narcotics????

[erin01]

I am always so careful when i give pain meds... just so paranoid about overdose and respiratory depression. The other day i had a 68 yr old female pt who was 2 days post op after a hip fx. she had very bad copd and had many respiratory meds she took daily, as well as nc 2L and tachypneic and sat was 98%. She was getting loratab q 4hrs alternating with Dilaudid 0.5mgs sq q 4hrs. The orho doc came and she was still complaining of +6 pain so he added oxycontin 5mgs sch bid. I verified with the dr that he wanted her to start the oxy tonight and i stupidly assumed he d/c one of the other meds. Well 6 am rolls around and the patient wants dilaudid only about 5hrs after oxycontin doses. I call our house dr to verify it was ok to give, as i look up these drugs and i know that they can cause resp probs! How do i go about making theses decision on pain management. Am i being overly cautious? Pt was so upset with me that i wanted to check to make sure it was ok to give, as to her the dr told her that oxy was a base for her and lortab and dilaudid were going to be used all the time too! Any suggestions? thoughts?

[leslie :-D]

the oxy will be slowly released throughout the day.

by the time the pt is ready for dilaudid (.5 mgs!), its half-life will have been attained, diminishing its potency.

while i understand your reluctance, you nurses are there to monitor its effects.

it sounds like some inservicing is needed on pain mgmt.

leslie

[FLArn]

Per my patients with bone pain, it is the worst type of pain they have ever had. The Oxycontin is a low dose, the lortab is no more than a glorified tylenol IMHO and the dilaudid dose is not excessive either. The oxy is your base and the other meds are for break through pain. I would ask the patient to scale her breakthrough pain and if less than 5/10 I would give Lortab for 5/10 or greater I would give Dilaudid. You say her sats are in the high 90's and she is tachypneic. 98% sats are unusually good for "very bad" COPD'er and she does not sound like resp distress is going to be a problem for her. I would medicate her to an acceptable (according to her evaluation) pain level.

Definitely monitor her resp but control her pain. If she is in pain she will be less compliant with her rehab PT goals and will heal more slowly.

[erin01]

Thank you for clarifying

[Flo., BSN, RN]

I work on an ortho floor and we give insane amounts of pain meds. The thing I would question about the order is why is she still on shots. Could the lortab dose be increased or the frequency changed to q3? 5mg of oxycontin is not a big dose at all and as previous posters stated it acts as a base drug since it is long acting and you add short acting drugs to it like the lortab. Was she getting a muscle relaxant, if not consider adding one. Muscle spasms do not respond well to narcotics. If you are scared about the resp problems keep the pt on cont. pulse ox and do frequent assesments. Pain meds can be scary but untreated pain delays healing. Where was your charge nurse during all of this? They are a great resource to turn to when you are uncomfortable. The more you are exposed to pain meds the easier it will get.

[HiHoCherry-O]

As long as the patient's vital signs, respiratory rate and arousability are within appropriate ranges I would give the medications, especially if she is still reporting pain. As others have mentioned, establishing a tolerable pain level will enable her to participate in rehab and heal faster.

Does she have a prior history of narcotic use? This may affect her tolerance level as well, meaning she may need a higher dose. Also, I ask my patient's what a tolerable level of pain will be for them, warning them that if "zero" is not possible at this point in time, what is an acceptable level for them.

I believe in medicating for pain and addressing it as quickly as possible, but I also believe that broken bones, major surgery etc is not a pain free process, and with that in mind, I want to establish what level the patient considers tolerable if "zero" is not realistic. 99% of the time my patients are able to pick a number that they can live with and I inform them to let me know when that number is starting to rise. My patient's seem to be pretty happy with this approach and know that I am reliable in keeping up on pain meds so long as safety is maintained. Happy patient, happy nurse!!:)

[scoochy]

This analgesic "recipe" IMO needs some "tweaking." Pain d/t orthopedic procedures is not pretty. Why is this patient on three different opiates? You could suggest to the MD to increase the Oxycontin, thereby giving a stronger dose of slow release, long acting analgesia, with Oxycodone for break-through pain. Lortab can be eliminated.

As FLArn stated, pain must be controlled before a patient will be an active participant in her PT goals and rehab.

[morte, LPN, LVN]

i dont think oxycontin comes in 5 mg tabs.

[Up2nogood RN, RN]

Maybe a dumb question but why did she have O2 on if a COPD'er and sats were 98%? I would have been happier if sats were 90% on RA.

[Forever Sunshine, ASN, RN]

i dont think oxycontin comes in 5 mg tabs.

It does.. they are white. I have a patient on 5mg every 6 hrs and 20 mgs every 12 hrs.