PRN narcotics for patients who cant request it?

Nurses Medications

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I recently started working on a subacute unit; majority of the patients are unable to verbalize needs. Many of these patients have PRN narcotics and anti-anxiety meds. At this facility the LVN gives all the PO meds, and injections; as an RN I am not to give them. I work on the night shift so I'm the only RN and basically in charge. There have been several times where I noticed that two of my patients are visibly agitated, and appear to be in distress. I have been asking the LVN on my shift to give the prn meds as often as they can ex: MS PRN q1hr. They would give it every hr. However, there is one LVN who refuses to give the narc until the patients are visibly agitated. I feel that the med should be given before this happens, to keep the pain in control and to prevent it from increasing to the point where the dose is not enough. Am I right in this case or is the LVN? If so how should I handle this situation? In this facility it is very clear that the LVNs act as if they are above the RNs and often try to tell us what to do...

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Can you get orders for a longer acting routine meds? The just have orders for breakthough pain. The would make patient more comfortable and less stress on med pass? Review pain theroy with lvn.

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Education for the LVN. Big time. Talk to the manager if you have to because that's unacceptable.

It doesn't matter if you're not usually doing direct patient care. You're the charge, you're the RN--if a patient isn't being adequately managed, you need to discuss the issue with the LVN and give meds as ordered to achieve adequate pain control. Then you need to document the crap out of it.

As mentioned above, talk to the ordering physician about adding an long-acting narc to better control pain.

Above all, don't let yourself get pushed around. In the end, it isn't about us--it's about the patient. Your gut instinct is right in this case. Do the right thing!

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When I worked on the trauma floor, if a pt required intervention for pain more often than q 2hrs (especially with IV medication) then their pain was not considered 'controlled' I would definitely see about changing up the meds if they are needing morphine every hour consistently. Also about the whole LVN education thing, what is her reasoning? Has she been burned in the past after over medicating someone? And as the RN in charge of the pt's care, why are you not allowed to give a medication? (Not saying that you should have to... Just wondering why the RN's aren't allowed to give pain meds. Is it so 2 people aren't potentially giving the same med twice?)

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If the med orders exist- the physician has determined the need for them. For the meds not be given, that indicates a lack of assessment. Sad.

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Well, to play the devil's advocate here, I'm not going to just give PRN Ativan/Morphine/whatever in anticipation that the pt might become agitated. I'm going to wait until the pt actualy presents with some symptoms. Especially if we're talking about q1hr PRN morphine. That's a lot of morphine. Is this pt actively dying or something?

Frankly, if this facility is staffed like 99.9% of skilled units, this LVN sees this pt far more than you do. Unless she's totally lazy and/or incompetent shouldn't you assume she knows how to assess pain/agitation? Why do you want all these pts to receive as many doses of their PRN meds as they possibly can? If the situation is such that they really need q1hr morphine, isn't there something far more serious going on? I mean, yikes, that's a ton of narcotics. Does the doctor need to be called for order changes?

I'm sorry, I'm not going to give a PRN just because a RN tells me to. Nothing in the nurse practice act dictates that I have to do that, any more than you have to blindly do what a physician tells you.....

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Well, to play the devil's advocate here, I'm not going to just give PRN Ativan/Morphine/whatever in anticipation that the pt might become agitated. I'm going to wait until the pt actualy presents with some symptoms. Especially if we're talking about q1hr PRN morphine. That's a lot of morphine. Is this pt actively dying or something?

Frankly, if this facility is staffed like 99.9% of skilled units, this LVN sees this pt far more than you do. Unless she's totally lazy and/or incompetent shouldn't you assume she knows how to assess pain/agitation? Why do you want all these pts to receive as many doses of their PRN meds as they possibly can? If the situation is such that they really need q1hr morphine, isn't there something far more serious going on? I mean, yikes, that's a ton of narcotics. Does the doctor need to be called for order changes?

I'm sorry, I'm not going to give a PRN just because a RN tells me to. Nothing in the nurse practice act dictates that I have to do that, any more than you have to blindly do what a physician tells you.....

The patient in question appears to have established a pattern of becoming agitated without the PRN medication on a more regular basis than what it is being given. The issue isn't overmedicating, as your post seems to indicate. It's a matter of underestimating the patient's pain control needs despite a pattern that suggests that they need pain control meds more frequently.

Of course you're not going to just give something because a doctor or another nurse tells you to do so. But if you notice that a patient who you've been giving morphine q4hr gets agitated at the 2-3 hour mark and the order is for q1hr, then it's on you to adjust your medication frequency based on your assessment of the patient.

And honestly, 1mg of morphine is NOT a lot of morphine, especially for a patient who likely has a tolerance (q1hr PRN suggests they have had pain control issues before).

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Was it 1mg? That's an odd dose.

You're right, of course, if the resident really has an established pattern of needing the morphine q1hr.

The case could very well be that the OP is right, and this LPN needs some guidance/re-education. Like I said, I was playing devil's advocate. :)

And based purely on my own anecdotal LTC experience, q1hr morphine seems highly out of the ordinary. Even most of my hospice and fresh post-op residents have been more along the lines of q2-3hr PRN pain meds. Is q1hr PRN common in subacute/rehab?

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Was it 1mg? That's an odd dose.

You're right, of course, if the resident really has an established pattern of needing the morphine q1hr.

The case could very well be that the OP is right, and this LPN needs some guidance/re-education. Like I said, I was playing devil's advocate. :)

And based purely on my own anecdotal LTC experience, q1hr morphine seems highly out of the ordinary. Even most of my hospice and fresh post-op residents have been more along the lines of q2-3hr PRN pain meds. Is q1hr PRN common in subacute/rehab?

For fresh post-ops, it's not terribly uncommon. Usually, when a patient needs a short-acting narc dose that frequently, I've asked physicians to either put them on a PCA or add a long-acting narc on top of their pain regimen and decrease the frequency and/or dose of the PRN. It's easier on everyone and provides more continuous coverage for the patient.

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Specializes in Geriatrics, Transplant, Education.
For fresh post-ops, it's not terribly uncommon. Usually, when a patient needs a short-acting narc dose that frequently, I've asked physicians to either put them on a PCA or add a long-acting narc on top of their pain regimen and decrease the frequency and/or dose of the PRN. It's easier on everyone and provides more continuous coverage for the patient.

Are you speaking of PCA use in the LTC/subacute setting? If so I am surprised. I did subacute for four years prior to my current employement on a GI/hepatobiliary/organ transplant floor and never never saw a PCA until I came to the hospital. I'm not saying it's impossible, but I wonder if a PCA is the best solution in that setting? I would think a long acting PO or transdermal narcotic with a breakthrough dose PRN would be more appropriate.

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Ha, my bad. I defaulted back to med/surg/onc nursing and momentarily forgot we were discussing LTC/subacute rehab. I probably should have posting privileges revoked for Mondays. :***:

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Specializes in Oncology, Med-Surg.

I worked in a facility that converted to sub-acute and hospice. The LPN's there were very experienced in LTC but not so much post-op and hospice care. They were very uncomfortable giving "heavy hitter" meds for pain and sedation. I had to do a lot of teaching with them. Ultimately, it became more effective when we had a facility-wide inservice on pain management. Maybe you could suggest that to your DON (without naming people course).

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