Postpartum pain management

[breastfeedingRN]

Just wondering if I am too liberal with pain medication as a new nurse or if I am pretty normal. I sometimes feel as if more experienced nurses are questioning why I was giving the medication so often, etc. Or I see them only giving one type when I use a combo.

Our docs' standing orders are for Motrin 800 mg q 6-8 hours for mild-moderate pain and Percocet 1-2 q 3-4 for moderate to severe pain. They also write for Tylenol 3, but I rarely have patient's want want that.

I typically suggest taking the Motrin on a schedule sort of. I think it really helps with the cramping and my patients that were only getting Percocets always tell me how it is working better now that they are taking both. I always try to remind them to stay on top of the pain and sometimes that means taking it on a bit of a schedule.

I had a Vag delivery with that had a 1st degree lac that was repaired. She was allergic to NSAIDS and was just getting Percocets. When I gave report in the morning to the day nurse, she was just 12 hours post delivery. She and her hubby had both said that she had a low pain tolerance even with her first child. She was having quite a bit of cramping. I was giving her the Percocet, 2 q 3 hours or so. When I gave report, the day nurse told me that that wasn't happening on her shift and why was she having so much pain, she was "only a vag". It really upset me because she was obviously in pain and the Percocets q 3 were just keeping it under control.

I thought that our job was to believe what they tell you their pain was and go from there. When I came back that night, she was on 1 q 4 hours and it was kind of helping. I told her to call me when she needed one and if it was only 3 hours, I would still give it to her. Her doctor even told her that she would like to see her on 1 q 6-8 hours before she went home. I don't get that. She couldn't even have Motrin!

Anyway, just venting. I really try to keep my patient's pain under control and hate to come back to see that they haven't been medicated except once in 12 hours. I know they can ask, but still. I always ask how their pain is everytime I am in the room.

I also do other measures to help them like ice packs for the first 24 hours and then sitz baths after that. I offer warm blankets when cramping, peppermint or chamomile tea for gas, etc. I am not just about medication.

Any suggestions? Am I completely off base here?

Thanks guys!

[BETSRN]

We do the Motrin thing, also, doing a lot of the 600 mg variety probably more than the 800mg, but we do that, too. Sounds as if you did fine.

My experience tells me to go easy on the 2 Percs, however. 2 can put people over the edge really easily as far as nightmares go and I have to agree that I think it is the rare patient after a NVD that degree that probably needs 2 as opposed to 1 Perc.

Don't forget, too, that narcotics are very constipating and I tell patients this also. The last thing a new mom with a sore bottom needs is constipation on top of things!

We also ahve used Tordol very successfully in patients who have difficulties with Motrin.

IV Tordol works like a charm after a C/S, too!

[palesarah]

Palesarah,

We had something very similar until just before JCAHO this year. The current administration decided that this was unsafe to allow the patient meds at the bedside. Where are your self-meds stored?? And have the inspectors ever given your facility a problem with it??

Self-meds are stored at the patient's bedside. JCAHO came through in June, after the self-med program had been implemented, and we passed; they actually liked our self-med program. Note we have all private rooms, only tylenol, motrin & pericolace are kept at the bedside (no narcs!), and patients are screened for eligibility by both the practitioners and nurses. Patients are given a sheet to record what they take, when they take it & pain scale before & after; this sheet becomes part of the patient's medical record after discharge.

The powers that be did a lot of research before implementing this program to make sure that it would be safe, effective & JCAHO compliant.

[BETSRN]

"When I gave report, the day nurse told me that that wasn't happening on her shift and why was she having so much pain, she was "only a vag". '

THAT burns me up!!!! I had lady partsl deliveries with 4th degree lacerations and hematomas. With one I also had hemorraghing with aggressive uterine massage and packing. I HURT!!!! FOR TWO WEEKS!!!!!!! WHO do these nurses think they are to DECIDE who has pain and who does not?

My doc did send me home on Percocets and I needed them. I did get off of them after a few days and onto Tylenol/Advil but I would have been absolutely miserable without them.

I commend the OP for her interest and empathy for the patients under her care. For all your patients who need pain control, I heartily thank you!!!

4th degrees and hematomas are a far cry from a first degree. We're comparing apples and oranges here!

