narcotic policy

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My hospital is in the process of reexamining the narcotic policy and I am looking to get input from as many nurses as possible -- please!

We are a 600 bed Midwest hospital and we are trying to write a global policy that will work in all the units of the hospital. The idea is to lump PCA, epidural and IVP narcotics into one policy to cover assessment expectations for vital signs, level of consciousness and quality of respirations. The assessments are to be done ONLY by RN's following a set pattern of q 30 minutes x 4, q h x 4, q 2 h x 2 then q 4 h thereafter until all narcotics are stopped. The time of the first assessment to be at the initiation of dosing and restarts at the beginning with ALL dosing increases. As a Med-Surg unit, we do not have non-invasive methods for vital signs and the only way to assess LOC or quality of respirations is to talk to people. I don't see this as a huge issue with the PCA and epidurals because we don't change the rates very often but IVP is completely different. Our doctors usually give us a range [e.g. Dilaudid 0.5 - 2.0 mg IVP] and let us use nursing judgment to achieve pain control. With this new policy, if I don't start everybody at the max dose, I will be restarting the protocol each time I increase the dose -- this is intrusive enough during the day but is going to be really annoying at night. How would you like it if your nurse gives you something for pain and then wakes you up every 30 minutes to ask if you know where you are? And, if I wean you down then you go to PT and have pain, I restart at the beginning again if I up the dose -- even if it is just one time.

Additionally, we still have a few LPN's at our hospital and they are really fantastic nurses. We already have a policy against LPN's doing IVP drugs, but this policy goes even further and wouldn't even let them do the assessments or take vital signs! Is this really something they aren't qualified to do?

I know there has to be a better way and a better idea in use at other hospitals -- please share your hospital's policy!

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My God! LPNs can't take vitals!!! What is the rationale behind that policy?

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I can't explain this -- I am just trying to stop it. If I can't prove that other hospitals are handling this in a better way, I am afraid this policy will be enacted.

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In the hospital I work at we have epidural checks that are every hour (epidural site, respirations, B/P, o2 sat, pain, pulse) and PCA checks that are every two hours with the same criteria except for the site. If they are a surgical pt we do vs Q15 min x4, Q30 min x4, Qhr x2 then Q4 hrs for the next 48hrs. Many times if a pt is getting a narcotic pain med for something like...a bowel obstruction the DR. will have written an order for vs Q4hr. To my knowledge we don't have a policy regarding required vs for giving IVP or oral narcotics...we are trained to consider recent vs, take respers, consider LOC prior to drug administration. I will research our policies & post again if I find something that might help.

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I should've added in my earlier reply that we allow LPN's & CNA's to take the vitals and there are parameters to follow regarding when to notify the RN.....if the RN isn't already checking them :-)

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Thank you, earned RN 2008" for your data - may I ask the approximate size and general regional local of your hospital?

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It's a smaller hospital, less than 100 beds, in the midwest.

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Specializes in vascular, med surg, home health , rehab,.

That policy sounds like a nightmare, how in all reality could you do this, really unless you have a max of 4 pts per nurse? We have a policy with PCA/epidurals, most of the q 30 min stuff completes while the pt is in PACU, other than that we have orders for zofran/benedryl/narcan. Pain evals are done before a narc is given and within the hour a re-eval. If the pain score is less than 5, thats enough, if not you have to document your intervention. In many cases of the" I had to shake you awake for 5 minutes and then your pain is 10 and is still 10 no matter what we do and the doc isn't upping your meds any more" I just document that. PCA and epidurals are charted on q 4. JCAHCO seemed happy with that last survey. Hope that helps? In reality that policy is going to lead to a lot of narcan, in my experience busy nurses will give the max dose so they don't have to start all over again, its unworkable.

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Thanks, "AnnMarieRN" !

Could you tell me the approximate size of your hospital and your general local please?

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