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.
I would think you would get into more trouble for leaving a patient writhing in pain but...maybe that's just me.
You would think. I still give the prn pain meds weather they have a scale attached yet or not. The managers have been doing the job of looking through each patient's EMAR and when they see that a doctor's prn pain medication order doesn't have a specific "pain scale # range" to give it, they say 'oh, looks like you'd better call up dr. suchandsuch and get a pain scale for which to give this med by. we don't wanna risk our licenses!!' That's what they say. The floor nurse managers are RNs too.
IMO, you can't lose your license for there not being a pain scale for PRNs. However, if it's your facility's P&P to have a pain scale present on all PRN orders, then your job could be at risk. Though it would be the MD who determines the scale, I would think?
It may be required for Medicare and Medicaid reimbursement, but that doesn't put a nurse's license in jeopardy. There's a huge difference there. Insurance reimbursement and laws are two different things. I'm surprised though that your charting system doesn't have you put a pain scale number in when charting meds. Every charting system I have seen will not let us exit the MAR without typing in a number in the pain scale. I don't get why any type of management would threaten with losing your license. Why not say we won't get reimbursed if you don't type in a pain scale number, therefore if you forget first time a warning, second time a write up and so forth. Telling out and out lies does not get compliance, rather it gets defiance.
Today, I did clinical on an OB floor. We had a patient that was knowledgeable and wanted to stay ahead of her pain. When I did vitals, she told me her pain number was a 2. She knew the next dose was around 9:30 for the narcotic. She had been alternating ibuprofen and the narcotic. I told her to call me when it was time. We pulled it, gave it to her at 9:30, asked her pain scale later, it was a zero, no pain. This is a woman that did labor without an epidural or any kind of pain medication so she is a tough cookie. There was no problem giving her the narcotic. I charted the pain number and that was it. She was also not a Medicare or Medicaid patient, nor were the prn meds on a scale, but I have seen them that way.
I know you are kind of stuck between a rock and a hard place here as this is management telling you crazy things. But I honestly think this person just does not know how to manage people and wants to be a micromanager. If you deal with your employees and treat them properly, they should do it correctly. Doing what they are doing just demoralizes people and lowers the overall morale.
Question: What does it take for a patient to get pain medicine around here AND keep my job?
Answer: Put a number in the box.
There are many different tools to use to arrive at that number.
Numeric tool involves asking pt what number would they give their pain on a scale of 0-10 with zero being no pain and 10 being the most agonizing pain. Nurse writes down or enters number stated by pt and gives pain medication based on nursing judgement.
Faces tool involves presenting a pt with a card on which there are faces associated with level of pain and a number. Pt points to face, nurse writes down or enters number associated with that face and gives pain medication based on nursing judgement.
Visual tool involves nurse observing behaviors and vocalizations of pt, associating that with a number on the scale. Nurse writes down or enters that number and gives pain medication based on nursing judgement.
Pre-medicating for a procedure is a little tricky because the pain being treated hasn't actually happened yet but I still treat it based on my nursing judgement of that anticipated pain.
I work in the PACU where people wake up and can't figure out who they are let alone figure out some pain scale mumbo-jumbo but they know they hurt. I can sometimes get through to them using the Modified McDonald's scale of small, medium, large or super-size and still, using my nursing judgement can medicate them for pain.
Put a number in the box and carry on.
(Modified McDonald's Pain Scale is a product of Mavrick's imagination. Do not google.)
I have actually never seen an order that specifies a certain level of pain on a numeric scale. We have orders to give some meds for "mild to moderate pain" and orders to give other meds for "moderate to severe pain." Sometimes there are no orders for this at all, and the docs trust us enough to decide if the patient needs ibuprofin or morphine based on our own intelligence and experience.
Specializes in Mental Health, Gerontology, Palliative.
The pain scale IMO can have limited effect. I've said to elderly patients "on a scale of 0-10, 0 being no pain, 10 being the worst pain you've ever felt, how would you rate your pain?"
And they just look at me blankly.
whether you use a pain scale, or whether you use non verbal cues to determine a persons level of pain you should be documenting why you gave it, what you gave, when you gave it and the effect.
As to whether you can loose your license over it I would highly doubt it, especially with proper documentation
Question: What does it take for a patient to get pain medicine around here AND keep my job?
Answer: Put a number in the box.
There are many different tools to use to arrive at that number.
Numeric tool involves asking pt what number would they give their pain on a scale of 0-10 with zero being no pain and 10 being the most agonizing pain. Nurse writes down or enters number stated by pt and gives pain medication based on nursing judgement.
Faces tool involves presenting a pt with a card on which there are faces associated with level of pain and a number. Pt points to face, nurse writes down or enters number associated with that face and gives pain medication based on nursing judgement.
