Accused of withholding pain medication

[trucol]

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!

T.C.

[Here.I.Stand, BSN, RN]

Demerol is q 6 hrs prn, Lortab is q 4 hrs prn. 4 hrs from 2200 would have been 0200, so he should have gotten Lortab any time he requested it after 0200. 0700 would be NINE hours after the last dose. Also, think about your pharmacokinetics. Three hours after IV Demerol, why would he be at risk of oversedation from Lortab? Especially if you had assessed him and found he's awake, conversational, and in pain?

Sorry, I do think you were wrong here. We've all made mistakes, take it as a learning opportunity.

[Here.I.Stand, BSN, RN]

why is a patient getting iv/im pain med when he can take po? if a walkie talkie requires an EJ, I am going to be questioning IV drug abuse, so no going out!

Because many pt's require both. I recently had a pt who required scheduled Methadone, PCA Dilaudid, continuous Dilaudid, clinician-given prn Dilaudid, AND an epidural...the poor man was still moaning in pain. If the physical ability to take PO meds precluded IV meds, we'd have many a patient in agony.

Also, I thought the OP said the EJ was out? He went out to smoke after the EJ was pulled and another IV access established.

[Here.I.Stand, BSN, RN]

As for the smoking issue, the OP may well have been within their policy to allow it. Every hospital I've worked for has allowed pt's to leave to smoke, at least from the floors. ICUs not obviously. They had to have an MD order and PT clearance, but once they had that they were allowed to go.

The first place I was at (my state's U hospital) even had pt's go outside with new trachs. They "capped" them w/ a finger on one hand and held the cig in the other. Another young man, frequent admit for sickle cell crises, had 20 mg IV Dilaudid q 2 hrs (yes, I said 20 mg), Benadryl IV q 4 hrs (I imagine you'd get pretty itchy from all that Dilaudid!) and went out to smoke. MD and PT cleared him. We had 20-somethings w/ CF who left on passes in between doses of their antibiotics and vest treatments all the time--as in went home, went to watch 4th of July fireworks, went to dinner w/ friends.

Now a nursing assessment would have been one thing, but to say "If he's in the hospital, he shouldn't be going outside," or "Well he MIGHT become altered even though he's been walking around fine on these same pain meds," or "he MIGHT shoot street drugs up his IV..." that's treading on the line of false imprisonment.

[iPink, BSN, RN]

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!

I agree.

I would think this would be information a Charge RN would know. If you were concerned about possible over sedation, check his vitals. You needed to advocate better for your patient but I believe his smoking break clearly bothered you.

[morte, LPN, LVN]

the patient in the OP was a WALKIE TALKIE no where near your example!

Because many pt's require both. I recently had a pt who required scheduled Methadone, PCA Dilaudid, continuous Dilaudid, clinician-given prn Dilaudid, AND an epidural...the poor man was still moaning in pain. If the physical ability to take PO meds precluded IV meds, we'd have many a patient in agony.

Also, I thought the OP said the EJ was out? He went out to smoke after the EJ was pulled and another IV access established.

[Esme12, ASN, BSN, RN]

Your actions appeared punitive for his smoking. I have worked at many facilities that allow the patient to go out and smoke.

He can have both pain meds alternating to have the best pain Rx coverage unless otherwise indicated by physician order or patient assessment. Telling him when he came back that he has to wait extra long for pain Rx appears you are being punitive for his leaving the floor. something you cannot do. You already medicated 2-3 hours after after po Rx then told him he would have to wait 6 for po medication. The patient had the right to be annoyed.

The IM was Demerol? I guess some places still use this drug.

[BuckyBadgerRN, ASN, RN]

Because facilities just have staff sitting around waiting to take patients out for a cancer stick....sense the sarcasm, but please note it's not directed at you trouble. I know you didn't write the policy!

I suspect withholding the pain meds was a punitive action, decided upon when the pt felt well enough to go out and smoke.