[BETSRN]

Self-meds are stored at the patient's bedside. JCAHO came through in June, after the self-med program had been implemented, and we passed; they actually liked our self-med program. Note we have all private rooms, only tylenol, motrin & pericolace are kept at the bedside (no narcs!), and patients are screened for eligibility by both the practitioners and nurses. Patients are given a sheet to record what they take, when they take it & pain scale before & after; this sheet becomes part of the patient's medical record after discharge.

The powers that be did a lot of research before implementing this program to make sure that it would be safe, effective & JCAHO compliant.

After many years of self-administered meds, we did away with them. The patients didn;t lke them, nor did we nurses, really. We are much happier

back the old way.

[gypsyatheart]

We use a self administration med pack also, I'm not a big fan of it, myself. Many times I find the pt is not really educated as they should be, so many never even open their pack!

And I also agree....it really, really depends on what the pt's situation is....a normal SVD, no lacs/tears, no epis, multip definitely will not need the same pain control as an SVD w/4th degree, extensions, extensive repair, huge swelling, etc!

As always, every pt is different and it is up to the nurse to do an appropriate assessment.

After many years of self-administered meds, we did away with them. The patients didn;t lke them, nor did we nurses, really. We are much happier

back the old way.

[SmilingBluEyes]

You are probably going to have to do away with self-medicating at bedside IF you want to continue JCAHO accreditation. We were told we had to,anyhow ----and the practice was discontinued prior to the last JCAHO visit. It's really a bad idea, anyhow, if you think about it. Too many chances for overdosing or the wrong hands getting on the meds under OUR watch at the hospital. No THANKS! That is a liability most of us do not need.

Most patients do well w/Percoset where I work, Betsy. I just make sure they start on stool softeners---- anyone who has had ANY narc should, anyhow. And of all the people getting Perc or Vicodin that I take care of, I can only report 2 or 3 having any real adverse effects such as nightmares or things on that order. I would NOT hold back narcs for "just lady partsl deliveries" ever......sometimes Motrin and Toradol are NOT enough for such pain. Personal experience tells me that after a nasty forceps/3rd deg delivery w/my son. No one thought I needed pain meds either, and it hurt too much to sit down for days after my son came. So I have a lot of sympathy for my of my patients. I keep MY judgement out of it and medicate them when they need help, no questions asked.

Steph , pain control is a huge issue for me, too. There is a competency out there, but I am unsure how to get hold of it......we should pose the question to the PAIN Management Forum, perhaps. They are the experts, after all!

I still say keep on pressing on, Breastfeeding Rn. And IF patients are receiving inadequate pain relief, then you need to take care of it. Educate your coworkers or discuss this w/the manager. No patient should have her pain meds held back on "anyone's watch", just cause of misunderstandings about what pain is after birth and who should receive meds and who not. It's not for US to judge, after all! My hat is off to you!

[CoffeeRTC, BSN, RN]

The nurses where I delivered were pretty aggressive on the pain control, however when I asked for prune juice or colace bid they looked at me like I had three eyes. Pain meds should = bowel meds.

[SmilingBluEyes]

pain control should be wholistic---not just about medicating anyhow. Any nurse worth his or her salt, knows that already. The whole person must be cared for!

[BETSRN]

You are probably going to have to do away with self-medicating at bedside IF you want to continue JCAHO accreditation. We were told we had to,anyhow ----and the practice was discontinued prior to the last JCAHO visit. It's really a bad idea, anyhow, if you think about it. Too many chances for overdosing or the wrong hands getting on the meds under OUR watch at the hospital. No THANKS! That is a liability most of us do not need.

Most patients do well w/Percoset where I work, Betsy. I just make sure they start on stool softeners---- anyone who has had ANY narc should, anyhow. And of all the people getting Perc or Vicodin that I take care of, I can only report 2 or 3 having any real adverse effects such as nightmares or things on that order. I would NOT hold back narcs for "just lady partsl deliveries" ever......sometimes Motrin and Toradol are NOT enough for such pain. Personal experience tells me that after a nasty forceps/3rd deg delivery w/my son. No one thought I needed pain meds either, and it hurt too much to sit down for days after my son came. So I have a lot of sympathy for my of my patients. I keep MY judgement out of it and medicate them when they need help, no questions asked.

Steph , pain control is a huge issue for me, too. There is a competency out there, but I am unsure how to get hold of it......we should pose the question to the PAIN Management Forum, perhaps. They are the experts, after all!

