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Oral vs IV Pain Medication

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Specializes in Acute care and rehabilitation. Has 10 years experience.

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This question is specifically targeted to nurses that work with inpatients in the hospital. If you have 2 options for administration of pain medication, when would you chose to give IV over PO if they are both available?

Usually, I give IV over PO if they are NPO, vomiting, end of life or the pain is severe enough to warrant immediate release vs waiting for PO to work.

Recently I had fresh admissions from the ER, one with bilateral PEs and bilateral DVTs and the other with probable cancer with metastasis. They were both rating their pain 10/10 and we're visibly in a lot of pain so I gave them both the IV doses even though there was also oral pain medication available.

It was near the end of shift and since IV is shorter acting the night nurse questioned when she could then give the oral dose because they were q2h frequency for the IV and the result would completely wear off before 2 hours. After reflecting I think that I should have just educated the patients and let them know that the IV route was reserved for "breakthrough pain" AFTER the PO has had a chance to work.

So, my question is would any of you have done the same thing or had them wait for the oral to work when they were in severe pain?

Thanks

Sour Lemon

Has 9 years experience.

6 minutes ago, kristine_bean said:

This question is specifically targeted to nurses that work with inpatients in the hospital. If you have 2 options for administration of pain medication, when would you chose to give IV over PO if they are both available?

Usually, I give IV over PO if they are NPO, vomiting, end of life or the pain is severe enough to warrant immediate release vs waiting for PO to work.

Recently I had fresh admissions from the ER, one with bilateral PEs and bilateral DVTs and the other with probable cancer with metastasis. They were both rating their pain 10/10 and we're visibly in a lot of pain so I gave them both the IV doses even though there was also oral pain medication available.

It was near the end of shift and since IV is shorter acting the night nurse questioned when she could then give the oral dose because they were q2h frequency for the IV and the result would completely wear off before 2 hours. After reflecting I think that I should have just educated the patients and let them know that the IV route was reserved for "breakthrough pain" AFTER the PO has had a chance to work.

So, my question is would any of you have done the same thing or had them wait for the oral to work when they were in severe pain?

Thanks

I would have given the IV medication, although technically, there should be order parameters that dictate what's to be given and when. In some cases, I even give the IV and PO together or one hour apart.

As a general rule, I transition towards PO medication as a patient is improving and getting closer to being discharged.

I'm not sure why the oncoming nurse was asking you when to give the PO medication. She can assess the patient and read the orders just like you can.

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

The answer to me would depend on a few things. It was becoming common practice in the hospitals here for the MD to set parameter or additional instructions on PRN pain meds for example "give if pain 1-5, give for paint 6-10" or "give this medication first then give X if no relief obtained". This gave the provider more control over how they wanted the patient's pain managed and made things more consistent.

Without those instructions, I probably would have done the same thing you did. 10/10 acute pain certainly would indicate to me the need for IV analgesic and once pain control was established utilize oral medications with IV for breakthrough.

I find it surprising that anyone would criticize a nurse for giving IV meds to a metastatic cancer patient and a patient with clots everywhere.

1 minute ago, Sour Lemon said:

I would have given the IV medication, although technically, there should be order parameters that dictate what's to be given and when. In some cases, I even give the IV and PO together or one hour apart.

As a general rule, I transition towards PO medication as a patient is improving and getting closer to being discharged.

I'm not sure why the oncoming nurse was asking you when to give the PO medication. She can assess the patient and read the orders just like you can.

You literally took the words out of my mouth 😂

If there is no scheduled PO meds, giving them PRN as the order allows to keep things steady and under control.  Pain is easier to control, than it is to catch up to.  Give the IV meds for pain uncontrolled by the PO meds.

CalicoKitty, BSN, RN

Specializes in Med-Surg, Geriatrics, Wound Care. Has 9 years experience.

If the pain was severe, and the orders did not say otherwise (give PO first), I would have given the IV. Then come back in an hour (or the soonest time) and given the PO if the patient was still in pain or the pain was starting back to help get it under control. I'd also want to try heat packs and other medications if available (Tylenol with the IV, unless the PO option had Tylenol in it). Anti anxiety medications if available. Offer comfort stuff like hot tea (did not have may options at my job).

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown. Has 8 years experience.

In PACU we are allowed to give both PO and IV at the same time if patient is in severe post-op pain, like after orthopedic surgery. For example IV fentanyl and PO oxycodone. The fentanyl starts controlling the pain quickly while the oxycodone starts working and will last longer. In the hospital I often found the PRN pain orders confusing and had to clarify whether PO and IV could be given together or had to spaced apart, or PO first, or could they put parameters based on pain level, etc.

