At my new job... a few of the nurse managers have been telling us who work the floor that if we administer a PRN for pain that doesn't have a pain scale given as a parameter, that our licenses are in jeopardy.
Say, if there's an order for morphine 1mg, ivp, q6h, prn, for pain... without a specific pain parameter say like "5-10" or what ever the doctor wants it to be ...
that we shouldn't be giving the medication until we get a specific pain scale range to use.
Although I have limited experience working at another hospital and a snf, I have never been told this before and was wondering if this is normal?
Also, say if a doctor orders a foley.... and doesn't write in their notes specifically WHY...we nurses are supposed to call the docs and get a specification as to why.
And just today, I opened my work email only to discover another NASTYGRAM about how if we nurses are not repeating orders back to physicians that we are supposedly "out of our scope" and "prescribing without a license" and that our nursing license is "in jeopardy" if we fail to repeat back orders. Yes, I learned in school to read back all orders. I know it's the right way.
Your employer sounds nasty and not someone I would want to work for. It's unlikely you would lose your license but that employer probably finds issues to suspend and terminate people.
I can count on one hand, in my 12 years of nursing, that a provider has written for prns to be based off the pain scale. I think ordering meds that way is extremely simplistic; I mean the 1-10 scale is so subjective, and doesn't take into account physiological and non-verbal s/sx of pain.
Quick example: a while back I took care of a sheriff's deputy--big burly guy, your stereotypical "man's man," and extremely stoic about pain. He had a bunch of broken ribs (and a reeeeeally ugly femur fx) so really needed quite a bit of pain meds...he'd get tachycardic into the 130s (with no other explanation--not dry, not septic, etc.), and tachypneic if he didn't take enough pain meds. But he'd always rate his pain from 3-5, say it's not that bad, and that he doesn't want to "use that **** as a crutch." I told him that ultimately it's his decision, but explained to him physiologically what I was observing--unable to breathe deeply, pulse way too high etc.--that I was concerned that he would decompensate if that kept up, and that I really felt it would be appropriate for him to take more pain meds. Had his order said give 5 mg oxy for pain scale 1-6, 10 mg for 7-10, and Dilaudid 0.2-0.4 mg for breakthrough pain 6-10, and had I simply taken his report of "3," he would have been significantly undermedicated. He could even have developed pneumonia as a result of not being able to properly cough'n'deep breathe, or his heart could have suffered from those sustained high rates.
On the other side of the scale, I have heard of RNs telling patients something to the effect of "A 10 is like having your limbs ripped off and then set on fire," or some other exaggerated reference like that. I've rated my pain 10/10 during the transition phase of labor, with corneal erosions, and with dry sockets after having my wisdom teeth out. My experiences were horrible but likely don't compare with getting your limbs ripped off and being set on fire... so then the pt says "okay, I guess my pain isn't that bad. Maybe it's a 6?" Perfect, you get 5 mg oxy per the order. I've never had big surgeries or anything to compare to, but with my examples of corneal erosions and dry sockets, I can promise you that 5 mg oxy would be completely insufficient.
Seriously, professional nurses have nursing judgment. If they didn't want nursing judgment, why don't they just hire monkeys?
Specializes in Psych, Addictions, SOL (Student of Life).
At my new job... a few of the nurse managers have been telling us who work the floor that if we administer a PRN for pain that doesn't have a pain scale given as a parameter, that our licenses are in jeopardy.
Say, if there's an order for morphine 1mg, ivp, q6h, prn, for pain... without a specific pain parameter say like "5-10" or what ever the doctor wants it to be ...
that we shouldn't be giving the medication until we get a specific pain scale range to use.
Although I have limited experience working at another hospital and a snf, I have never been told this before and was wondering if this is normal?
Also, say if a doctor orders a foley.... and doesn't write in their notes specifically WHY...we nurses are supposed to call the docs and get a specification as to why.
New rules for Medicare reimbursement state that all pain medications need to be accompanied by a pain scale. Most computer generated orders for non-opioid pain meds now default to mild to moderate pain scale 3-5/10 and ask for a progress note indicating pain level with a follow-up progress note for effectiveness also indicating anew pain level. Opioid is my facility have to be for moderate to severe pain 6-10/10.
Also for Medicare reimbursement Foley's have to have a medical reason such as neurogenic bladder. agree with this because long term foley use is just an invitation to the little critters that cause UTI. Ay our SNF we try to pull the foleys that don't have a medical necessity and opt for check and change.
And just today, I opened my work email only to discover another NASTYGRAM about how if we nurses are not repeating orders back to physicians that we are supposedly "out of our scope" and "prescribing without a license" and that our nursing license is "in jeopardy" if we fail to repeat back orders. Yes, I learned in school to read back all orders. I know it's the right way.
Yes, reading back orders is proper, but my question would be, how are they monitoring whether or not it was done? Any possible answer that I can conceive of would make me want to quit on the spot!
New rules for Medicare reimbursement state that all pain medications need to be accompanied by a pain scale. Most computer generated orders for non-opioid pain meds now default to mild to moderate pain scale 3-5/10 and ask for a progress note indicating pain level with a follow-up progress note for effectiveness also indicating anew pain level. Opioid is my facility have to be for moderate to severe pain 6-10/10.
You are correct and this is where it is coming from. I also believe Medicaid reimbursement may be affected by this.
Our institution has already built pain scales and classifications of pain (mild, moderate, or severe) into our EMR system. If a patient has 2 medications (Tylenol and Morphine) the practitioner must write which medication may be used under which circumstance. For example: Give Tylenol 650 mg by mouth every 4 hours prn mild to moderate pain. (or pain score of 1-5). Give Morphine 2mg IV for moderate pain not relieved by Tylenol in 1 hour or severe pain. (or it could be ordered for pain rated a 6-10)
OP, before you run from your job as others have suggested, maybe you should consider there will always be new rules and new guidelines and some we cannot control.
While this is not something you are likely to lose your license over, not complying could cost you your job.
And just today, I opened my work email only to discover another NASTYGRAM about how if we nurses are not repeating orders back to physicians that we are supposedly "out of our scope" and "prescribing without a license" and that our nursing license is "in jeopardy" if we fail to repeat back orders. Yes, I learned in school to read back all orders. I know it's the right way.
Sigh. Wish you were kidding about this. Again, sounds to me like reimbursement issues that someone was dinged on, so they are making stuff up....
Is your supervisor a nurse? A nurse who has practiced recently? Or even one that realizes that most nurses practice read back order taking?
If this is a surgery center, perhaps the supervisor could think about standing orders?!?!?! Chart audits right away so that specific things can be dealt with then and there instead of threats?
Specializes in orthopedic/trauma, Informatics, diabetes.
I work on an ortho floor and all of our prn pain meds are ordered with a scale. Also, we do not take verbals unless it is an urgent situation and then we have to make sure they put the order in that will link to an override med. many of our meds cannot be overriden.
Hmm... Very heavy handed management. These days of computer charting and lots of auditing makes hiding out on nights and weekends to avoid management all that much harder.
Cola89
316 Posts
And just today, I opened my work email only to discover another NASTYGRAM about how if we nurses are not repeating orders back to physicians that we are supposedly "out of our scope" and "prescribing without a license" and that our nursing license is "in jeopardy" if we fail to repeat back orders. Yes, I learned in school to read back all orders. I know it's the right way.