Accused of withholding pain medication

[CaringGerinurse525]

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)' date=' 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?[/quote']

I really don't understand this policy. PRN in itself is used for "breakthrough" pain. As a pp stated if it wasn't for breakthrough pain it would be scheduled. We take prn orders as separate orders. Obviously we use nursing judgement and don't give one med on top of the other without giving the first prn a chance to be effective. I agree that OP withheld pain medication.

[Karou]

I really don't understand this policy. PRN in itself is used for "breakthrough" pain. As a pp stated if it wasn't for breakthrough pain it would be scheduled. We take prn orders as separate orders. Obviously we use nursing judgement and don't give one med on top of the other without giving the first prn a chance to be effective. I agree that OP withheld pain medication.

I am not sure if I got you quoted right Gerinurse, I have never used this function before. I hope it works!

Sometimes I am not sure that I get it either. I follow it, but don't agree with it many times. This is the first place I work that does it this way. Previous facilities always treated them as two entirely separate orders. However, the policy is specific. I agree the OP withheld pain medication. If her policy were like ours she would be in the right, but apparently it is not since her manager agreed she withheld.

[Been there,done that, ASN, RN]

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?

If you find this (most confusing policy ) confusing... so do I.

What is this magic word known as "breakthrough" and what does it mean in the grand scheme of administration?

Is not continued complaints of pain "breakthrough". Are nurses not covered to assume the term "breakthrough' pain?

Your facility needs to define a policy .. that works toward the goal of relieving the patient's pain instead.. of screwing it up with semantics.

[redhead_NURSE98!, ADN, BSN]

An I&D on the lip area sounds quite painful

Which makes me wonder why any facility would allow him to step outside to drag smoke across it. Not my facility, but where a close friend works, stepping outside means you've discharged yourself AMA

Stepping off topic...what does your facility do when they want to come back in after that? Put them back through the ED? I would be ever so happy to AMA anyone who leaves the floor after we've told them not to, multiple times, then comes back in and acts ignorant like they didn't know they couldn't leave.

[redhead_NURSE98!, ADN, BSN]

AND.....out of sight with venous access?? Not in any hospital I have ever been in. We would not even discharge patients home with access for home care if we had reason to suspect 'self-medication" IV of heaven-knows-what!

Yep. Tolerant of narcotics...needs EJ access....abscess...all signs point to high risk patient leaving the floor.

[lmccrn62, MSN, RN]

First your facility needs to review their use of Demerol. This is a medication that is used very rarely if at all. Poor pain medication.

Yes you should have given the patient his pain med when he requested it. If you don't understand the orders then you need to clarify. Hopefully it will serve as a lesson learned.

[trishmsn]

Yep. Tolerant of narcotics...needs EJ access....abscess...all signs point to high risk patient leaving the floor.

My point....I feel like I "know" this patient from dealing with so very many of his brothers and sisters in Florida (HUGE drug problems!). But there really are several issues in this post.....smoking policy, potential for drug abuse and other dangers while unsupervised, and the pain control issue. As to the latter, I would have given him his meds....but I might have called the doc first to get better orders, if not better meds. This ole' hospice nurse HATES Demerol AND polypharmacy!

[Gabby-RN]

If the patient last received the q4h prn Lortab at 2200, they could receive it again at 0200 regardless of any other prn order. The only time it would be appropriate to hold it would be if nursing judgement said it was unsafe to give it - patient lethargic, BP too low, etc. PRN pain medications are for as needed to treat breakthrough pain in my opinion. If a patient states they are in pain then they are in pain. I would assume if the patient received their Lortab q4h and the demerol q6h their pain could very well be adequately managed. As far as the patient smoking, if your facility allows that and you had concern over the patient going outside after receiving demerol you should have had someone go with him maybe and charted rationale. Was his gait unsteady, speech slurred? It is important to use assessment skills and document objective findings.

[OCNRN63, RN]

I don't think you understand the terminology regarding pain management.

Breakthrough pain= pain a patient experiences when he is a long-acting analgesic, e.g. a basal rate on a PCA; MSContin or OxyContin.

PRN pain medication can be used as breakthrough medication, or it can exist without a long-acting med being in place. You can have different PRN medications on their own schedule.

If you had a concern about the patient's med regimen, you should have taken it up with the doc. It's not appropriate to take your irritation with the patient out on him; he's at your mercy. Sometimes you just have to "buck up" and do the right thing, even if the patient annoys you.

Another thing: Why is this patient getting Demerol? Demerol should only be reserved for situations like post-op rigors, chemotherapy-induced rigors, or in situations where it's a one-time dose only. When given frequently, Demerol's active metabolite can lower the seizure threshold.

If the pt. needs pain medication around the clock, he would be better served being placed on a long-acting analgesic, with PRN/rescue doses if needed. When his lip heals, he can be weaned off the meds. There's a formula to calculate PRN doses and convert them to a long-acting med, but I don't want to get into that now.

Consider this a lesson learned. Maybe you could do some CEUs on pain management; that way you could show your supervisor that you took her criticism as a learning experience.

[OCNRN63, RN]

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.

It could have been an opportunity to explain that smoking will not only impair healing, but will increase pain at the site.

[CodeteamB]

OP, you really did need to give those meds when he asked for them, or you needed to call the doc and get the order changed if you felt that the patient's behaviour was unsafe (although I would be trying to lose the Demerol, not the lortab.

That being said, here's a policy for you. We have a very strict no smoking policy. Patients are offered multiple forms of nicotine replacement, but the policy is firm that no smoking can occur on hospital grounds, which are extensive, it's a long walk to get to an acceptable area. I am lucky enough to work in the ER, meaning I have my docs Johnny-on the spot 24/7, so this must be tougher on floor nurses.

If I am giving a patient a narcotic analgesic and they have been going out to smoke I warn them that this means they will no longer be able to go out as I need to monitor them. If they then turn around and say they are going out, I tell them no, they must wait x amount of time (our post narc monitoring period). Most will wait, if they walk out I let them go, chart my conversation and talk to the doc. When they return they will find (depending on level of illness):

A) they are discharged

B) their analgesic options are Tylenol and Ibuprofen

C) they get to choose between AMA papers or following the plan of care

Going off unit with their IV intact, post medication is a liability issue and should be taken seriously, but you need to cover your butt with orders and policy.

[wooh, BSN, RN]

Stepping off topic...what does your facility do when they want to come back in after that? Put them back through the ED? I would be ever so happy to AMA anyone who leaves the floor after we've told them not to, multiple times, then comes back in and acts ignorant like they didn't know they couldn't leave.

I'd really like to hear what facilities REALLY do. Not their "policy," but reality. I remember my old facility changing to this, "Can't leave the floor to smoke without an MD order" policy and asked, "So what do we do if they leave the floor?" Management just kept repeating, "They can't leave." And I kept asking, "What if the MD won't write an order and the patient leaves." They kept repeating, "The can't leave." So I finally just said, "WHAT DO WE DOOOOO?????? Tackle them? 4 point restraints?" Management said, "Use your therapeutic communication skills." Apparently management thought "therapeutic communication skills" were taught in the "magic for nurses" class in school.