Anyway, I think you did the right thing! Horrible pain and those diagnoses need fast relief. Then I would ask if I could give the PO with the IV or shortly after, maybe 30 mins to make sure the IV didn't affect VS or mental status, so the PO would start kicking in while the IV was still in effect, then last longer. Then you could give the PO PRN or around the clock, and the IV for breakthrough. Sometimes PRN pain orders are very confusing! And not something you want to mess up even if pt is fine, so unfortunately I usually bothered the doctors for more clear orders. 

RNperdiem, RN

Has 14 years experience.

I would have done the same thing. I work with trauma patients in the SICU. They have just been scraped off the pavement, moved through the ED, scanned and brought to us. Often they have visibly broken limbs and are still on full spine precautions. Moving them to the bed really and moving them in general really hurts.  IV pain meds is the way I start for that level of pain. Of course, we are able to monitor these patients closely and as a previous poster pointed out, the docs are writing orders for po or IV depending on pain level. 

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

15 hours ago, TheMoonisMyLantern said:

The answer to me would depend on a few things. It was becoming common practice in the hospitals here for the MD to set parameter or additional instructions on PRN pain meds for example "give if pain 1-5, give for paint 6-10" or "give this medication first then give X if no relief obtained". This gave the provider more control over how they wanted the patient's pain managed and made things more consistent.

Without those instructions, I probably would have done the same thing you did. 10/10 acute pain certainly would indicate to me the need for IV analgesic and once pain control was established utilize oral medications with IV for breakthrough.

I find it surprising that anyone would criticize a nurse for giving IV meds to a metastatic cancer patient and a patient with clots everywhere.

You literally took the words out of my mouth 😂

The "dose by the numbers" practice came out of a fake professional practice group called the "American Pain Foundation", the group was shut down as a result of a Senate investigation that revealed the group was actually a cabal of marketing departments of a few different opiate manufacturers.  

The American Society of Pain Management Nursing has a position statement on the topic and considers the practice to be ineffective and unsafe, the Nursing Board of my state considers it to be failing to practice to our license.

27 minutes ago, MunoRN said:

The "dose by the numbers" practice

Ugh. One of the more nonsensical concepts for sure. A terrible substitution for applied nursing knowledge and judgment. I don't have good thoughts about the entities who readily incorporated it as part of their quest to protocolize all things nursing, either.

CalicoKitty, BSN, RN

Specializes in Med-Surg, Geriatrics, Wound Care. Has 9 years experience.

For the "how much pain are you in from 1-10", after being in pain I would rather die than go through again. I don't believe there is 10. It can always get worse. =*(  Probably around 8 is when I'd have difficulty breathing because breathing is pain. 

Sour Lemon

Has 9 years experience.

1 hour ago, JKL33 said:

Ugh. One of the more nonsensical concepts for sure. A terrible substitution for applied nursing knowledge and judgment. I don't have good thoughts about the entities who readily incorporated it as part of their quest to protocolize all things nursing, either.

I just give what I want and make the numbers match up so everyone stays happy. It amuses me when I see nurses ask for the numbers ...especially for reassessments. I used to assume that everyone did what I did.

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

For 10/10 pain I choose the IV because it works quicker than oral and I find oral medication is ineffective for 10/10 pain.  I will try to give the oral for some longer lasting pain effect after their 10/10 pain level is reduced.   

 

Edited by Tweety

mmc51264, ADN, BSN, MSN, RN

Specializes in orthopedic; Informatics, diabetes. Has 9 years experience.

Depends on situation. I am an orthopedic nurse and ain management is a large part of our day. 

Usually, pain meds are ordered PO xmg QxH as needed for pain, with a pain scale (5 mg for pain 3-5, 10mg for pain 6-8 and 15 mg for pain 9-10). Then there may be an order for IV breakthrough pain QxH. 

PO is almost always given first unless something is going on like a painful dsg change or x-ray. 

In your situation, I would have given the IV first to try and knock the pain down and then give the PO. Pain is hard to rein in if it gets past a certain point. 

I tend to be a little more aggressive with pain meds than some of my colleagues. 

End of life situations are different. 

On 2/21/2021 at 8:03 PM, Sour Lemon said:

I just give what I want and make the numbers match up so everyone stays happy.

😂

I do think patients' use of the pain scale provides useful information. The specific treatment for the pain is only loosely connected to that, though, certainly not something where I would ever say, "Well, 8/10. The only reasonable treatment is IV dilaudid!"

 

On 2/22/2021 at 8:07 AM, Tweety said:

I find oral medication is ineffective for 10/10 pain.

Clarification: Are you referring to personal experience(s) or to reports from patients/others? Just curious.

