Pain management

[jennyrds07]

After leaving work this morning I left with my mind totally blown and I need advice. I had a patient who is s/p placement of a jp drain in an intraabdominal abscess after a bout of diverticulitis with subsequent perforation. The patient has an order for dilaudid 1 mg IV q 4 hours prn for pain and percocet 5/325mg 1-2 tabs PO q 6 hours prn for pain. When I arrived on the floor the pt was crying and rated their pain as 10 plus saying that they had been for hours and was livid that the prior nurse had obtained a new order for percocet and let the pt believe they could no longer have dilaudid. By the end of the shift the pt was sitting in a chair brushing their teeth with managed pain. I had given a dose of dilaudid at 1930, 2 percocet at 2100, another dose of dilaudid at 0100, 2 more percocet at 0330, and one more dose of dilaudid at 0530 with a consistent pain rating through the night of 4-5 out of 10 and the low of 2/10 at 0630. When I gave report the oncoming nurse told me that you cannot give 2 different pain medications during either of the pain medications duration for example when I gave the 1930 dose of dilaudid I should not have given another dose of pain medication until 2330 and then I could have either given the dilaudid or the percocet but if I gave the percocet then I could not have given another dose of pain medication until the 6 hours between doses was up. The pt's VS remained stable if not elevated throughout the night, they had continuous tele monintoring (in fact HR never went below 90) and 15 and 60 minute follow up after IV dosing and 30 and 60 minute follow up after PO dosing. I used my nursing judgement to manage pain without going overboard and I gave the medications that were ordered in order to control breakthrough pain. The oncoming nurse said "it's not our call, that is why the doctors write the orders so you could give one or the other but not both." That statement left me absolutely dazed and confused. Please help.

[morte, LPN, LVN]

After leaving work this morning I left with my mind totally blown and I need advice. I had a patient who is s/p placement of a jp drain in an intraabdominal abscess after a bout of diverticulitis with subsequent perforation. The patient has an order for dilaudid 1 mg IV q 4 hours prn for pain and percocet 5/325mg 1-2 tabs PO q 6 hours prn for pain. When I arrived on the floor the pt was crying and rated their pain as 10 plus saying that they had been for hours and was livid that the prior nurse had obtained a new order for percocet and let the pt believe they could no longer have dilaudid. By the end of the shift the pt was sitting in a chair brushing their teeth with managed pain. I had given a dose of dilaudid at 1930, 2 percocet at 2100, another dose of dilaudid at 0100, 2 more percocet at 0330, and one more dose of dilaudid at 0530 with a consistent pain rating through the night of 4-5 out of 10 and the low of 2/10 at 0630. When I gave report the oncoming nurse told me that you cannot give 2 different pain medications during either of the pain medications duration for example when I gave the 1930 dose of dilaudid I should not have given another dose of pain medication until 2330 and then I could have either given the dilaudid or the percocet but if I gave the percocet then I could not have given another dose of pain medication until the 6 hours between doses was up. The pt's VS remained stable if not elevated throughout the night, they had continuous tele monintoring (in fact HR never went below 90) and 15 and 60 minute follow up after IV dosing and 30 and 60 minute follow up after PO dosing. I used my nursing judgement to manage pain without going overboard and I gave the medications that were ordered in order to control breakthrough pain. The oncoming nurse said "it's not our call, that is why the doctors write the orders so you could give one or the other but not both." That statement left me absolutely dazed and confused. Please help.

Personally, I might have given more than you did. That said, you need to check the P+P manual. If no help there, question the doc directly. The oncoming nurse makes little sense, but we all know that that doesn't mean she may not prove correct, unfortuately,

If you take orders like these, clarify with doc how he/she wants them used.

[Perpetual Student]

As stated, always follow your facility's P&P. That said, what that other nurse was telling you was VERY stupid. If your policy is consistent with what she said it should be changed promptly. I highly doubt that with those doses and frequencies the physician intended for you to give one or the other. If that were the case he's an idiot or total sadist, as either alone would be inadequate for that patient. More likely, the doc isn't an idiot or sadist and knows that the longer duration of the the Percocet (plus the added bonus of the acetaminophen) with Dilaudid for breakthrough pain would be most helpful for the patient.

You did an excellent job of managing the patient's pain. Your dosing was very safe. Whenever you gave an additional dose the prior one had already peaked, allowing you to be confident that the patient would tolerate it well. You reassessed the patient appropriately.

The nurse you reported off to needs significant remediation regarding effective pain management practices.

[jennyrds07]

Thank you so much for the feedback. I should have mentioned earlier that I did check our P&P and it wasn't clear; all it said was "The nurse will promptly reassess pain in an hour after any pain management is provided and if ineffective will provide additional pain management" But did not specify pharmacological or non.

[rgroyer1RNBSN, BSN, RN]

I will always give iv med, then about 2 hours later I will give po pain med before iv med wears off to give po med time to work, its basic pain management, plus if this was a pt at my hospital I would have pushed to get her a dilauded or fent pca thats what this type of pt needed.

[turnforthenurse, MSN, NP]

IV med is used for breakthrough pain. I have had a lot of patients in the past on more than one PRN pain medication. It is always good to clarify with the doc, though.

[danggirl]

That sounds really off the wall to me as well. In the ER we frequently give overlapping medications for acute pain management...IV dosing to bring it under control and IV/PO/IM to maintain control. I personally think you did an excellent job for your patient. Proper pain management goes a long way toward faster and better recovery.

[Sun0408, ASN, RN]

Sounds like you did everything right. I would talk with your NM or educator to clear the matter and get everyone on the same page. Education may be needed on the unit. I have given IVP pain meds with PO meds. IV to decrease pain levels until the PO kicks in. Once pain is under control, you can give the IV for breakthrough..