Administering pain meds to a sleeping pt

[opossum]

I'm a new nurse and recently received my first "negative" comment on a patient survey.

Pt was a young woman s/p lap appendectomy; she complained that I "must have forgotten" about her pain meds and claimed that I medicated her once at 11pm and that she woke up in severe pain at 6am...saying it was too long to go without pain meds. According to a note I wrote in my documentation, I medicated her twice during my 11pm-7a shift...I didn't go back and consult the MAR, which would definitely have a more accurate record of when I gave the meds.

I can't help but feel bad about all this...I almost feel betrayed in a weird way, since I felt I had a good rapport with her. I remember being concerned about her pain, explaining that the PO meds were "long-acting" and that IV Dilaudid would be for breakthrough pain. I remember checking in on her a couple of times and she was asleep. I had other pts that were less stable, and figured if she's sleeping, she's relatively "OK'.

I *now* realize that just because a pt is sleeping, that does not mean they are not experiencing pain. I can't remember what the orders were, but I'm guessing the PO was q4 hrs...and if what she says is correct, that I medicated her at 11pm (actually unlikely, given that my shift starts at 11pm and by the time I finish taking report and looking over charts, I don't start rounding until closer to midnight), then I probably could have given her another PO around 4am, which I must have missed.

But would you wake a sleeping pt to give them a PO pain med? I guess that's my big question here...I feel a little weird giving any pain med to a sleeping pt (unless they are on a vent, sedated, etc.) - not because I think they are pain-free while asleep, but because I don't want to disturb their much-needed sleep and jostle them awake just so they can focus on their pain again - does that make sense? Or am I talking crazy here...

Any thoughts/advice on this is appreciated...

[rn/writer, RN]

"Sit and twirl." I'm going to keep that one for future use.

[vashtee, RN]

I don't wake sleeping patients for PRN pain medications (unless terminal) if they appear to be comfortable. Am I the only one who uses the FLACC scale to assess for pain?

[mbuchanan2107]

When I worked night shift I would talk with my patients that I thought would have more pain before they went to sleep. I would give them their nightly meds and ask if they would like to just be left alone throughout the night, or would they like me to come and wake them to take them and they can decide if they want to be medicated. Only a few times did I medicate with IV narcotics when someone was asleep, and that would be the med seeker that no matter what would request the meds exactly on time and I can verify they get it say Q4hr on the dot for the past few days. Being a newer nurse you have to learn judgement calls, but you need to always make sure you are looking out for the patient. They do not know how some of the meds work like you do, and what they "think" could harm them. Don't worry, it is one survey and one patient. You will get more that just don't like you for whatever reason or give you a bad review.

[MunoRN, RN]

I don't wake sleeping patients for PRN pain medications (unless terminal) if they appear to be comfortable. Am I the only one who uses the FLACC scale to assess for pain?

FLACC is for pediatric patients or patients without verbal abilities, it is not validated for use in sleeping adults.

Patients can be asleep and appear comfortable and still be experiencing significant pain and/or get behind on their pain control.

[MunoRN, RN]

Yeah, sometimes it sounds like we get bonus points for every PRN med we don't give. With that in mind, we surely wouldn't want to bring the subject up. And if a call bell goes off and someone actually asks for one, dang! there go those points.

It'd be funny if there weren't nurses who actually function like this. I know, because I've had some of them. And so have family members.

We ARE supposed to bring up the subject and assess, with the patient, whether additional meds are needed or not. That's a big part of our job!

And when they do call to ask then we label them as a "seeker"; either way they lose.

[xtxrn, ASN, RN]

When I worked night shift I would talk with my patients that I thought would have more pain before they went to sleep. I would give them their nightly meds and ask if they would like to just be left alone throughout the night, or would they like me to come and wake them to take them and they can decide if they want to be medicated. Only a few times did I medicate with IV narcotics when someone was asleep, and that would be the med seeker that no matter what would request the meds exactly on time and I can verify they get it say Q4hr on the dot for the past few days. Being a newer nurse you have to learn judgement calls, but you need to always make sure you are looking out for the patient. They do not know how some of the meds work like you do, and what they "think" could harm them. Don't worry, it is one survey and one patient. You will get more that just don't like you for whatever reason or give you a bad review.

How about the patients YOU didn't think would have more pain? What happened to them? Were those the med seekers?

[rn/writer, RN]

And when they do call to ask then we label them as a "seeker"; either way they lose.

They don't get labeled seekers by me. I tell my patients to call, even if they said earlier they were fine and were sure they wouldn't want anything until morning. I make it clear that they can change their mind at any time, and I'll get what's ordered, so long as we stay within the prescribed boundaries.

I don't believe I get bonus points for every PRN net administered.

[chevyv, BSN, RN]

I would not want to be woken up for a pain med. It's hard enough to get sleep when your a pt in a hospital so I would not have woken them up to offer pain meds. If your in pain, you wake up. I like the comment about asking before they go to sleep to see if they would prefer being woken up. I'll do that from now on.

[linearthinker, DNP, RN]

Only read the OP. Short answer, no, never.

[linsmirn]

just out of school here so i'm not speaking from experience. i was thought just because a patient is sleeping doesn't mean they don't have pain, so i would wake them and apologize and ask if they are in pain.

[MunoRN, RN]

Only read the OP. Short answer, no, never.

It's never appropriate? Any particular rationale behind that?

[Spritenurse1210, BSN, RN]

I always educate the patient about which pain meds are scheduled and which ones they have to ask for. I wake patients up for scheduled pain medications. Depending on the reason the patient is on my floor is if I wake them up for prn pain meds. We get a LOT of cancer patients and patients that are not able to vocalize their discomfort. For these patients I give them prn pain medications when I can as ordered by the doc and as long as they're not sedate. Also if the patient is contracted and or has a feeding tune, you bet I'm giving them something for pain ( usually those I get can't talk or communicate at all) relax and realize that patients are fickle. Make sure to document and follow md's orders and you will be fine. Also if the pain meds that are ordered aren't working for the patient the md should be notified.