Is my NM whack or is it just me? - page 2
I work on a busy orthopedic floor. We receive a lot of post-op patients. I work the night shift. The other night I medicated a patient of mine times 1 for some pain she having. After that, she was... Read More
May 8, '09All nurse managers are whack. End of story. :spin:
Even the great ones have some thing that is out of whack.
May 8, '09I recently had spine surgery (PLIF 3 levels) and I was in constant pain, I know when I was in pain I asked for my morphine and lortabs (surprisingly worked better then morphine) every 3 hours, but often at nights I'd be awoken in pain and then left in pain by certain nurses I work with.
It's a catch 22 and unwinnable, but I personally never said anything about it. Some patients do but they should had spoken up, I didn't.
May 8, '09Uh, PCA anyone? Why would you have a post op patient without a PCA? Pain control is big sentinental event for JACHO so why aren't your patients on PCAs? Then the patient can medicate away the pain!
May 8, '09Quote from Gr8DaneYou work with these people???? You can bet your sweet momma you should say something! I'd be giving them an earful.....and a nice slap upside the head to boot :angryfirebut often at nights I'd be awoken in pain and then left in pain by certain nurses I work with.
I think giving pain meds certainly requires best nursing judegement. Some people can withstand ungodly amounts of pain and not appear to be in distress, either visually or vital sign-wise. These folks are probably good with being checked on periodically (say every 4 hours if they are sleeping). Then some people stub their little toe and have 11/10 pain.....these folks might need to be awakened every 3 hours to check their pain levels....pain is very difficult to get a handle on once it gets out of control. PCA post op,or something similar,(I had a nifty thing called an On-Q with my c-section recently....sub-cutaneous lidocaine(?) infusion at incision site....worked better than a PCA for me...) would really be in order, I would think, rather than relying on PRN pain meds, at least for 24 to 48 hours post-op. It is a system problem, not an individual nurse's problem. Your NM needs to use some nursing judgement herself to try to help fix the issue.
May 8, '09I don't work night shift, but I like the idea of talking with your patient at the start of your shift about pain management. Do they want to be woke up when meds are due or would they prefer to call you? And then document the conversation. I once had a patient I had talked to about his pain and what he would prefer. We had it figured out, he seemed happy. Well apparently his wife wasn't happy because I didn't give him anything (he didn't want any pain meds at the time). She went to the supervisor, but it was fine in the end. I medicate the patient's pain, not the families.
May 8, '09Quote from It'sMe, RN, BBA, MBAMy IV blew at 0200 and although they tried a few times, they couldn't get a new one in. So...end of PCA. The next thing I knew, it was 0830. After a good long primal scream, day shift nurse came running in with an IM. Bingo. Everyone's happy.Uh, PCA anyone? Why would you have a post op patient without a PCA? Pain control is big sentinental event for JACHO so why aren't your patients on PCAs? Then the patient can medicate away the pain!
May 8, '09The answer would be YES...BTW, most hospitals require a follow up to determine pain med effectiveness...some require you to ask the patient their current pain level on a scale of 1-10 within an hour of medicating. If your hospital does not, I would do it as my own personal nursing practice. And document their response. Finally, it irks me that this patient wouldn't call out for pain med if he/she were in pain. Most patients are skilled at using that call button.
IMHO sleeping in a hospital should be solid evidence that this patient was very likely not in pain "all night". LOL
May 8, '09I think you're reasoning for not waking the patient was sound although I do understand that its important to medicate before pain becomes severe. I think you could argue this either way.
I liked another person's suggestion of asking the patient what they prefer...do they want you to wake them up or not. Ask them and then chart their response (although I wonder if it would be enough for JCAHO if they said they did not want want to be woken?). If you're having to wake them for vitals then you might as well go ahead and reassess pain though.
May 8, '09WOW! I thought I worked at podunk hospital but from some of these responses I must work at Cutting Edge Medical Hospital! Again, JACHO requires followup on pain rx administration, 1 hour after IV/IM and 2 hrs after PO. We are on EMR (electronic medical record) so it forces you to put in a time to go back and check on effectiveness. Patients serious enough to be in hospital post-op are serious enough to be work up at least every 4 hours and more often if requiring pain rx.