After all, if your lip can pucker up for a cigarette, it can't hurt all that much.

In the past, I've had to fight those judgemental thoughts myself.

The OP has been called out by the patient, and there's no adequate defense for not giving what's ordered.

Where I work, if the patient wanted to make a big enough stink, I'd be afraid for my job. A write up sounds like a gift.

Where I work, patients are allowed to go out to smoke, if accompanied by staff.

[Here.I.Stand, BSN, RN]

the patient in the OP was a WALKIE TALKIE no where near your example!

It was an example, although granted an extreme example. But in between my pt and say an outpt dental surgery, are many many surgical pt's who require a PO med and an IV med for breakthrough.

In any case, both were ordered. It's not really up to us to decide that a pt *should* only have PO, when 1) the MD ordered both and 2) the pt is having pain...and within the parameters of the ordered doses at that.

[AliceTrout]

There are several things about this post that seem like they just shouldn't be as confusing as OP makes them.

1. If a PRN medication for pain is available (as in you are within the time perimeters of when it is due/available) just give it as requested. If patient is requesting PRN pain medication when nothing is available, either try non pharmaceutical methods of pain management and/or call the physician about new orders. Simple.

2. Most facilities I have been to as a family member, patient, student, or nurse will not permit inpatients to leave the building to smoke. Especially if they have IV access! In my facility at least, this topic is covered during the admission process. If I feel that it will be an issue with a patient who smokes, I request a nicotine patch for my patient at that time.

3. Even if your facility does allow patients to leave the building to smoke, this patient was being treated for lip abscesses! This patient of all patients should not be smoking! This is when you could have turned the table from adversary to advocate by ordering your patient a patch to help with the cravings and protect the patient's injury! Granted nobody ever seems thrilled about the patch idea, but it's better than the alternatives.

[mmc51264, BSN, MSN, RN]

Almost all of our pts get scheduled, prn PO and IV for breakthrough. I work on an ortho floor. Sometimes if a pt is there for cultures to come back, they can ambulate, but they are in pain. Ours are allowed to leave the floor, but not if they have a PCA. I would have medicated the way he wanted if it was within parameters.

[Karou]

My facilities pain administration policy is similar. It's very confusing. If a patient has two different medications for pain and one is not specified for breakthrough (both are scheduled PRN), then the "clock" starts over at the last pain med given. Here is an example...

Patient has hydrocodone/acetaminophen 10/325mg PO q 6 hr PRN pain.

Patient also has morphine 2-4mg IV q 4 hr PRN pain

Neither is specified in the administration instructions as "breakthrough" pain. If the pt receives the Norco at 2000, the next available pain med isn't until 0200, after six hours has passed. If there were a "breakthrough" for the morphine then it could be given sometime before that and has its own "clock" . The Norco could still be given at 0200. Without the breakthrough order the pt has to wait six hours for either the morphine or Norco. Then the clock starts over for 4 or 6 hours depending on if the pt takes Norco or morphine.

Also, the pt has to take the Nocro before the Morphine because the morphine is for " breakthrough pain".

When I started I found this policy to be very confusing. I received a warning for giving multiple narcotics for a pt without an order for breakthrough pain on one of those narcotics. Using the above example, I gave the pt Norco at 2000, morphine at 2300, and Norco again at 0200. We also had a nurse warned for giving the morphine (ordered for breakthrough) instead of giving the Norco, which was within timeframe to give. Patient had requested morphine but per policy should have had the Norco first because the morphine would be only for pain breaking through the Norco.

After both incidents we got reviewed on med admin policy. It's now posted in our break room. I do not always agree with this policy and find it can be very confusing at times. But it is the policy. So maybe the OP was told similar at her facility?

[Karou]

Also, our policy for patients leaving the unit is that they must have a physicians order that they may so. We have a few physicians who will consider the pt leaving the unit to smoke the same as the pt going AMA. Once the physician says it is okay the pt still must sign a waiver releasing the hospital of responsibility when they leave.