I am on a med surg floor and recently I've had two occasions where patients were admitted to the floor and then asked for pain meds, both had been given dilaudid in the ED and that was the only prn pain med (other than tylenol for fever or pain). I always ask people whether the medicine they got in the ED was effective and did it make them nauseous, dizzy or sleepy. I ask if they've taken opioid pain medications in the past. These women both said they don't want opioid medications, one said she has a family history of alcoholism and wouldn't want opioids. They said no one in the ED told them what they were getting for pain.
I'm no pain expert and I don't work in the ED, I'm just looking for information, not pointing fingers. I'm sure that many people need narcotics, but one of these women reported that the tylenol was effective for her pain (her pain was 3-4, same that she reported in the ED and she got 0.5 mg dilaudid), but tylenol wasn't given in the ED. When someone comes to the ED, why are they often given opioids without trying anything else? Is it the speed of onset? I never see IV acetaminophen or ibuprofen, but I know they exist, does anyone use them?
With all the information about the current opioid crisis, I just wonder whether the medical system could be adding to some of this problem by so quickly administering opioids for any pain. I'd like to learn more about this if anyone has experience. Thank you.
We used to give IV Tylenol and IV Toradol for post-op open-heart patients but they were both limited to three doses due to cost and toxicity. I didn't find them to be all that successful when you've had your chest cracked open and we usually ended up giving narcs anyway. All that happened is the patient was in pain for longer. I think it's ridiculous to withhold narcotics because of an opioid abuse situation that is happening in a different context. This is acute post surgical pain we're talking about. For cripe's sake just give them the meds! That's what they were intended for!
Specializes in New Critical care NP, Critical care, Med-surg, LTC.
Thanks to all for the responses, I appreciate your time and feedback. I am well aware that I wouldn't single handedly end the opioid crisis by suggesting that my little old ladies not get dilaudid (wouldn't that be awesome), I was very interested to hear what my ER colleagues take on the pain control protocols are.
Specializes in New Critical care NP, Critical care, Med-surg, LTC.
We used to give IV Tylenol and IV Toradol for post-op open-heart patients but they were both limited to three doses due to cost and toxicity. I didn't find them to be all that successful when you've had your chest cracked open and we usually ended up giving narcs anyway. All that happened is the patient was in pain for longer. I think it's ridiculous to withhold narcotics because of an opioid abuse situation that is happening in a different context. This is acute post surgical pain we're talking about. For cripe's sake just give them the meds! That's what they were intended for!
I would never withhold pain meds from someone that needs them, I was just looking for information from those with expertise I do not have. (and I certainly did not direct this post towards post surgical patients) Thank you for sharing your experience.
I work in a couple of ICUs and see all patients except open heart patients. We frequently use IV Tylenol, especially with our surgical patients- it works very well. I've had patients with multiple different orders for pain relief- scheduled IV Tylenol, scheduled IV toradol, scheduled and PRN narcs. We also promote pain relief patches- lidoderm, etc., heating pads/ice. We have a great palliative/pain management team that we bring on board to help when needed.
I had a family member recently hospitalized in another state. They developed complications after surgery (I won't go into the details) and I was very upset when I heard about certain things that were/weren't being done. I specially told the spouse to request IV Tylenol- I wasn't happy the nurse was trying to give a patient on bowel rest PO tylenol. The spouse insisted on the IV Tylenol after our conversation, the patient then got the IV Tylenol and had significant improvement in pain/mood.
ER enviroinment is not well-suited for any type of pain management except acute pain caused by more or less clear pathology. It is especially so in our times of "customer satisfaction" madness and ER being utilized as primary care centers by a good segment of public.
Non-opioid pain modalities, let's face it, are often seen as "less effective" by patients, providers and health care administration as compared with "good drugs". And, on the outside, it may really seems like they are. If a schmolicy written by a complete idiot somewhere in ivory tower demands "pain assessment" within 60 min from administration of any pain-alleviating measure and anything reducing pain to less than 4/10 level as reported by a patient is deemed to be "ineffective" and therefore requiring "corrective actions", it is just easier for everyone involved to order/administer those 1 mg of Dilaudid IV and forget about the issue than try to prove the said idiot that the patient in question had migraine headache, which she suffers for the last 40 years, for which opioids are not generally effective and that her usual triptan spray was not in hospital formularly and the patient could not bring and use her own due to another schmolicy. Likewise, ordering acetaminophen in many EMR systems requires provider to click to one or two more red flashing "warnings" due to "overdose alert". It is a minor irritation, but when you have to do it 20 times every day, you might be tempted to do something which doesn't require any additional actions from you - like "just give 'im some pure morphine".
In addition to this, way too many non-opioid pain interventions which otherwise lie well within nursing scope of practice are taken from nurses and require "provider's order", plus the time they actually take to implement. I am pretty sure that many bedside nurses would love to just bring that lady with migraine a cool head wrap and sit with her for a little while and just comfort and reassure her - but, cool wrap might be considered "cold application" which cannot be done without an order; and, having 6 other patients and no supprting staff, the nurse simply has no time to do her job right.
Unfortunately, it is not something that can be "improved" by more schmolicies.
