Narcotics administration

TheCommuter, BSN, RN · Aug 25, 2012

In this day and age of healthcare where so-called 'customer service' overrules patient care, I've resigned myself to giving patients whatever they request to avoid having any petty complaints lodged against me.

As long as their respiratory rate is at or above a certain threshold and they are not overly sedated, I do not care if they are really in pain. They're getting their narcotics as long as it is time for the next PRN dose.

The nurse is in a no-win situation here. If a patient complains that the nurse did not give the Dilaudid promptly, management blames the nurse for creating a 'poor patient experience' and providing bad 'customer service.'

eatmysoxRN, ASN, RN · Aug 25, 2012

I've witnessed the same thing. There's not much you can do except be sure to watch vitals closely. I ensure them that I will recheck their bp in 30 minutes if it isnt high enough to get med now. Of counce seriously assess respiratory status before and after administering. And ALWAYS dilute it and give it slowly if per policy. I hate that some can ruin pain medication for all though. I've literally had to convince some patients who were in obvious pain that medication was okay, while others want the strongest thing for the tiniest pains. Oh, and they wonder why they are constipated....

Sun0408, ASN, RN · Aug 25, 2012

I have had pts set their cell phones to go off every two hours. Did I give the meds, yep yep as long as it was safe..The last pt I had was a CA pt with mets to all major organs. They set their cell phone to wake them when pain meds were due.. Do I think she was in pain, of course, this was her way of keeping the pain under control. She died about 2 weeks after DC home. Some of the other nurses were upset about the alarm, but when you think about it, it makes sense to keep it under control.. Most seekers have some type of chronic pain issue also, it may not be CA but who's to say it isn't real.. I try very hard not to judge, I would hate to be so jaded that I left a person in true pain because I thought they were seeking. Not my job to police meds, if the PCP writes the order for it and it is safe to give, I give.

schoolmack · Aug 25, 2012

I have never not given medication because I "thought" someone was bluffing about their pain status. As stated by other's, the pain is what the pt says it is, and if the PCP ordered it, then if the pt is safe to receive then they will.

I am just at a point where some of this seems so excessive. I have a CA patient now that is getting 2mg IVP MS Q4, and a pt with SSC who is getting 8mg IVP Dilaudid Q2! Obviously there is a tolerance built with the SSC patient, but some things just don't add up.

It is truly a customer service issue. We had a patient complain to management because we dilute the pain med. Management then asked that we only dilute in 2cc of NS vs. the 10cc standard flush. It is beyond me at times.

Frustrating is a mild description.

Just curious how others felt outside of my floor!

Thanks for the feed back, it is very interesting!

Trauma Columnist · Aug 25, 2012

You are right that it is a opiod tolerance issue: someone with cancer, if the smaller dose takes care of their pain, then that's the correct dose. SSC pts do, as a rule require far more pain meds than a cancer. SCC pts should be enrolled in a palliative care program:

Palliative care : Pain in palliative care

Jory, MSN, APRN, CNM · Aug 25, 2012

This is how I view drug seekers: I don't care about them. I don't care about their health. I don't care if they die an early death.

That is not a popular opinion as a nurse, but drug addiction IS A CHOICE...bottom line.

If they get admitted to the hospital, it is my job to assess them. If I think they are drug seeking, I'll communicate that to the doctor. you can only ASK THEM what else they are taking, IF THEY LIE TO YOU, YOU ARE NOT LEGALLY RESPONSBILE for what happens to them if they have a drug interaction or if they have taken something before they come in...and anyone that tells you any different, I challenge them to produce an article proving otherwise. Nurses are supposed to ASK but we are not required to be mind readers, nor does the law.

Now, after my assessment and report, if a doctor wants to prescribe them a narcotic, I don't care. My last responsibility is to make sure that GIVEN THE ASSESSMENT AND REPORT FROM THE PATIENT, if the dose is appropriate and if an injection, to give it appropriately.

That is where my responsibility ends.

Do you know why I don't care? I didn't create the system...doctors, lawmakers and hospital administrators did. It's not me that the DEA is going after for over-prescribing narcotics...it's going to be the doctor who wrote them out.

Pain is what the patient says it is and until someone comes up with a pain test, I'm not putting my license or job at risk for a drug seeker.

So, if they have loaded up on herion before they come in, lied about it, we can't see evidence of it and we give them something else and they drop dead? One less drug seeker as far as I'm concerned.

These people generally don't work, they mostly live on state assistance and they neglect their children and give birth to drug addicted infants. They are the lowest of the low and IT IS A CHOICE.

resurection · Aug 25, 2012

I am a Hospice nurse; so, I am used to large dose of narcotics being ordered ATC + PRN. My first and primary position is to make sure my patient is comfortable.

KelRN215, BSN, RN · Aug 26, 2012

I have never not given medication because I "thought" someone was bluffing about their pain status. As stated by other's, the pain is what the pt says it is, and if the PCP ordered it, then if the pt is safe to receive then they will.
I am just at a point where some of this seems so excessive. I have a CA patient now that is getting 2mg IVP MS Q4, and a pt with SSC who is getting 8mg IVP Dilaudid Q2! Obviously there is a tolerance built with the SSC patient, but some things just don't add up.
It is truly a customer service issue. We had a patient complain to management because we dilute the pain med. Management then asked that we only dilute in 2cc of NS vs. the 10cc standard flush. It is beyond me at times.
Frustrating is a mild description.
Just curious how others felt outside of my floor!
Thanks for the feed back, it is very interesting!

2 mg of morphine q 4 hrs is nothing. That's a dose a kid who weighs 20 kg gets q 2hrs following surgery! 8 mg of IV Dilaudid is a lot but without knowing more about the patient (how much he weighs, how long he's been on narcotics for, his mental status, the severity of his pain), it's hard to say that it's "too much". I don't know what SSC is. The highest dose of narcotic I have ever given is 100 mg of morphine/hr continuously. The patient was 8 years old and weighed 24 kg. He was an end-stage oncology patient but he lived for DAYS on this dose.

edmia, BSN, RN · Aug 26, 2012

I have a CA patient now that is getting 2mg IVP MS Q4, and a pt with SSC who is getting 8mg IVP Dilaudid Q2! Obviously there is a tolerance built with the SSC patient, but some things just don't add up.

I don't mean to insult you, but these dosages (and diagnosis) are normal. Dilaudid 8mg IVP (NOT DILUDED!) is absolutely necessary for a sickle cell patient. Shameful if held back due to prejudice.

Morphine 2mg? Please, let's not even discuss that.

Some doctors where I work order dilaudid 0.5 mg q 4 hrs. It's almost cruel.

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schoolmack · Aug 26, 2012

The concern regarding my first thread is being lost on the dosages of medicine mentioned. I struggle to continue to administer medication to pts setting alarm clocks to receive it vs those that are suffering and apprehensive to take meds.

edmia, BSN, RN · Aug 26, 2012

The concern regarding my first thread is being lost on the dosages of medicine mentioned. I struggle to continue to administer medication to pts setting alarm clocks to receive it vs those that are suffering and apprehensive to take meds.

No it's not lost. Pain is subjective and your personal feelings/judgments should not play a role in your administration of medication and care of patients. Chronic pain is a different beast, but there's plenty of literature that supports proper pain treatment. If it really worries you, advocate for a pain medicine consult.

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