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?
Specializes in orthopedic/trauma, Informatics, diabetes.
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.
I just give what I want and make the numbers match up so everyone stays happy.
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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.
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.
Specializes in Mental health, substance abuse, geriatrics, PCU.
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.
mmc51264, BSN, MSN, RN
3,319 Posts
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.