From 0200 to 0830 with no IV and no pain RX intervention? Someone would be written up and their final exit interview done by 0830! Call the ICU, call the Supervisor or call the ER attending but someone is coming up to get the IV in and the PCA going again within one hour. Or a call is going to hospitalist or attending and pain RX is going to be ordered and given IM or PO. Our hospital operates 24 hours a day (yes, I know yours does too) and it doesn't matter that it is 0200, someone is going to resolve the patient's need for pain rx.
And the nursing care plan calls for patient nurse conference on every shift to discuss pain management as routine for Surgical Standard of Care. You have to click on it and answer the questions related to teaching patient pain management. Our night shift is 1745 to 0615 so you have plenty of day light time to discuss "how do you want to handle your pain medication tonight?" I even wake my patients up and ask them if they are okay and have they hit their PCA pump button ("your button" as we like to call it) and then they usually say "oh, I meant to" then you hear "ding!" and the PCA whirs and the patient drifts off to happy land. Happy patient=happy MD=happy NM=happy floor nurse.
Now my hospital is instituting a new procedure. Hourly rounding. Every hour either the nurse or the PCT will physically enter the room, stand at the bedside and then document. We will have a sheet in the room that says "I was here." Proof that someone checked on the patient every hour. Interesting.
Oh, and finally, the real problem here is the patient. Do any of us really believe that this patient was "in pain all night?" Doubtful. They could have asked for pain rx. So we create yet another layer of defensive practice to ward off any negative results even though we know some patients just like to complain. Just like me!
May 8, '09When I worked nights, I usually asked earlier in my shift if the patient wanted to be woken up, and documented as such. If they had an issue later, I'd remind them of what they told me.
However, I do agree with whoever said that patients are expecting more and more to have meds brought to them without being asked. I had a patient yesterday afternoon in fact...I was bringing him his PO pain meds (we were getting him off the PCA, doc had increased the freq of the pills) and I was surprised to find him still using the button (day RN told me she stopped it, apparently she hadn't). I asked him why...he said "well no one has brought me any Percocet in a really long time." The "really long time" was 4 hours and 40 minutes (and it was q4h prn). He hadn't asked for any, either....I was bringing them in to stay on schedule. But good grief.....don't people ring any more?
May 8, '09Quote from it'sme, rn, bba, mbai agree with you about pcas, but. the pca decisions are made above my pay grade: it takes a provider to order one and a management team to commit to using them and buy the machines, tubings, cassettes, etc. in the first place.uh, pca anyone? why would you have a post op patient without a pca? pain control is big sentinental event for jacho so why aren't your patients on pcas? then the patient can medicate away the pain!
May 8, '09Could I just defend our patients for a little bit again please. Yes they are capable of asking and letting us know when they are in pain, but from my personal experience recently I didn't. Not because I expected the nurses to know that I needed something but for a few reasons.
Firstly I didn't know if my analgesia was due and I didn't want to appear too needy by asking if it wasn't, I had no concept of time passing so 5 minutes seemed like hours especially when I was hurting.
Secondly I didn't want to bother the nurses, they were busy enough and there were sicker patients than me that needed their attention, I didn't want to take them away from someone who may have needed the nurses more than me.
Thirdly, I didn't want to seem like a drug seeker, I know this sounds silly but because I wasn't aware of time I didn't want to be asking for analgesia if I'd only had it an hour ago.
Lastly, even though I am sure I wasn't in pain all night it felt like it because the period of time I was in pain seemed like so much longer than the time I was comfortable.
Pain does strange things to people, it can change the way they act and it makes you miserable.
I like the idea of asking the patient how they want their analgesia needs met during the night
May 8, '09Patients have the right to be completely free of pain..........the 6th right to medication.
Although it may not be board sanctioned in every state, it is being lobbied by many.
So, in many facilities and hospitals its now required to ask pts if they are in pain on a scheduled basis. Have even had this written as an order on the MAR. Not to be accused of shirking my duties, I dutifully awaken pts on a regular basis and ask "Are you having any pain? On a scale from 1-10, how would you rate your pain?" And, according to their answer, provide the pain meds just as ordered and document everything about the episode, including the cursing out I received for waking him/her up in the first place! Then, its usually the pt giving the MD the reaming out for having such a rediculous order as to wake them up in the middle of the night to ask if they're in pain. You'd be surprised how quickly that order is changed to ........"while awake".