Visual tool involves nurse observing behaviors and vocalizations of pt, associating that with a number on the scale. Nurse writes down or enters that number and gives pain medication based on nursing judgement.
Pre-medicating for a procedure is a little tricky because the pain being treated hasn't actually happened yet but I still treat it based on my nursing judgement of that anticipated pain.
I work in the PACU where people wake up and can't figure out who they are let alone figure out some pain scale mumbo-jumbo but they know they hurt. I can sometimes get through to them using the Modified McDonald's scale of small, medium, large or super-size and still, using my nursing judgement can medicate them for pain.
Put a number in the box and carry on.
(Modified McDonald's Pain Scale is a product of Mavrick's imagination. Do not google.)
Haha. Yes, yes, yes! I use the "Modified McDonald's" scale too... I mean these nurse managers have been saying that when/if the DOCTOR didn't specify for which # do we use x prn pain medicine and we give the med without having the number to use as our guide (lol) that's the reason our license would be in jeopardy... wouldn't this be a prescriber's issue??! The more I type about it and read these responses... the more annoyed I am that these nurse managers would even imply we could be into some sort of licensing trouble due to a prescriber failing to put in a reference pain scale for these prns. So, yes. I have already been doing my part and marking the pain box. No, I don't always ask a patient what their pain level is on a 0-10 scale and I am not worried about that aspect.
Specializes in Peds Urology,primary care, hem/onc.
I have a thought to this. I am a PNP and work in a pediatric hospital. I work in Urology so we write for a lot of PRN meds for post op and kidney stone patients. Interesting reading this because we, as a division, met with one of the APN's from our pain service 2 days ago. She advised us that JCAHO recently sited us because we did not have indications if multiple PRN's were prescribed. They said our nurses were "practicing medicine without a license" since they were using their judgement to give morphine over tylenol etc as the orders were just written "PRN pain". She advised we were told by JCAHO that every PRN had to have a specific indication. They wanted us to use the pain scale to delineate which pain med to use (morphine for patient reported moderate pain, tylenol for reported mild pain etc.). She told us the pain service pushed back and refused to implement the pain scale for pain med orders and said that they used the consensus statement a previous poster sited as it is not appropriate. What my hospital has done is created a hard stop in our EMR when we write for PRN meds. For pain meds we have to write something other than just PRN if we are writing more than one (we do not if we are only writing one thing). So we write for tylenol for prn pain. If we write for morphine in addition to tylenol, we have to add "PRN Pain not relieved by tylenol" etc. This is also required if you are using multiple PRN's for nausea/vomiting too. This only is needed for PRN meds, not scheduled meds. Our pain team is meeting with each division so it can be implemented. I do not know what is being said to the bedside nurses. Our EMR team and pharmacy are doing the changes to our EMR. So to the original poster, I am wondering if your hospital was dinged like mine was since your manager used almost the exact same verbiage we were told on Wednesday "nurses prescribing without a license". Your manager/hospital just may not be taking the time to communicate it appropriately and professionally to your nurses and MD's/APN's. I personally think JCAHO interpreting the previous practice like this is TOTAL hogwash. What happened to nursing judgement and assessment of pain? I am proud our pain team refused to use the pain scale as an indication for which pain med to use. We all know patients in horrific pain and abnormal vitals saying their pain is a 4 (which means they only get tylenol) and the snowed patient rating their pain a 10 (which means morphine). That is why they made that consensus statement. But once JCAHO says it is a no no, then everyone knows we HAVE to do what they say, at least in theory. What was proposed to us seemed reasonable. I wonder if the OP's manager was was threatened by the higher ups regarding this but was not given the resources or education on how to get into compliance.
I have actually never seen an order that specifies a certain level of pain on a numeric scale. We have orders to give some meds for "mild to moderate pain" and orders to give other meds for "moderate to severe pain." Sometimes there are no orders for this at all, and the docs trust us enough to decide if the patient needs ibuprofin or morphine based on our own intelligence and experience.
It's becoming increasingly apparent that the corporation for which I work doesn't believe in nurse intelligence. Or if they do, not very much. Seems like they don't even trust the prescribers... (?) Or, actually just want maximum reimbursement. They know all the rules because they helped write the ACA. From someone new to the company, it just seems overboard.
Specializes in Peds Urology,primary care, hem/onc.
It's becoming increasingly apparent that the corporation for which I work doesn't believe in nurse intelligence. Or if they do, not very much. Seems like they don't even trust the prescribers... (?) Or, actually just want maximum reimbursement. They know all the rules because they helped write the ACA. From someone new to the company, it just seems overboard.
May be reimbursement or may be JCAHO AS I said in my post previous to yours
Conqueror+, BSN, RN
1,457 Posts
I would think you would get into more trouble for leaving a patient writhing in pain but...maybe that's just me.