets a hold of those charts and sees what is going on their will be **** to pay. Not to mention that human beings are suffering and need to be cared for.
    Last edit by oramar on Apr 1, '09
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    Quote from oramar
    All I know is that joint commission and the state want people checked for pain. If the nurse is not asking about pain levels the standard of care is not being met. It is hard to decide what to do because if you bring it up to her she may take the hint or may be one of those people that just bristle at the suggestion. Maybe it is time to clue in management because if joint commission ever gets a hold of those charts and sees what is going on their will be **** to pay. Not to mention that human beings are suffering and need to be cared for.
    you may find she is doing the doc. quite prettily....."no c/o pain, no nonverbal indication of pain"......hence, no pain med required.....
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    If I'm helping one of my colleague's patients and they appear in pain, I do exactly what I would do if it were my patient--ask them for a number between 1-10, try to get them to clarify how they're feeling now compared to how they've been feeling. Ask them when they had pain med last. Ask them if they want pain med. If they do, I look them up, see what they can get. Then I let their nurse know this information: a) the patient is in pain, b) the context (they are out of bed, just got on CPM, just woke up, etc), c) numeric pain level, d) if they are due for any pain meds/what they took for their last dose. Then, if I'm available and it's appropriate, I offer to medicate the patient. Then there are moments when I am completely occupied with a patient and another nurse says to me "Mrs. Smith is in pain. She's on her CPM. She rates her pain 6/10. She last had oxycodone at noon--10 mg. She can have this again now--would you like me to medicate her?"

    I'd say 90% of ortho patients are in exquisite pain post-op. Then there are those few that really can control their TKR pain on extra-strength Tylenol (and do all their PT/CPM, etc). My floor is definitely not perfect in a lot of ways, but we do work as a team when managing pain since it is such a huge part of what we do and such an important part of the rehabilitative process. Sometimes, no matter what we do, we can't get a patient's pain under control. Sometimes a patient is extremely surprised at the pain they feel the first time OOB since they were so comfortable before. We all ask about pain--if we don't, our patients will tell us about it anyway. I think some nurses--especially those new to ortho--don't pick up on some of the nuances of joint replacement pain management (ie, did the patient have an epidural, are they getting toradol around the clock, do they have a long-acting narc on board, is this a chronic pain/tolerant opiate user already, does this patient have a hx of narc-confusion or are they afraid they'll get "addicted", are they nauseas and thus refusing pain med, or are the pain medication orders inadequate for the situation, etc). They may ask for a number on the 1-10 scale, and when they get a "I'm fine", they don't ask any follow ups.

    If you see one of this other nurse's patients in pain, I'd go talk to her--ask her why the patient hasn't been medicated (it's not necessarily an accusation--plenty of patients will refuse), and offer to help. If, by her response, it seems that she's not "getting it" (ie, not providing enough information to the patients so that the patient can advocate for himself better) take it as an education opportunity to help her along. (Plenty of people did this for me, believe me ) If she really seems to be neglecting her patient's pain management and doesn't show any improvement--she don't belong on ortho, and I'd let the manager know. Cause that just ain't fair for the patient!

    Last point: I have learned with 2 years of ortho nursing that it is OFTEN appropriate to try to convince a patient to take a narcotic pain killer. I feel it's my responsibility to gain "informed refusal" if a patient chooses not to take pain medication. A nurse from another specialty may not be as familiar with "pushing" the pain meds. Teaching moment teaching moment teaching moment
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    I'd probably have a conversation with the nurse rather than take it right up the chain of command off the bat. If she bristles, oh well. At least you'll be getting the problem on her radar, as she may not be aware there is a problem in the first place.

    If the problem continues though, then the nurse may need to have some further orientation in regards to the special pain needs of ortho patients. If she's got a problem with that, then she may not be cut out for the unit. Your manager would probably be interested to know!

    I'd certainly have no qualms about medicating the patient myself though, even if they weren't "mine."
    kanzi monkey likes this.


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