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.
Pain scales that I have seen tend to give higher doses of the same medication for higher pain ratings rather than different medications for those claiming more pain.
There is not even total agreement among experts in the field about the appropriateness of using subjective pain scales in such an absolute manner, so it is absolutely absurd for any facility to claim that a nurse's license is subject to revocation for failure to buy into it. Facility policy and ability to keep one's job for refusal to conform is totally different than an action so deemed to risk patient safety that the BON would pull a license for that refusal, particularly since rationale for questioning this practice can be found in the literature.
They want you to follow a policy. Fine. But saying a nurse could lose her license for failure to do so is so incredibly disingenuous, deliberately so imo.
Yeah, I just ignore the pain parameters and give patients what we agree they need. If someone has a raging headache, but the Tylenol pain parameter is 1-4 (Mild), I don't NOT give it. I just chart the truth.
Right...our docs usually write for Tylenol for mild pain and oxy for moderate to severe pain--or a "use first, use second" prn for "pain." Most of our pts also have a CADD; lots of times they are still showing nonverbal/physiologic signs of pain. If they're maxed out on their available CADD dosing, and have the usual Tylenol and oxy available, unless there's liver failure or other contraindication to Tylenol, I give both. My nursing judgment says that is a better pain control measure than oxy alone.
Guess what? It works. In my anecdotal experience, pts seem to get more results that way (and those who can speak have told me it works better), and lots of times are able to go longer in between doses of prns. As a secondary, I've been told "good idea" by more than one provider/more-senior RN.
The Joint Commission has never required pain scale based medication dosing. What they require is a common understanding of how prn orders will be interpreted by those writing the orders as well as those utilizing the orders. The lazy way for facilities to meet this requirement is to replace nursing judgement with a rigid, non-patient-specific algorithm. The Joint Commission used to include this an example of how to meet the requirement, which is why the two main pain societies came out with a consensus statement saying that this is bad practice. The Joint Commission does not prohibit the use of orders that support the use of nursing judgement in pain management, they just will want to know that both prescribers and nursing staff are on the same page in terms of how that judgement will be utilized.
One of the biggest problem with pain scale based prn orders, other than removing nursing practice from patient care, is that it is purely reactive. One of the main goals of good pain management is to optimize pain control while using the least amount of opiates necessary. Purely reactive pain actually results in much higher cumulative opiate doses and higher risk of adverse events while at the same time resulting in less effective pain control overall.
This^
Also the JC wants hospitals to get rid of the dose range (ie Dilaudid 2-4 mg) which is open to too much variance in practice. It's too subjective from the nursing side and how to implement it is confusing. For example, if you give the patient 2 mg and 30 minutes later they still have pain can you give an additional 2 mg to total 4 and if so when can you give the next dose? Every hospital interprets this differently and I daresay there is little consensus among the nurses.
The problem is that best practices and reimbursement and/or accreditation guidelines don't always match. The federal government has been getting deeper and deeper into directing medical and nursing management for years now. It's really getting out of hand.
A level 4 pain to one person may be equal to7-8 to another.
I totally disagree. A pain level of 4 to one person is a pain level of 4 to any patient. That is the point of the scale, for a patient to select their pain level based on their own experience.
The noxious stimuli may be the same but the person's response will vary. For example, ask someone to place their hand in a bucket of ice water for one minute. The noxious stimulus is the exact same, yet people will experience it differently. One person may say the "pain" is a "4", another may rate it an "8" based on their experience. Does that mean one person's "4" is the same as another person's "8"? NO IT DOESN'T. It means one person experiences this stimuli as moderate pain while the other experiences the same stimuli as severe pain and as a nurse I would treat the pain based on their perception of it.
I totally disagree. A pain level of 4 to one person is a pain level of 4 to any patient. That is the point of the scale, for a patient to select their pain level based on their own experience.
The noxious stimuli may be the same but the person's response will vary. For example, ask someone to place their hand in a bucket of ice water for one minute. The noxious stimulus is the exact same, yet people will experience it differently. One person may say the "pain" is a "4", another may rate it an "8" based on their experience. Does that mean one person's "4" is the same as another person's "8"? NO IT DOESN'T. It means one person experiences this stimuli as moderate pain while the other experiences the same stimuli as severe pain and as a nurse I would treat the pain based on their perception of it.
I agree with your statement in the last sentence, but then I would expect the person experiencing moderate pain to give a rating in the middle of the pain scale and the person experiencing severe pain toward the high end of the scale, not for both people to rate their pain the same number.
We have all had the experience of asking the person who is sitting up in bed, calmly talking on the phone, or laughing with visitors, or watching TV and having completely normal vital signs, who tells you their pain is a 10/10. We have also seen what a person who is actually experiencing 10/10 pain looks like: rolling on the bed, moaning, sweating, elevated BP and HR, vomiting, etc. So no, a pain level of 4 or any other pain level is not the same from one person to the next. It SHOULD be, but we all know it isn't.
I agree with your statement in the last sentence, but then I would expect the person experiencing moderate pain to give a rating in the middle of the pain scale and the person experiencing severe pain toward the high end of the scale, not for both people to rate their pain the same number.
That's exactly what I said. One person rated the pain a "4" and another person rated the pain an "8".
Then there are the folks who game the system and don't really answer the pain level question. They are answering the question "What do I have to say to get the pain medicine I want" That's why in my previous post I stated the nurse gives pain medicine based on nursing judgement no matter what the pain scale or number is.
People with chronic pain are extra tricky in that their physiological response to pain is different. Fatigue can be a symptom of chronic moderate to severe pain.
GM2RN
1,850 Posts
Pain scales that I have seen tend to give higher doses of the same medication for higher pain ratings rather than different medications for those claiming more pain.