The other day, I was working night shift until 0600. I check on my residents regularly. I had last seen this reservation at 0400. At 0550 he called, stating he wanted his morning pain pill early. He gets tramadol at 0800, but the nurses usually start med pretty early. I offered him tylenol, which he refused. He also has a norco order, but being that early with no food and lethargic, knowing he would get the tramadol at at least 0630 or 0700, I once again offered tylenol in the meantime and repositioned him. His norco order is q 6 hrs prn and Ultram q 4 hrs prn. I have always been taught (8 years) to use non pharmacological means first, and never give a prn that close to a rtn. I followed my gut. Now they are saying I neglected the pt! I was only trying to be safe. They have put me on leave, and it's up to regional if I even get to keep my job. I dont feel I was wrong. The next nurse stated that he always gives this reservation his med btw 0630 and 0700, which proves a prn at 0600 is too close. Am I wrong? Please help.
It's always good to try non-pharmacologic treatments first, such as repositioning, but the problem seems to be that you didn't actually assess if that had worked and move up to other interventions when that was ineffective.
Personally, I think I would have given the ultram he asked for, pass that info on to the next nurse & he/she could have non-administered the sched ultram for 0800, documenting that a prn was too recently given. I don't necessarily think you're wrong either though (it's a nursing judgment situation - lots of opinions) & absolutely no reason for you to be called out on it.
From the information you providex, I would have given the prn ultram and passed on to the day nurse that you did so. It is up to that nurse to decide if they will give the scheduled ultram, hold the ultram and to document why. The patient requested a medication that they were ordered to be able to get q4h prn. From what you stated the order did not specify to hold prn med if within 2 hours of scheduled dose.
I felt stuck, last 5 mins of shift, not sure what the other nurse would feel about that anyways. I feel like he should have accepted the tylenol. I didn't have time to assess after, I was off at that point and the next shift was on
It's always up to the nurses discretion whether or not to give a med, but I'm not totally clear what your rationale was. Generally you start with the least aggressive intervention for pain, unless you already have knowledge of how the patient responds to various interventions. It doesn't sound like this is the first time this patient has had pain, so there must be some way of knowing what type of intervention is required to control their pain.
Specific policies define how prn med orders are to be interpreted, but in general if a patient has the same med ordered as both scheduled and prn, the MD is OK with the patient getting both. And in a non-opiate naive patient I wouldn't be concerned with giving a prn and a scheduled prn dose together since the adverse effects of tramadol are fairly minimal compared to true opiates.
10 mins prior to the end of my shift, the patient asked for his rtn early. I offered tylenol. Refused. He allowed staff to reposition him. Shift over. Oncoming shift starts meds first thing. The pt would revive the rtn within the hour. That was my thinking. I did not think I should run down and give him a prn, on top of the rtn.
Generally the MD's intent in ordering both scheduled and prn pain control is that the prn is to be given at any time the scheduled pain med is not providing adequate pain control. If it's ordered properly, the scheduled med should be providing a fairly constant effect, and if you don't think you should be giving a prn when a scheduled pain med is still exerting it's effects then the patient would never be able to have the prn, which wouldn't seem to be what the MD intended. In this situation it really doesn't make any sense to give the scheduled med early, that's precisely what the prn is for.
I know you have clarified much but I still want to be clear...
He has Norco ordered as needed, tramadol as needed, and scheduled tramadol for 08:00, right?
At close to six (05:50) he asked for the tramadol. Refused tylenol or Norco.
He had at minimum one hour before the scheduled tramadol could be given (07:00 at the earliest).
I would have given him the PRN tramadol when he asked for it.
My rationale is that the resident is in pain now and 07:00, one hour from now, is the absolute earliest that he can have the scheduled tramadol. That doesn't account for the oncoming nurse possibly running late or needing to respond to an emergency, ect... He could go over an hour in pain without medication.
