okay, this could be a stupid question/story, but my degree is not in nursing - i start this summer
so, when i was in the hospital after a c-section (with my 2nd child) and my son was in NICU - i was prescribed to lortabs (2 every four hours). since i was staying in the hospital, i didn't have to go out and get a prescription - the nurse brought it to me...while i was there.
when i had my first child, i was released from the hospital the next day after my c-section - went to the pharmacy, and took MAYBE 5 or 6 pills once i was home. the rest stayed in my med. cabinet.
but with my 2nd child being in NICU and me being stuck at the hospital without being able to breastfeed, hold him, and do all the things new mothers usually do - i was a nervous wreck and stir crazy - wanting to walk to see him, wanting to walk to the ice machine, wanting to put on make up, wanting to go develop pictures - wanting to do ANYTHING besides sit in the hospital bed without my baby!
point being - since i was doing so much running around, i actually needed the pain meds this time. so, after about 6-7 hours without, i asked the nurse if i could have some and she was nice and brought them to me. i suspected that she'd bring me some 4-5 hours later. when she didn't, i asked again. she brought them to me. i asked if they could just bring them to me when they had the chance (around the time i was prescribed) because i would be needing them and i didn't want to bother them - and she said no, and that i had to ask for them. i felt like a drug addict begging for meds every 4-5 hours! i hated it. and after a few times of asking, i felt like THEY were treating me like one!
why do you have to ASK for pain meds in the hospital when they're prescribed after surgery? i'm sure there's a reason - it just made no sense at the time.
That's been my point all along. PRN pain med administration should be triggered by our pain assessments, and pain should be assessed whether the med is ordered as prn or scheduled. These assessments should occur when the med should have taken effect, as well as when it should have lost effect, which in the case of Vicodin and Percocet would be about 4 hours after it was administered.
If they need it every 4 hours and it's ordered ever 4 hours then there is no reason to change the order. How do you define "occasionally"?
Here we go talking about doing proper pain assessments prior to giving meds - when has anyone ever said on this thread we shouldn't be assessing? That is not the discussion here. The issue is that a prn med is just that - a PRN - do you know what PRN means? I'm not sure. If your patient has an order for Percocet two tabs q4h prn and they are needing that Perc q4h on the nose or asking for it sooner and this has been going on for days then YOU as the nurse need to reassess their meds, either get that Perc ordered for q4h straight or better yet get them on long acting and see if they're needing the prn less. This is initiating proper pain control for your patient. If a prn is being used regularly instead of occasionally then it defeats the purpose of a prn and needs to no longer be a prn. And occasionally is defined as once in awhile not q4h straight. Clear as mud?
Here we go talking about doing proper pain assessments prior to giving meds - when has anyone ever said on this thread we shouldn't be assessing? That is not the discussion here. The issue is that a prn med is just that - a PRN - do you know what PRN means? I'm not sure. If your patient has an order for Percocet two tabs q4h prn and they are needing that Perc q4h on the nose or asking for it sooner and this has been going on for days then YOU as the nurse need to reassess their meds, either get that Perc ordered for q4h straight or better yet get them on long acting and see if they're needing the prn less. This is initiating proper pain control for your patient. If a prn is being used regularly instead of occasionally then it defeats the purpose of a prn and needs to no longer be a prn. And occasionally is defined as once in awhile not q4h straight. Clear as mud?
You may want to re-read the post you quoted, and my other posts for that matter, as I never argued that we shouldn't be doing pain assessments, my point has been that we give pain meds based on a pain assessment, and it's at least partly our responsibility to initiate a pain assessment and do them at a reasonable frequency, rather than do them only by request. Here is the first line of my last post: "As has been re-asserted many times in this thread, we all agree that we need to assess pain prior to giving pain meds." Although it has been suggested that scheduled pain meds don't require a pain assessment in the same way a prn does.
As I've pointed out before, a patient asking for pain meds on a regular basis should trigger more aggressive pain assessments and treatment, not less, we've agreed on that all along.
