Can you become a PACU nurse w/o experience

azhiker96, BSN, RN · Feb 9, 2016

Maverick, what was the hx of the pt that took 63 mg of dilaudid? That's impressive.

Mavrick, BSN, RN · Feb 9, 2016

Totally a new high. My previous record was 23 mg of Dilaudid.

The guy had chronic pain and was on Opana so even after the 63mg of Dilaudid I got some of his own stuff to keep him at baseline.

One of my workmates was also impressed with my "collection".

All but one of these are 2mg syringes.

offlabel · Feb 10, 2016

A not uncommon order is "whatever you think". After getting an order for 8mg of Dilaudid for pain the Doc started another case and was not readily available. In the next hour and a half I gave 63 mg of Dilaudid IV using my clinical judgement as my guide.
"

So, something didn't seem wrong after, say, 40 mg?

twozer0, NP · Feb 10, 2016

Totally a new high. My previous record was 23 mg of Dilaudid.
The guy had chronic pain and was on Opana so even after the 63mg of Dilaudid I got some of his own stuff to keep him at baseline.
One of my workmates was also impressed with my "collection".
All but one of these are 2mg syringes.

HOLY ****! I thought my 1400 mcg Fent, 10mg Dilaudid, 30mg morphine patient was a record, this totally destroys it! We put this patient into the K hole after this.. rather the K canyon, it had some deep ravines!

azhiker96, BSN, RN · Feb 11, 2016

Thanks Mavrick. That makes sense.

I had a pt once who took morphine like I was pushing water (order was 2mg q5min prn x 5 doses). She said 4 mg of Dilaudid usually helped her. In the chart from her care facility I found she took 120mg Oxycontin bid with 4mg Dilaudid prn for breakthrough pain. They had held her morning dose because of NPO order for surgery.

I called anesthesia with this information. He laughed and said "We're not even close are we?" He gave me orders for her baseline oxy and enough dilaudid to take the edge off while waiting for the oxy to kick in.

Mavrick, BSN, RN · Feb 11, 2016

So, something didn't seem wrong after, say, 40 mg?

Not sure what you mean by "wrong". Of course, by 20mg I was thinking "this is gonna take what it takes" and I was relying on my assessment and clinical judgement to guide me as we were already way out of the ballpark of usual/normal doseage.

This is an example of nursing judgment, not some preprinted number on the order sheet. At 40mg, then 50mg, then 60mg, the guy was still in pain, not comatose as might be expected of anyone else.

ms boogie, BSN, MSN · Feb 12, 2016

Totally a new high. My previous record was 23 mg of Dilaudid.
The guy had chronic pain and was on Opana so even after the 63mg of Dilaudid I got some of his own stuff to keep him at baseline.
One of my workmates was also impressed with my "collection".
All but one of these are 2mg syringes.

I thought you were going to say Sickle Cell crisis

offlabel · Feb 12, 2016

Not sure what you mean by "wrong". Of course, by 20mg I was thinking "this is gonna take what it takes" and I was relying on my assessment and clinical judgement to guide me as we were already way out of the ballpark of usual/normal doseage.
This is an example of nursing judgment, not some preprinted number on the order sheet. At 40mg, then 50mg, then 60mg, the guy was still in pain, not comatose as might be expected of anyone else.

Google 'opioid induced hyperalgesia' and 'central sensitization'. As we encounter more and more and chronic pain/chronic opiod users, we'll need to get out of the "normal" patient paradigm when dealing with them.

twozer0, NP · Feb 12, 2016

Google 'opioid induced hyperalgesia' and 'central sensitization'. As we encounter more and more and chronic pain/chronic opiod users, we'll need to get out of the "normal" patient paradigm when dealing with them.

I agree that we need to decrease opiod usage around the gamut but you have to think that this is the recovery setting and this problem transcends our scope. This would be an issue that is up to whomever is prescribing the patients opana as he is obviously way above baseline (and should have never gotten that far). Mavrick was just doing his job with the resources available to him, something I also would have done if put in that situation. Our jobs are to manage airway, control pain (as best we can), and facilitate the continuum of care from the anesthesia provider. What we cannot do is solve chronic problems in the recovery room.

offlabel · Feb 12, 2016

I agree that we need to decrease opiod usage around the gamut but you have to think that this is the recovery setting and this problem transcends our scope. This would be an issue that is up to whomever is prescribing the patients opana as he is obviously way above baseline (and should have never gotten that far). Mavrick was just doing his job with the resources available to him, something I also would have done if put in that situation. Our jobs are to manage airway, control pain (as best we can), and facilitate the continuum of care from the anesthesia provider. What we cannot do is solve chronic problems in the recovery room.

Good discussion... the anesthetist is the one to consult in recovery for patients like these and, sadly, they may not be skilled at getting these patients under control either. This is where the bedside nurse, thinking outside of the box, can make a monumental contribution to getting the patient back to his baseline pain score.

These patients require a specific plan that includes (but is not limited to) a multimodal approach in which narcotic is just one part. Ketamine, precedex, iv Tylenol, toradol, COX II inhibitors, peripheral nerve blocks....

As more and more of these patients come through our PACU's, it will become critical for us to become experts at treating acute surgical post operative pain superimposed on a chronic pain/ opioid dependent picture.

twozer0, NP · Feb 12, 2016

Good discussion... the anesthetist is the one to consult in recovery for patients like these and, sadly, they may not be skilled at getting these patients under control either. This is where the bedside nurse, thinking outside of the box, can make a monumental contribution to getting the patient back to his baseline pain score.
These patients require a specific plan that includes (but is not limited to) a multimodal approach in which narcotic is just one part. Ketamine, precedex, iv Tylenol, toradol, COX II inhibitors, peripheral nerve blocks....
As more and more of these patients come through our PACU's, it will become critical for us to become experts at treating acute surgical post operative pain superimposed on a chronic pain/ opioid dependent picture.

In a perfect world everyone would receive regional anesthesia but unfortunately that rarely happens (at least at my facility). You bring up good information with the multimodal approach and a lot of patients are done this way. Toradol is used readily and we rarely use COX II since we are already blocking both with toradol. IV tylenol was used but it was determined to be too expensive to its benefit and thus was shelved at my facility. Its really up to the doc and the patients history that dictates anesthetic approach, IE lumbar fusions hx do not get spinals for TKA. Then you get into the customer satisfaction area. The whole process is a mess and a lot of the time, you just end up giving them what they want, opiates.

But yes I agree, Multimodal is a great approach but its not really up to me, its up to the provider. I can load the gun but I cant pull the trigger!

offlabel · Feb 12, 2016

Well, how about a nursing led initiative for chronic pain strategies in the PACU? Would take some doing, like anything worth while does, but with leadership, it could be of immense benefit to a lot of patients. Not to mention the gratitude of surgeons.

Like a guy once said, objects that flow the direction of the river are dead... it takes being alive to swim up stream...