Pain management

Sun0408, ASN, RN · Sep 29, 2012

Fresh post-op, give the IV meds and don't worry so much about getting them off it. I have given IV and PO together. IV morphine or dilaudid is short acting, it will knock out the immediate pain and the PO will last longer once it starts working. It could take up to an hour for PO meds to start working tho so that's why I do both. I don't do both all the time but if IV is not holding them longer than a hour or two I will do both. I have never had an issue with over sedation. With experience you will become more comfortable giving pain meds. Don't worry too much about dilaudid, while it is stronger than morphine it should not be avoided unless the pt has issues with it. Always dilute and push slow. I like to use PO for pain management and IV for break through pain.

mandaaRN · Sep 29, 2012

So are you saying you give both together? Or space them out such as two hours apart? Sometimes the doc writes for breakthrough pain especially with the multiple IV pain med orders. Alternating with PO and IV isn't against a rule especially as rule of thumb 2 hours apart? Arghh sorry, I'm going to bring this up at work again tonight

Sun0408, ASN, RN · Sep 29, 2012

Yes, I have given both at the same time. You must remember the on-set times of both drugs, IV morphine or dilaudid has a quick onset, meaning almost instant pain relief while PO can take up to an hour for pain relief. Depending on the strength of the PO meds; I may just give one tab with the IV. By giving both, I am relieving their pain now and after the morphine or dilaudid has worn off I am keeping their pain at bay with the PO meds. Once I get their pain under control, I do the PO as ordered and use the IV for breakthrough pain etc...

If its a lil old lady or someone that is new to IV morphine or other narcs I do use caution depending on their vitals, pain level etc.. I work trauma ICU so we give a lot of pain meds, we also get the fresh belly surgeries, spinal surgeries etc.. This is something we do daily.

NewbieNeedsHelp · Oct 1, 2012

In my opinion it's not our job to wean pts off pain meds... If she is in pain then medicate her. If the pain is severe give the dilaudid, less severe do the morphine. If those don't hold her through 4 hrs then give her one of the pills to help manage it. VS and pt stable? Then keep administering until she is comfortable.

The way I look at it the PO order is for breakthrough pain or just pain the IV meds aren't totally relieving... Not as an option to slowly get her off IV.

Always remember we aren't the moral police. I've seen many frequent flier drug seeking pts and I medicate them the same as I would my mom. People do what people do. I'm nobody's keeper... Tell them when they are dc'ed they'll have a script for PO so they can make their own choice

Aurora77 · Oct 1, 2012

Your doc wrote great orders! I wish we had so many options sometimes. The IV meds are going to be out of the patient's system well before the four hours is up, so depending on age, vitals, pt condition, kidney/liver function, you could give an IV med Q2 hours. I like to alternate IV and PO pain meds, to keep something on board all the time. When it comes to weaning them off to prepare for discharge, I'll alternate like I said, then just offer PO, with the education that if they need more to tell me. How quickly you wean them down depends on how quickly they are going home. I'd be hesitant to give IV pain meds for a lap appy, since most likely they're going home tomorrow and we need to know if PO meds will work. A bowel resection or something like that, I'm going to be pretty free with the good stuff since they'll be in hospital for awhile.

I don't know why the other nurse was upset about the 1mg of dilaudid. That's not a lot. Unless your patient was old and had other issues, they should be fine. Obviously, you would watch them for changes after administration, but it's no less safe than other pain meds. They all need to be used correctly and pts should be monitored.

In this situation, the only concern you might have with a person who's a frequent flyer or takes lots of pain meds is that it will take more meds to manage their pain. Whether a frequent flyer or not, surgery still hurts so you should manage pain.

sckimrn · Oct 1, 2012

As a general rule, if I am unsure about the effects of a drug or have never given it before (as with the morphine and dilaudid for you), I always look up the monograph. Pharmacy should provide this, but if not, find a drug book. I agree with Sun0408, I give IV and PO until I get the pain under control, then switch to PO and give IV for breakthrough. Post Op pts are in a lot of pain and if we don't keep the pain under control, it will hinder their recovery. These people have got to get up and get moving. And trust me, I have seen my fair share of little old ladies up and moving with dilaudid on board, lol. We all loathe dealing with drug seekers, but post ops are different. Drug seekers get diluted morphine or dilaudid, if they get it at all...depends on the situation. Post ops get the works, I remember being post op after a c section, that morphine was such a help. Oh, and don't feel dumb, you're just learning a new field :yes:

PediLove2147, BSN, RN · Oct 1, 2012

You have great orders! Our fresh post-ops get two options, IV something (usually Dilaudid) and PO something (Dilaudid or Percocet.) I usually will start with the IV pain meds (unless they already started PO in PACU) then transition them to PO. They can't go home on IV so letting them have it up until discharge does nothing for the patient.

I agree that nurse had nothing to be upset about. She doesn't have to give anymore Dilaudid if she doesn't want to. If the MD was opposed to it, he/she wouldn't have ordered it!

katnurseswims · Oct 1, 2012

As a general rule, if I am unsure about the effects of a drug or have never given it before (as with the morphine and dilaudid for you), I always look up the monograph. Pharmacy should provide this, but if not, find a drug book. I agree with Sun0408, I give IV and PO until I get the pain under control, then switch to PO and give IV for breakthrough. Post Op pts are in a lot of pain and if we don't keep the pain under control, it will hinder their recovery. These people have got to get up and get moving. And trust me, I have seen my fair share of little old ladies up and moving with dilaudid on board, lol. We all loathe dealing with drug seekers, but post ops are different. Drug seekers get diluted morphine or dilaudid, if they get it at all...depends on the situation. Post ops get the works, I remember being post op after a c section, that morphine was such a help. Oh, and don't feel dumb, you're just learning a new field

I had no idea it was legal to dilute pain meds like that. Is this in the US?

NewbieNeedsHelp · Oct 1, 2012

Yes it's entirely legal to dilute pain meds.

turnforthenurse, MSN, NP · Oct 1, 2012

IV is good for that "breakthrough" pain because it's onset of action is much faster than PO, but the effect doesn't last long. PO is better for long-term control. I agree, I would give both IV and PO. Keep the patient comfortable. As long as the patient's VS are stable, and they are A&O, appropriate and not slurring their speech, I wouldn't worry about overmedicating them.

mandaaRN · Oct 2, 2012

Wouldn't you want to worry about the peak of the PO occurring at the time of IV onset?