The purpose of a prn med is to allow for flexibility in dosage and timing based on pt assessment data while still achieving the goal of the med. If a prn is ordered q 4hrs, then yes you can give it every 4 hours unless there is a DNE order, if you want clarification feel free to ask the MD if he wants to add a DNE order or change it scheduled, although in my experience Docs do not like to order vicoden and percocet as scheduled unless the patient is having pain that is not expected to fluctuate. As long it the prn order is sufficiently controlling the patient's pain then it does not defeat the purpose of a prn, rather it fulfills it's purpose which is to adequately meet comfort and activity goals. If a patient has chronic pain which would be expected to be consistent (ie pancreatic cancer) then yes, it makes much more sense to change to a long acting/ scheduled med. While there is an upside to scheduled meds in that I have at times asked Docs to switch a PRN order to scheduled because I've come on shift to find a patient with uncontrolled pain, even though I was told on report the patient is having no pain. In that situation, the only purpose of having it scheduled is to trigger the pain assessments and treatment that should have been occurring with the prn order anyway.
The downside to scheduled pain meds for potentially fluctuating pain levels is that it conflicts with a basic premise of pain control; give the minimum amount of narcotic required to meet the patient's comfort and activity goals. Making a prn scheduled removes the flexibility in dosing and timing that is so important in pain control that is likely to fluctuate. Yes, you could call the Doc every time you want to give 1 tab instead of 2, or give it 5 hours after the last dose, but aside from annoying the Doc since it was your idea to change it to scheduled, we all know that there are many times when RN's will just give it based on the time of day, Doc on call, or how busy they are, which then results in unnecessary narcotic administration.
OCN gets it. I note that she has 25 years experience, and I suspect this is why we are on the same page. We have been there, done that, know better.
Any patient that requests prns in advance, without even knowing if they are going to need them, is demonstrating ineffective coping, at best. And yes, it is a red flag. It raises eyebrows. Reasonable people, after being informed that they misunderstood the meaning of prn, and the role of their nurse, would say "Oh, I wish I had known that. I wish they had communicated that to me more clearly, but thanks for clearing it up." Asking learned, experienced people for their perspective and then telling these same people that they are somehow at fault for failing to agree with her, is a tell tale sign that the individual has an agenda. I made a guess as to what it is (justifying misuse of narcotics) but it certainly could be any number of other things.
Something to note, interventions are not intended to make one pain free, they are intended to make the pain bearable. Only the patient can determine what is bearable, but I think that is oft misunderstood point that needs to be acknowledged I can tolerate at least an 8/10 before taking pain meds, but it neither shocks nor offends me when people with 5-6/10 require intervention. Less than that, well yeah, I start thinking you are just a *ussy, lol, but if it is ordered, and you ask for it, you still get it. All you have to do is call. It isn't that strenuous, and I think c/o that you are required to actually voice your own needs is laughable. But actually, it is the indignation that is the give away.
I've had that same surgery, and I know what it feels like. It is uncomfortable, I took motrin for several days afterward, and that is sayig something because I am loathe to take drugs of any kind. It isn't excruciating. It is odd to me that someone could be certain that they would be in pain four hours from now -severe enough to require narcotics before even trying other measures. Very very odd. Frankly, after 20 years of dealing with patients, I know the difference b/w drug seeking and relief seeking behavior when I see it. But I didn't see the OP, so I can only go by her very odd behavior in this thread. IME, most patients whom are not drug seeking want to take as little medication as necessary, and welcome the assessment and advice of a seasoned nurse to help them achieve optimum comfort with the least amount of chemical intervention and the associated risks and SE profile. Patients who decline to try any other measures, who insist they are entitled to narcotics just because there is a "as needed" order in place, and whom try to justify this behavior by blaming nursing staff for failing to anticipate or meet their perceived needs are a breed that experienced nurses like OCN and myself know how to spot. They cannot be reasoned with, and are usually best handled by being explicitly clear about the orders, and their own responsibility for their needs. I gather from the OP that this is where the staff failed here. They were not clear with the patient about her own responsibility. They should have been.
A patient demonstrating the behavior described in the OP requires intervention to be sure, but I can't say without laying eyes and hands on that they require opiates, and four hours in advance neither can they, lol. Unless of course the primary objective is to be taking narcotics, and not to achieve a measure of comfort. MY goal is the latter. If the pts goal is the former, there is going to be a disconnect. FWIW, I medicate my patients, when it is time even when I know they are seeking. You see, it doesn't matter to me. I'm a big believer in natural selection, and I just don't care if they are addicts or not. I'm going home to my happy, non substance abusing life either way. They are stuck in their own hell, and if they want to get out they will have to ask for help. IF they ask for help, I am going to fall all over myself trying to provide it, because you see, that is why I chose this profession. IF all they want is to be enabled, and they have a valid order, I will do that too. But they still have to ask.
