Pain & Nursing Judgement

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    We are taught to think critically as RNs, right? I was in a meeting yesterday regarding pain management on our orthopedic unit. We've been internally audited and found to be praciticing out of our scope of practice...such as pre-medicating a pt with a knee replacement prior to their therapy session when orders say to medicate for 4-6/10 or 7-10/10. If we are pre-medicating when the patient has no pain, then we are making a medical judgement and not a nursing judgement...even though we KNOW that the patient will be in excruciating pain during PT if we don't medicate. (The auditor was clear in saying we shouldn't change our practice, just that docs need to include an order for premedicating in their preprinted order sets.)
    ANYWHO - a question that was raised was if a patient is complaining of severe (9/10) pain, which calls for two Norcos, but the nurse assesses the patient and sees that they are utterly snowed from too much pain medication or anesthesia, have a low respiratory rate etc, and gives less than ordered. The auditor stated that if we don't give the prescribed pain medication (2 tabs) then we are undermedicating and making a medical judgement. WHAT?!?!? I thought that was critically thinking! If we did as "ordered" then we'd be calling a Rapid Response team, the doc, pushing narcan, etc... I was shocked! Do anyone know of any literature that supports the auditor's claim? This is the same idea as not giving Lisinopril if the pt's SBP is less than 120 or 100...the RN knows not to give it even if there's an order for it. That's why we take pharmacology in nursing school!

    Sorry if this is confusing...I'd love to know your thoughts!
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    I don't know about the legalities but I have always been told to premedicate before therapies or ugly wound care regiments. Also to use judgement in giving one or two tabs for c/o pain, as well as holding meds r/t AHR or B/P being too low. I've been a nurse for over 25 years and that's always been a given. Is this auditor trained in medical/nursing issues or is he just a bean counter of sorts???
    Last edit by KaroSnowQueen on Mar 24, '10 : Reason: clarity


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