Accused of withholding pain medication


I am Charge RN on a 26 bed Med/Surg unit. I was accused of withholding a patient's pain medication. Here's the situation. I would appreciate hearing how other nurses interpret this situation.

The patient had a lip abcess I&D'd. He had two PRN pain medication orders. Demerol q6 prn, and Lortab q4 prn. He had received Lortab at 2200. At 2400, he was going to leave the floor to smoke, but his EJ access had come out, so it took almost an hour to resite him so he could get his antibiotics. After this was done, he asked for his Demerol. I asked him if he was going to go smoke, and he said that he was through for the night, so I gave him the Demerol. About 30 minutes later, he was going to smoke. I advised him of the risks, but he went anyway! When he returned, I told him that it would be 0700 before he could get anything else. About 0300, he was asking for the Lortab.

I was taught that if neither order was written for breakthrough pain, which neither was, you had to wait the time frequency of the last medication received, before giving anything else, to keep from overmedicating someone.

Thatmorning, he complained that I had withheld his pain medication. I was written up for this. My nurse director said that I should have given the medications 'as ordered'. I attempted to explain to her how meds are given, if neither are for breakthrough pain. All she said was, 'what is the policy?' She could not even tell me. I have not had the chance to see if my facility has a clear policy on this.

Please let me hear some perspective on this. I feel I carried out the orders correctly. It would be great if someone could direct me to a definitive policy on this.

Thanks for any advice!


MunoRN, RN

8,058 Posts

Specializes in Critical Care. Has 10 years experience.

There are no set rules on this, the closest thing is the JC's rule that facilities must have a policy to clarify how such orders should be interpreted. Without anything to limit the interpretation, it could be argued that both are to be given and on their own schedules (even if it means "doubling up"). Really though the answer is how the MD intended for it to be interpreted, without that all guesses are unprovable to be either right or wrong.

You'd have a better argument if there were signs of overmedication, however he sounded pretty awake with lortab on board from 2200 in addition to the demerol.


22 Posts

I'd say you withheld them, yes. These are prn orders, not regular standing orders so in essence I'd treat them as BTP.


861 Posts

Specializes in Med Surg. Has 4 years experience.

In my hospital PRNs are for breakthrough pain. We alternate IV and PO drugs all the time. Sorry, but I do think your manager was right.

roser13, ASN, RN

6,504 Posts

Specializes in Med/Surg, Ortho, ASC. Has 17 years experience.

I guess I'm curious how you define breakthrough pain and why you thought a PRN needed to be designated as such?

I'm not surprised that your nurse director did not abide by your definition of how PRN's are to be given. You should have given the Lortab as requested.

The smoking issue is really irrelevant, although I suspect that it played into your decision because you were aggravated with the patient for going out to smoke after he told you he was done for the night.


1,549 Posts

Specializes in Post Anesthesia. Has 30 years experience.

What I get from your post is you were punishing this patient for smoking against your explicit instructions by witholding ordered pain medication. " I asked him if he was going to go smoke..." He wasn't driving to go have a cig.! What does him going to have a cigarette have to do with giving demerol or not? You are an educated , skilled health care professional. Is his pain severe?, Is he so close in time to any other medication that he is likely to still get relief from that medication?, Can you see any sign that he is impaired and in danger of depressed VS for an additional dose of analgesic? I think you should have been written up as well. You either don't understand pain management well enough to work in this type of facillity, or you are wanted to punish your patient for breaking your rules. If you saw the orders as you described- then at the very least you should have called to get expanded pain management orders. You didn't need them. Were you really afraid you were going to obtund him with a lortab two hours after a dose of demerol?

blondy2061h, MSN, RN

1 Article; 4,094 Posts

Specializes in Oncology. Has 15 years experience.

I would take them as two separate orders with their own schedules. I'm confused what the difference between PRN and breakthrough means to you? I take PRN meds to mean for breakthrough pain. I'm surprised your facility is still using Demerol for pain and I'm surprised your facility lets inpatients go out to smoke.

Specializes in Emergency Department. Has 8 years experience.

While I'm but a student, I would think that a PRN med for pain is written for BTP, otherwise it'd be given on a schedule and not PRN. I've seen patients on PCA and/or scheduled pain meds and had PRN orders for additional pain meds. Even if it's not written as such, to me the fact that it's a PRN implies that its for BTP. If the patient meets parameters at the time the meds are requested... I'd certainly consider whether the med should be administered.

Specializes in Pediatrics.

If he was awake and asking for pain medication and with how you interpreted the order waiting for one to wear off before giving the next. Then why didn't you call the MD for clarification or new orders. As his pain was not being managed.

I am sure the MD would have been irritated however.

Because those are separate orders with separate schedules and unless your patient was becoming sedated by the medication I see no reason why you would have held the medication and let him be in pain without trying to do something about it.

When patients pain is not appropriately managed you get patients who develop an anxiety about their pain medications worried that they will not be properly managed.

If you were the patient how would you feel?

Sorry but feel like your manager was right. I really feel for patients when nurses are scared to medicate for pain.


1,076 Posts

I realize only a couple hours had passed since you gave him the Lortab, but as long as its been 6 hours since he got his demerol (the order was demerol prn q6)... then I would by all means give it. It may be the Lortab is not managing his pain very well (hence asking for more pain meds only 2 hours later). In this case I would call the doc and tell him that the patient is still in pain after the Lortab. The dr could then change the dose, the frequency or whatever he/she decides to do. It does sound to me like pain management needs to be addressed with the doctor

jadelpn, LPN, EMT-B

51 Articles; 4,800 Posts

Pain does need to be addressed by the MD if the current regimine is not working. However, I would think he could get demerol q6 every time he needs same for pain, as well as lortab q 4 should he still be in pain per pain scale-- each with its own timing. So you can't give the demerol closer than 6 hours apart, and you can't give the lortab closer than 4 hours apart. However, I have never followed a policy where it is a case of the "last medication given"--these are 2 seperate meds with 2 seperate mechanisms of actions, therefore, one would not preclude the other. 2 seperate PRN orders. If you are giving dilaudid that is bringing a 10/10 to a 6 or 7 then that is not working well. Same if it is bringing a 10/10 to a 2 for only 2 hours.

And be sure that you have an MD order that the patient can go out to smoke and follow your facility policy on that. With an EJ and such, going out to the street to smoke would not be my thought--so if any policies need to be clear on your unit, it would be that one. I would not want to be the charge nurse who gives a patient permission to go outside and smoke--this would be for me, the bigger of the 2 issues. And only because we are talking a patient who has venous access, has issues with pain in the moment, and unsupervised time in which he is not in the facility. This could be a thought process on why you would deny further pain medication, however, that open a whole other can of worms but definetely something that needs addressing unit wide.

Has 33 years experience.

The patient went 6 hours without pain medication. That is unacceptable. An I&D on the lip area sounds quite painful.

If you were questioning the timing of the ordered meds, you needed to call the physician , clarify ,and medicate the guy!