I also have 25 years of nursing experience, and worked ED as a clerk before that. To me your attitude is one of the big problems in nursing...your way or the highway. Your ASSumption of narcotic abuse had no basis in the facts presented and was insulting. The concept that the patient DESERVED assessment Q4 hours OR less is valid in acute care. Your ASSumption that just because you had the same surgery and declined opiates and attempting to extrapolate that to the general population is unscientific and unprofessional. Taking NSAIDS post op can delay healing, do you think that was a wise decision? Declining pain med for yourself is one thing, accusing another of abuse of said med because they chose to use it ONE DAY post op, is again unprofessional
You may be doing as you say, and medicating your patients, but at least a few of them are going to pick up on your attitude.
Here we go talking about doing proper pain assessments prior to giving meds - when has anyone ever said on this thread we shouldn't be assessing? That is not the discussion here. The issue is that a prn med is just that - a PRN - do you know what PRN means? I'm not sure. If your patient has an order for Percocet two tabs q4h prn and they are needing that Perc q4h on the nose or asking for it sooner and this has been going on for days then YOU as the nurse need to reassess their meds, either get that Perc ordered for q4h straight or better yet get them on long acting and see if they're needing the prn less. This is initiating proper pain control for your patient. If a prn is being used regularly instead of occasionally then it defeats the purpose of a prn and needs to no longer be a prn. And occasionally is defined as once in awhile not q4h straight. Clear as mud?
In terms of the discussion here, we are essentially on the same side, although you seem determined to put me in the other group, if I unknowingly kicked your dog or something then I apologize.
To summarize through my admittedly slanted filter: The OP had asked that pain meds be brought to her when they are due, whenever that is. We all agree that we can't just bring pain meds without a pain assessment, and that the OP's request should trigger a re-evaluation of our pain control plan and narcotic use. We also agree that narcotics should only be used after other alternative interventions have not been sufficient. This is where to two groups diverge.
Group A argues that the patient's request should trigger us to more aggressively assess and potentially more aggressively treat the patient's pain, and that while we can't just give the meds q 4hrs we can at least agree to assess the patient's pain q hrs when possible and possibly facilitate more consistent pain med administration.
Group B also believes that the patient's request should trigger a re-evaluation of the patient's narcotic use, but that her request indicates likely narcotic abuse which would potentially decrease the aggressiveness of our narcotic pain control. Also, that the patient must always call for pain meds, and apparently also pain assessments since we agree the two go hand in hand. In other words, 'you snooze you lose' / 'the squeaky wheel gets the grease'.
maybe she thought by coming in the room to see what i was doing, i was being "assessed" but as far as asking me, "are you in pain" or anything of the sort - no, she didn't. the only thing that happened that i would consider an assessment is when i wanted to take a shower. the nurse had me go from the bed to a chair and said she'd come back in an hour and if i was able to get to the chair, sit there with no problem, etc. then i could shower when she came back. i had to have help to the shower and help putting on some funky underwear, but afterward i started feeling better and being more active (so long as i had medication). i never got medication in the middle of the night when i was asleep, but i do remember the pain was always bad when i first woke up and tried to move - and i would wake up a lot earlier than normal like 5am. i'm pretty sure i could've gone with very little medication had i stayed in the bed like i did with my first child, but why would i stay in the bed to keep from being in pain/needing meds when i could take them and be productive.
OP, I'm sure that if and when you complete your nursing studies and begin clinical practice as a nurse your view of "assessment" will continue to evolve.