I still say keep on pressing on, Breastfeeding Rn. And IF patients are receiving inadequate pain relief, then you need to take care of it. Educate your coworkers or discuss this w/the manager. No patient should have her pain meds held back on "anyone's watch", just cause of misunderstandings about what pain is after birth and who should receive meds and who not. It's not for US to judge, after all! My hat is off to you!

I don't think anyone was discouraging the use of Percocet. However, the less you give of any narcotic, the better for Mom (and her bottom). We actually offer Motrin and percs together as they do two different things anyway:one decreasing inflammation which CAUSES the pain) and the other covering up the present pain. That is how I expllain it to my mothers. My personal experience is that most women don't want (and many don't need) the percocet. If their dose of Motrin is strong enough (600-800) that often covers it.

I know that most of us have seen those moms with a history of some use of a narc for some unrelated chronic pain (say in her neck) who has NO stitches at all who is on the buzzer asking for 2 percs every three hours.........hello??

[SmilingBluEyes]

Betsy, Of course you individualize meds/dosing to patients. I don't debate that. And short-term narc use is not going to hurt most people when they are used for PP pain control. In my own practice, I find as many needing SOME (maybe only 1 or 2 doses) Percoset in the first PP day as not. I won't judge one or the other; the meds are ordered for those needing them, and I never hesitate to give them when patients ask for pain relief. And, limiting meds to Motrin is not what the OP was about advocating-----and she is right. The whole point is, pain is what the patient says it is. If Motrin does not do the trick, then they get Percoset or Tyl 3, as ordered.

Now, if there is unrelated pain (such as the neck pain you refer to), then I offer heat packs/and/or ice to treat that, not just push pills. Treat the individual, assess, reassess, and update as needed. That is what we do, right? I will not behave as the nurses on the OP's unit do, saying "not on my watch" will a person get narcs for Vag births. That is just plain wrong, to me. :angryfire

[breastfeedingRN]

Interesting responses. I am just going to follow my gut like I have been. I was just worried about being too liberal or something with some of the comments that I get. Not all nurses, but several.

I also get some pretty irritated looks when I say that they are getting it pretty much on a schedule, even the Motrin. I get the feeling they don't plan on it happening on their shift. I know days are different, but I am never even to be found at my desk. I am busy all night almost everytime I work, teaching, helping breastfeeders, etc. I hate to make it a priority and put it on my to-do list just as my assessments are a priority.

We use the self administration kits as well. Ours have Tylenol, Motrin, Stool softener and Benzocaine spray. Most patients seem to like it. We only use it for vags and it is not a given. They are given the choice of us giving their meds or getting the kit. They have a form to fill out when they took what and it describes in detail how many to take, etc. We have to sign it q shift and that gives us opportunity to reteach them if they aren't sure and assess what they have been taking. It also goes in the chart.

Our sections get simethicone QID and stool softener BID until they go home to help with the gas. Our vags get just the stool softener. I always tell them that the narcotics can constipate and that they might want to pick up an OTC stool softener and take it for a bit after they get home.

I wonder if we will have to do away with our self kits? I still assess for pain when they have one and they also get asked for pain at least twice a day when they get their vitals. It is part of our aides duties when they get vitals. I think we do a good job at assessing for pain. I always try to do my best to treat it.

Thanks again for all the replies. I plan on continuing like I am doing. I know my patient's appreciate it from the comments I have received from them and that is all I need to know.

[ADN 2002]

Quick question about the self-med kits - how does that work with JCAHO? We've been told that EVERYTHING has to be locked up - Tylenol, Motrin, IVFs, Tucks, whatever. I'm not opposed to it, but just curious as to how it works. (Not that our guys would change ANYTHING right now, we're about to go through a JCAHO survey next month...:uhoh21: )

A couple of our docs have standing orders for Motrin 600 mg Q6H around the clock - not prn. Also on their standing orders is Lortab 5mg Q4H prn. Their patients seem to do really well with just the Motrin (assuming they don't have a 4th degree). I always offer the Lortab but not everyone needs it. Just an observation...there will always be the patient that requires more pain meds to be comfortable -- I am, unfortunately, one of those people. With any pain med I give to my SVDs, I encourage them to get in a hot bath 30 minutes or so after I've given the med - many of them think I'm nuts (and a few have told me so to my face) but I rarely have a a patient come out of the bath that says they don't feel better to some degree.

BreastfeedingRN - you sound like you're in tune with your patients' pain! Keep doing what you're doing, it sounds great.