New Nurse Pain Med Question

[ricksy]

Hi. I am a new nurse working my first job in LTC (RN) for about 4 months. I am older (second career---know some of you younger ones question my motives for second career), but it is the job I wanted...anyway, in clinicals we were never to pass pain meds/narcs without full set of vitals, specifically respirations....so here is question. In my facility, I have been watching and NO ONE but me seems to follow that protocol. Specifically resident on Dilaudid.... I always do and chart it. Any answers or responses????????? Thanks in advance!

[SoldierNurse22, BSN, RN]

I have seen nurses give meds and not know their pt crashed bc they were out with other PTs.

Say your floor does vitals every 4 hrs and you are giving meds at hr 2, what happens if your pt codes shortly after and dies? How does it look in court if you say, "well they were fine 2 hours ago and our floor doesn't check vitals before we give meds". You probably will being paying out.

I as well didnt say not to check on them for 2 hours.

You indicated that the nurse wouldn't see the patient for another couple of hours after administration because the VS were q4 and the meds were q2.

My point is that even if that were the case, the nurse should at least check on the patient post med-admin (15 min for IV, 30 min for PO per my ward's protocol) and every hour. So no, you wouldn't be paying out if your patient mysteriously coded after the med admin because you followed protocol and something abnormal happened.

Eyes-on the patient is an effective assessment tool that can pick up changes in patient condition before the physiological indicators show up. If the nurse is curious, they can always check VS, but that isn't standard practice.

And a patient crashing while you're in another room? That happens. It isn't necessarily the mark of a "bad nurse" or a nurse who isn't paying attention. You can't sit on your patient for the whole shift. That's why teamwork on a ward is so essential along with a good eye for assessment.

[VANurse2010]

It's not standard of care to get full VS before every narcotic administration. If you CYA'd everything you'd never get anything done other than documenting care you supposedly gave.

How long does it take to do vitals. Say your floor does vitals every 4 hrs and you are giving meds at hr 2, what happens if your pt codes shortly after and dies? How does it look in court if you say, "well they were fine 2 hours ago and our floor doesn't check vitals before we give meds". You probably will being paying out. My philosophy has always been CYA. Why do the least amount to get by? I would do what you feel comfortable with and what can cause the least amount of problems for your professional life.

[VANurse2010]

It's not a regular standard of care to do this ... so it probably wouldn't matter in court. VS tell you nothing about the physical assessment pieces you're mentioning. So I guess you need to document a physical assessment before each narcotic admin? Hogwash - except in a few very limited circumstances none of which I could EVER imagine being applicable/relevant to LTC.

Keep doing what you are doing. If its documented its easier to prove you did the right thing if ever in court. If not documented how can you prove the pt was not lethargic or was breathing irregular.

[manusko]

You indicated that the nurse wouldn't see the patient for another couple of hours after administration because the VS were q4 and the meds were q2.

My point is that even if that were the case, the nurse should at least check on the patient every hour. Eyes-on the patient is an effective assessment tool that can pick up changes in patient condition before the physiological indicators show up. If the nurse is curious, they can always check VS, but that isn't standard practice.

And a patient crashing while you're in another room? That happens. It isn't necessarily the mark of a "bad nurse" or a nurse who isn't paying attention. You can't sit on your patient for the whole shift. That's why teamwork on a ward is so essential along with a good eye for assessment.

Really? Read again. Give meds 2 hrs post VS and then pt codes shortly after (never said 2 hrs later). And never said 2 hrs later. Actually said short time after and quoted saying VS were fine 2 hrs before. As in 2 hrs before meds given.

Yes PTs crash and it can happen all the time but how do I as a family member feel if you have given narcotics to my mother and didnt check vitals? I as a family member may question it and seek legal advice. Doesn't matter if you feel like you did the right thing, but I as a nurse would feel better I I had checked and documented the vitals.

[SoldierNurse22, BSN, RN]

Really? Read again. Give meds 2 hrs post VS and then pt codes shortly after (never said 2 hrs later). And never said 2 hrs later. Actually said short time after and quoted saying VS were fine 2 hrs before. As in 2 hrs before meds given.

Yes PTs crash and it can happen all the time but how do I as a family member feel if you have given narcotics to my mother and didnt check vitals? I as a family member may question it and seek legal advice. Doesn't matter if you feel like you did the right thing, but I as a nurse would feel better I I had checked and documented the vitals.