We could continue to debate all day whether or not your pain was adequately "assessed" -- but I would still wonder why, even if the nurse failed to assess whether or not pain was an issue, an alert and oriented patient would fail to state that she was having pain and request meds if that was what the patient wanted.
i also have 25 years of nursing experience, and worked ed as a clerk before that. to me your attitude is one of the big problems in nursing...your way or the highway. your assumption of narcotic abuse had no basis in the facts presented and was insulting. the concept that the patient deserved assessment q4 hours or less is valid in acute care. your assumption that just because you had the same surgery and declined opiates and attempting to extrapolate that to the general population is unscientific and unprofessional. taking nsaids post op can delay healing, do you think that was a wise decision? declining pain med for yourself is one thing, accusing another of abuse of said med because they chose to use it one day post op, is again unprofessional
you may be doing as you say, and medicating your patients, but at least a few of them are going to pick up on your attitude.
really? you have 25 years of nursing experience? yet you still resort to calling other nurses an ass when you don't agree with the opinion? you think you are pretty clever, don't you? it sounds like you are the one with the your way or the highway attitude.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
really? you have 25 years of nursing experience? yet you still resort to calling other nurses an ass when you don't agree with the opinion? you think you are pretty clever, don't you? it sounds like you are the one with the your way or the highway attitude.
haven't you heard the expression assume = "ass-u-me"? assuming "makes an ass out of you and me". it isn't so horrible an insult that you assume it to be. it's bandied about pretty frequently - i heard it from my instructor in 1975.
I would just like to say that I read most of this thread, and find it rather comical that everyone is so thoroughly debating semantics. PRN stands for "pro re nata" which translates to "per the need." The job of an RN is to assess the patient. If the patient needs the PRN med, you give the PRN med. Many RN's wait for the patient to ask, and many RN's are more proactive. I, personally, believe in taking care of my patients, with some patients that means assessing them whenever the next dose is available. If a patient asks me to assess them whenever the next dose is available, there's no reason not to perform that assessment. I'm not going to judge a patient that recently had surgery for their perceived pain just because I have a higher pain threshold, and I certainly won't write them off as drug seeking on post-op day one or two.
I only shared my experience and perspective, as requested by the OP. *I* have not insulted anyone at any time. That you do not like my point of view does not change a thing. My opinion remains unchanged. I believe it appropriate to admin prn meds if and when they are requested, therefore I believe the OPs nurse acted properly.
I am not nearly as emotionally invested as some appear to be in this topic, so I'll leave it to you.
ocn gets it. i note that she has 25 years experience, and i suspect this is why we are on the same page. we have been there, done that, know better.
any patient that requests prns in advance, without even knowing if they are going to need them, is demonstrating ineffective coping, at best.
::::sigh:::: pain medication only lasts for so long. it would be a rare bird who would not need a dose at the prescribed intervals (when they should be wearing off) right after surgery if that person is mobile, especially.
and yes, it is a red flag. it raises eyebrows. reasonable people, after being informed that they misunderstood the meaning of prn, and the role of their nurse, would say "oh, i wish i had known that. i wish they had communicated that to me more clearly, but thanks for clearing it up." asking learned, experienced people for their perspective and then telling these same people that they are somehow at fault for failing to agree with her, is a tell tale sign that the individual has an agenda. i made a guess as to what it is (justifying misuse of narcotics) but it certainly could be any number of other things.
when did i say you were at fault? what on earth are you talking about? i have gotten lots of responses here, and most people have been rather sensible and not yelling "drug seeker!"
something to note, interventions are not intended to make one pain free, they are intended to make the pain bearable. only the patient can determine what is bearable, but i think that is oft misunderstood point that needs to be acknowledged i can tolerate at least an 8/10 before taking pain meds, but it neither shocks nor offends me when people with 5-6/10 require intervention. less than that, well yeah, i start thinking you are just a *ussy, lol, but if it is ordered, and you ask for it, you still get it. all you have to do is call. it isn't that strenuous, and i think c/o that you are required to actually voice your own needs is laughable. but actually, it is the indignation that is the give away.
i'm really beginning to wonder if you have read even half of what i've said. if you had, you would know i did ask once that particular nurse wanted to be a stickler about it, but my intent which i have stated repeatedly was to not have to bother the nurse - not because it was "strenuous."
i've had that same surgery, and i know what it feels like. it is uncomfortable, i took motrin for several days afterward, and that is sayig something because i am loathe to take drugs of any kind. it isn't excruciating. it is odd to me that someone could be certain that they would be in pain four hours from now -severe enough to require narcotics before even trying other measures. very very odd.
would you like an award? i know what it feels like also - i know what it felt like both times. each time was different. i find it hilarious that you are assuming i'm a drug seeker - absolutely hysterical!