This is all difficult because even the pain scale is presented and used in a variety of different ways. For example, some nurses will say "zero is no pain at all and 10 is the worst pain you can ever imagine." Some say, "Zero is no pain and 10 is the worst pain you've ever had." Some say, "Zero is no pain and 10 is getting run over by a semi/getting your arm sawed off with a butter knife/having your face on fire/[etc.]"

And nothing about the pain scale is necessarily an interaction with the patient in terms of what they mean by the number they've assigned; the whole thing actually still amounts to an assumption about what the patient has said. I  could never count the number of patients who have given me a pain number >7 and then told me that no intervention is required; that it isn't upsetting their day too much; that they wouldn't worry about it unless it was really bad.

The pain scale is inadequate enough in and of itself, but to tie it to some mandatory action by the nurse in terms of which specific treatments will or won't be considered or which intervention the nurse *must* choose.....well, I should suffice it to say that's an even bigger disappointment.

With the two suffering patients in the OP, after a prudent assessment I would likely try to provide quick relief (IV med) and also get on a plan for baseline pain control right away. So I'd give both in whatever timing seemed most appropriate.

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

2 hours ago, JKL33 said:

😂

I do think patients' use of the pain scale provides useful information. The specific treatment for the pain is only loosely connected to that, though, certainly not something where I would ever say, "Well, 8/10. The only reasonable treatment is IV dilaudid!"

 

Clarification: Are you referring to personal experience(s) or to reports from patients/others? Just curious.

This is all difficult because even the pain scale is presented and used in a variety of different ways. For example, some nurses will say "zero is no pain at all and 10 is the worst pain you can ever imagine." Some say, "Zero is no pain and 10 is the worst pain you've ever had." Some say, "Zero is no pain and 10 is getting run over by a semi/getting your arm sawed off with a butter knife/having your face on fire/[etc.]"

And nothing about the pain scale is necessarily an interaction with the patient in terms of what they mean by the number they've assigned; the whole thing actually still amounts to an assumption about what the patient has said. I  could never count the number of patients who have given me a pain number >7 and then told me that no intervention is required; that it isn't upsetting their day too much; that they wouldn't worry about it unless it was really bad.

The pain scale is inadequate enough in and of itself, but to tie it to some mandatory action by the nurse in terms of which specific treatments will or won't be considered or which intervention the nurse *must* choose.....well, I should suffice it to say that's an even bigger disappointment.

With the two suffering patients in the OP, after a prudent assessment I would likely try to provide quick relief (IV med) and also get on a plan for baseline pain control right away. So I'd give both in whatever timing seemed most appropriate.

Experience.  I work post op. I know it's subjective and 10/10 really is dramatic.

If someone is in severe pain, give the IV.  You want to get the pain under control.  Then work on oral medication for longer-term relief.  Depending on how different people metabolize oral medication, it could be an hour before the oral medication kicks in.  I would not feel comfortable making someone with metastatic cancer wait an hour for - possible - pain relief when I had a perfectly good IV order there as well.  Sometimes with acute pain, a patient may need to be on frequent IV meds for a while before they improve to the point that PO is adequate (which is why some people end up on PCA pumps).  If the current orders are not enough for adequate pain relief, discuss it with the doctor to see if you can get new orders.  

In general, I give IV when I need fast action.  Podiatrist just showed up to do an excruciating dressing change?  Yeah, that patient is getting IV dialudid, even if his current pain level is 0 because I know his pain is going to be a 10 in about 5 minutes.  If I gave oral, the wound care would be over before it even started to work.  On the other hand, if I know someone needs pain relief before physical therapy, I'll find out their appointment time and give an oral dose 45 minutes before that.

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

On 2/21/2021 at 6:25 PM, MunoRN said:

The "dose by the numbers" practice came out of a fake professional practice group called the "American Pain Foundation", the group was shut down as a result of a Senate investigation that revealed the group was actually a cabal of marketing departments of a few different opiate manufacturers.  

The American Society of Pain Management Nursing has a position statement on the topic and considers the practice to be ineffective and unsafe, the Nursing Board of my state considers it to be failing to practice to our license.

Interesting, I remember when the opioid crisis was first coming to a head reading about different experts who were saying that the pharmaceutical companies basically strong armed their pain management philosophy into nursing and medical practice. I grew up with "Pain as the 5th vital sign" and worked on units where nurses were threatened with write ups if we didn't reassess pain within 1 hour post medication even if it was Tylenol, and how we needed to aggressively control pain during every round to make sure the "customer experience" was positive. Yet, you can have a little granny eaten up with cancer moaning all night and the MD won't order a thing for pain. It's so messed up. I really wish we could find some diagnostic technological gizmo that would tell us how bad someone is hurting.