I understand your concern about giving him a PRN when the scheduled is available soon. If you give the PRN at 06:00 then the oncoming nurse can administer the scheduled tramadol at 08:00 (as ordered) or wait until 09:00 (still within timeframe), whichever appeals to her nursing judgement.
I wouldn't have held it just based off him being drowsy/sleepy as long as his vitals were WNL (it's 6:00 after all). Was he really lethargic? I would consider true lethargy to be a possible change in LOC and something to possibly notify the MD about... True lethargy in LTC would warrant some further interventions.
In the future I would document this in a nurses note. "At 05:50 Mr. Brown requested tramadol for pain. Resident has scheduled tramadol at 08:00. Tylenol and Norco were offered but the resident refused. Resident repositioned and informed that scheduled tramadol could be administered at 07:00, patient voiced agreement. Will inform oncoming nurse."
Except if the plain Tylenol doesn't work, then he *can't* have the Norco next, since Norco contains acetaminophen. At least not for 4-6 hrs or whatever the interval is.
Was this a brand new Rx? If not, does he have a history of getting completely snowed after a dose of narcotic? If not, I don't see the problem in just giving either the Norco or the PRN tramadol. (I didn't see in your OP that he refused Norco--just that he refused plain Tylenol. Forgive me if I missed something there) I mean, first off he was in pain and apparently enough to request a stronger med; you couldn't promise that he would receive his scheduled dose early, since it's not you doing the med pass; even if he did, that's still more than an hour to wait when he has PRN's available; and finally, if he did get snowed from the prn, the oncoming RN/LPN would have assessed that and had the option to delay the tramadol.
That said, I do think putting you on leave and possibly terminating you is a harsh action over this one incident. I would think that some education on pain management would be more appropriate. Hugs...I hope all goes in your favor!
I repositioned him, offered tylenol, as nurses we always go from less to more. The tylenol may work. He specifically asked for his rtn Ultram early.
Also, something important to keep in mind is that untreated pain can lead to confusion/delirium in elders. Lots of times narcotics get the blame, when the culprit is untreated pain. (Unfortunately I don't have a reference handy...it was something I learned in a geriatric nursing class taught by this human Google of a GNP. I saved most of my notes from her class, but they are on a bookshelf at my other residence.)
Is the facility also investigating why the day nurses are giving scheduled medications long before their earliest possible administration? They are setting you up for failure when they are giving it early and now you are in trouble for not doing that also.
You could learn from this and remember you are responsible for your patients and charting. He asked for a pain medication and you had several options which you could have given. It would have been upto the day nurses to decide if they wanted to give the Ultram, or given the 1 hr before and after rule they could have administered it at 0900, more than 3 hours after you were asked for the dose.
Hope things work out for you. It is so scary how something that seems so simple at the end of a busy shift can spiral out of control like this.
10 mins prior to the end of my shift, the patient asked for his rtn early. I offered tylenol. Refused. He allowed staff to reposition him. Shift over. Oncoming shift starts meds first thing. The pt would revive the rtn within the hour. That was my thinking. I did not think I should run down and give him a prn, on top of the rtn.
Resident might have refused Tylenol bc he knows from past experience that with his pain level of X/10, that drug alone is ineffective. Where I'm at, the MD writes orders for meds for mild pain (1-3/10), moderate pain (4-6/10) and severe pain (7-10/10). So for your pt. it might look something like, administer 500mg Tylenol for Mild pain q6* PRN, 25mg Ultram for Moderate pain q4* PRN (not to exceed 400mg daily including rtn administration) and Norco 10/325 1 pill q6* PRN for Severe pain (total acetaminophen not to exceed 4,000mg/day combined).
In your situation I would have administered the PRN Ultram and in shift report notified the oncoming nurse that I had given it at 0550, so she might need to alter her med pass to not give the rtn dose too closely to the PRN.
MunoRN, RN
8,058 Posts
It's always good to try non-pharmacologic treatments first, such as repositioning, but the problem seems to be that you didn't actually assess if that had worked and move up to other interventions when that was ineffective.