ER enviroinment is not well-suited for any type of pain management except acute pain caused by more or less clear pathology. It is especially so in our times of "customer satisfaction" madness and ER being utilized as primary care centers by a good segment of public.
Non-opioid pain modalities, let's face it, are often seen as "less effective" by patients, providers and health care administration as compared with "good drugs". And, on the outside, it may really seems like they are. If a schmolicy written by a complete idiot somewhere in ivory tower demands "pain assessment" within 60 min from administration of any pain-alleviating measure and anything reducing pain to less than 4/10 level as reported by a patient is deemed to be "ineffective" and therefore requiring "corrective actions", it is just easier for everyone involved to order/administer those 1 mg of Dilaudid IV and forget about the issue than try to prove the said idiot that the patient in question had migraine headache, which she suffers for the last 40 years, for which opioids are not generally effective and that her usual triptan spray was not in hospital formularly and the patient could not bring and use her own due to another schmolicy. Likewise, ordering acetaminophen in many EMR systems requires provider to click to one or two more red flashing "warnings" due to "overdose alert". It is a minor irritation, but when you have to do it 20 times every day, you might be tempted to do something which doesn't require any additional actions from you - like "just give 'im some pure morphine".
It takes more clicks to order Tylenol so why not just give morphine???? Seriously. If you want to know the problem look right here.
Specializes in New Critical care NP, Critical care, Med-surg, LTC.
ER enviroinment is not well-suited for any type of pain management except acute pain caused by more or less clear pathology. It is especially so in our times of "customer satisfaction" madness and ER being utilized as primary care centers by a good segment of public.
Non-opioid pain modalities, let's face it, are often seen as "less effective" by patients, providers and health care administration as compared with "good drugs". And, on the outside, it may really seems like they are. If a schmolicy written by a complete idiot somewhere in ivory tower demands "pain assessment" within 60 min from administration of any pain-alleviating measure and anything reducing pain to less than 4/10 level as reported by a patient is deemed to be "ineffective" and therefore requiring "corrective actions", it is just easier for everyone involved to order/administer those 1 mg of Dilaudid IV and forget about the issue than try to prove the said idiot that the patient in question had migraine headache, which she suffers for the last 40 years, for which opioids are not generally effective and that her usual triptan spray was not in hospital formularly and the patient could not bring and use her own due to another schmolicy. Likewise, ordering acetaminophen in many EMR systems requires provider to click to one or two more red flashing "warnings" due to "overdose alert". It is a minor irritation, but when you have to do it 20 times every day, you might be tempted to do something which doesn't require any additional actions from you - like "just give 'im some pure morphine".
In addition to this, way too many non-opioid pain interventions which otherwise lie well within nursing scope of practice are taken from nurses and require "provider's order", plus the time they actually take to implement. I am pretty sure that many bedside nurses would love to just bring that lady with migraine a cool head wrap and sit with her for a little while and just comfort and reassure her - but, cool wrap might be considered "cold application" which cannot be done without an order; and, having 6 other patients and no supprting staff, the nurse simply has no time to do her job right.
Unfortunately, it is not something that can be "improved" by more schmolicies.
Thank you, I appreciate all the responses, but this is exactly the sort of explanation I was looking for. It's too bad that the people making decisions are sometimes so out of touch with reality. Guess trying to change things is like spitting into the wind.
In answer to your question- this happens for a number of reasons. Occasionally it results from laziness or poor assessment skills. More frequently it is because we see the patient in an acute phase, and the treatment is warranted.
And- narcotics for pain is pretty much the default path. And it generally works. The path of least resistance.
But, sometimes a provider simply overlooks the obvious, and the nurse either doesn't know how to advocate, or doesn't know enough to advocate. Or is just tired of trying to get docs to do the right thing, and picks his/her battles. Toradol for kidney stones is a good example. Most experienced ER nurses have treated kidney stone pain refractory to narcotics with Toradol. This comes not only from the analgesia, but from the effects on smooth muscle. It is not a magic bullet, but it makes no sense not to try it.
Regarding IV Tylenol- Recently had an abdominal pain who got no relief from nearly 4g Dilaudid in 2 hours. Complete relief with Ofirmev. Not sure why it works so well, sometimes, but it does. Some reluctance to use it due to cost, but that really doesn't make sense. According to Dr Google, it's 13 bucks a dose. A trivial cost in a hospital visit. Those Kleenex were probably $10.
Do you mean to say that Toradol is the IV formulation of ibuprofen? That's incorrect. They are both NSAIDs, but ketorolac (Toradol), whether IV or po, is a different medication than ibuprofen (Motrin(po), Caldolor (IV), NeoProfen (IV)).
I was using it colloquially. It is by far the most common IV nsaid and commonly described to pts as "IV ibuprofen".
Rocknurse, MSN, APRN, NP
1,367 Posts
We used to give IV Tylenol and IV Toradol for post-op open-heart patients but they were both limited to three doses due to cost and toxicity. I didn't find them to be all that successful when you've had your chest cracked open and we usually ended up giving narcs anyway. All that happened is the patient was in pain for longer. I think it's ridiculous to withhold narcotics because of an opioid abuse situation that is happening in a different context. This is acute post surgical pain we're talking about. For cripe's sake just give them the meds! That's what they were intended for!