I did read again. In fact, I quoted your own posts to prove my point. My point is that if you have baseline VS on the patient and the patient is medically stable, VS aren't indicated every time you administer narcs.

You as a family member may feel however you'd like. I as a nurse have 5 other patients to tend to. If I'm giving your mother meds every 2 hours and doing the same for 5 other patients, time management will be an issue and your mother will be at even greater risk because I'm busy with other patients.

I'd really like to see some evidence to indicate that VS should be checked EVERY time narcs are given, just routinely. I have never seen it before, and I come from a very, very narc-intensive background. To say my experience is extensive is putting it mildly.

[manusko]

I did read again. In fact, I quoted your own posts to prove my point. My point is that if you have baseline VS on the patient and the patient is medically stable, VS aren't indicated every time you administer narcs.

You as a family member may feel however you'd like. I as a nurse have 5 other patients to tend to. If I'm giving your mother meds every 2 hours and doing the same for 5 other patients, time management will be an issue and your mother will be at even greater risk because I'm busy with other patients.

I'd really like to see some evidence to indicate that VS should be checked EVERY time narcs are given, just routinely. I have never seen it before, and I come from a very, very narc-intensive background. To say my experience is extensive is putting it mildly.

Read it the way you want. I was only trying to tell the OP to do what they feel comfortable with. Never even said it was routine to do so.

[SoldierNurse22, BSN, RN]

Read it the way you want. I was only trying to tell the OP to do what they feel comfortable with. Never even said it was routine to do so.

You're right--you didn't. But I'd hate for the OP to think that it was somehow unsafe to administer narcs without first assessing VS without reason to suspect a problem. New nurses have enough to learn without feeling overburdened by tasks that aren't necessary to ensure patient safety/safe practice.

Sometimes, new nurses will check VS before administering meds. This teaches the new nurse to correlate patient presentation with vital signs--in other words, they start to associate a downtrending patient with the physiological cues on the monitor. That, I understand and encourage. But as stated before, it's not routine and probably won't be a practice carried out throughout one's career.

[chrisrn24]

Keep in mind that OP works in long term care. At my facility these people have been on PO narcs for a long time. To me, there is no sense in checking vitals.

[manusko]

Keep in mind that OP works in long term care. At my facility these people have been on PO narcs for a long time. To me there is no sense in checking vitals.[/quote']

I agree. And I have not done this work before but know how busy it can be. The OP will probably get more comfortable and be able to make their own judgement on practice.

[manusko]

You're right--you didn't. But I'd hate for the OP to think that it was somehow unsafe to administer narcs without first assessing VS without reason to suspect a problem. New nurses have enough to learn without feeling overburdened by tasks that aren't necessary to ensure patient safety/safe practice.

Sometimes, new nurses will check VS before administering meds. This teaches the new nurse to correlate patient presentation with vital signs--in other words, they start to associate a downtrending patient with the physiological cues on the monitor. That, I understand and encourage. But as stated before, it's not routine and probably won't be a practice carried out throughout one's career.

No it's not normal practice and the OP will learn when to make the right call. I only worked critical care and we had vitals usually every 15 mins and continuous EKG so it was easier for me.

[SoldierNurse22, BSN, RN]

No it's not normal practice and the OP will learn when to make the right call. I only worked critical care and we had vitals usually every 15 mins and continuous EKG so it was easier for me.

Absolutely, that makes things a lot easier because of the continuous monitoring. LTC--even med-surg--doesn't have the benefit of a near-constant look into the patient's underlying physiological state. You learn to compensate with a (very quickly!) trained clinical eye for trouble. Some of my coworkers could simply look at a patient and know something was wrong. Others could sense that things weren't going well. It takes time to develop, but it's really rather incredible.

[NurseDirtyBird]

I work SNF, and I always check the VS from the start of the shift before giving a dose of narcs. If the patient's VS were a little off (brady, hypotensive, ect.), then I'll go take another set before administering narcs. Or antihypertensives or diuretics or whatever else could significantly alter their VS, because I'm supposed to. But if their VS were WNL to begin with, there's really no need. You assess LOC and all that stuff when you go into their room for the pain assessment. You'll be able to see if it's a bad idea to give narcs at that time.