the only times i've been given narcotics were when i had the c-sections and two other times in my life (when i really didn't even need them, actually). i too did fine without pain medication the first time. i was also mostly lying around. the second time i did need them - i was active and in pain. i see nothing odd about taking two 5mg lortabs every 4,5,6 hours when you're able to take them every 4 even if you're lying like a bump on a log. what are these "other measures" that you think i should have and say i didn't try?
frankly, after 20 years of dealing with patients, i know the difference b/w drug seeking and relief seeking behavior when i see it. but i didn't see the op, so i can only go by her very odd behavior in this thread. ime, most patients whom are not drug seeking want to take as little medication as necessary, and welcome the assessment and advice of a seasoned nurse to help them achieve optimum comfort with the least amount of chemical intervention and the associated risks and se profile. patients who decline to try any other measures, who insist they are entitled to narcotics just because there is a "as needed" order in place, and whom try to justify this behavior by blaming nursing staff for failing to anticipate or meet their perceived needs are a breed that experienced nurses like ocn and myself know how to spot. they cannot be reasoned with, and are usually best handled by being explicitly clear about the orders, and their own responsibility for their needs. i gather from the op that this is where the staff failed here. they were not clear with the patient about her own responsibility. they should have been.
a patient demonstrating the behavior described in the op requires intervention to be sure, but i can't say without laying eyes and hands on that they require opiates, and four hours in advance neither can they, lol. unless of course the primary objective is to be taking narcotics, and not to achieve a measure of comfort. my goal is the latter. if the pts goal is the former, there is going to be a disconnect. fwiw, i medicate my patients, when it is time even when i know they are seeking. you see, it doesn't matter to me. i'm a big believer in natural selection, and i just don't care if they are addicts or not. i'm going home to my happy, non substance abusing life either way. they are stuck in their own hell, and if they want to get out they will have to ask for help. if they ask for help, i am going to fall all over myself trying to provide it, because you see, that is why i chose this profession. if all they want is to be enabled, and they have a valid order, i will do that too. but they still have to ask.
Well, after reading aaall of these responses, it seems to me that there is a policy to be followed, BUT the nurse has some discretion.
In my experiences, both at the same hospital (which would have the same policy both times), the nurses clearly had different opinions and methods just like on this board.
The first time, my nurse was asking ME about my pain and offering medication. Sometimes I took it, sometimes I didn't. It mostly made me fall asleep and they ended up switching the prescription. I was afraid I would drop my baby after dozing off. :)
The second time, I was never, ever asked about pain. I would ask, "can I get some pain medication" and again maybe 6 hours later, "can I get some pain medication." As I said, after a couple times of doing that and the nurse still not asking any questions or making any comments like, "sure - they should last at least X number of hours, but they may last longer than that - just let me know if you're in pain again." you DO feel like a nuisance and like you're "begging for drugs" as I stated in my original post.
nobody who legitimately would be expected to be in pain 24-48 hours after surgery or however long it may be! should not be made to feel like a "drug seeker." we're talking about surgery - not some man who smells like beer coming into the ER and saying he fell and hurt his back.
Anyhow, I've experienced both types of nurses regarding their philosophies when it comes to handling pain meds apparently and I was much more comfortable and happy with the nurse who was pro-active (EVEN if i didn't accept the medicine) than the one who would just hand me the cup every time i asked, only when i asked and never say a word. Thanks for everyone's responses - even the nurse Ratchet's as a pp metioned
:yawn:
Belle Epoque
156 Posts
Here we go talking about doing proper pain assessments prior to giving meds - when has anyone ever said on this thread we shouldn't be assessing? That is not the discussion here. The issue is that a prn med is just that - a PRN - do you know what PRN means? I'm not sure. If your patient has an order for Percocet two tabs q4h prn and they are needing that Perc q4h on the nose or asking for it sooner and this has been going on for days then YOU as the nurse need to reassess their meds, either get that Perc ordered for q4h straight or better yet get them on long acting and see if they're needing the prn less. This is initiating proper pain control for your patient. If a prn is being used regularly instead of occasionally then it defeats the purpose of a prn and needs to no longer be a prn. And occasionally is defined as once in awhile not q4h straight. Clear as mud?