Should I just "go along", or possibly rock the boat?

[JohnBearPA]

Hi everyone,

I just started a job in an LTC, closer to home, full time, permanent staff (means I usually will get the same assignment). However I will have to float sometimes, which I actually like. It's alot better than agency, where you get cancelled at a moments notice, and have to travel over an hour to and from work sometimes. Also, financially, I need this job badly, and can't really afford to go back to agency. There-in lies my problem.

I was assigned to a unit other than what will be my "home" unit yesterday. Mostly long-term pt's, but a few just in for rehab. During my last med pass, every, and I mean EVERY one of my pt's was astonished that their med cups didn't contain all the pills they usually get. See, I was giving the meds they were to recieve at the given time, but not automatically giving the prn's for pain, sleep, or anti-anx. All of my pt's were a&ox3, and were aware of what meds they should be getting at what time. I expalined that if they wanted a prn med, to please ask me, and let me know why they wanted it so I could assess, and chart the reason for the prn. Most of them were a bit miffed, to say the least.

I have no problems giving prn's, if and when the pt needs them. However, when I wake a pt up form what appears to be a sound and untroubled sleep to give them their meds, and they request a pain med, a sleeper, and an anti-anx all at once, I have a slight problem. I'm not comfortable with this at all.

I feel as if the facility is failing these pt's, almost turning them into addicts. Some of these people will eventually go home, and will be addicted to these meds one way or another when they do, if they aren't allready. Most have been here more than a month, and take ALL meds, prn and atc, on EVERY shift.

I might add that I'm the only one within the last months MAR to record other actions besides giving the med, such as repositioning, offer of a snack, or any other diversion. Also, when asked, all these pt's rated their pain a "10", which I didn't see in my assessment. They were sleeping or resting quietly, vs wnl, no other s/sx of distress.

I really need this job, and don't want to get canned for not going along with the flow, but by the same token, I don't want my license pulled when state comes in and checks things out, which they're due to in the next month or so.

I tried other interventions, and charted that, but ultimately gave the meds as per pt request. What should I do at this point? Talk to the DON, admin, etc? Like I said, I really don't feel comfortable contributing to addicting pt's, and I really don't feel comfortable unless trying any and all other interventions before a narc. Any suggestions would be greatly appreciated.

Thanks in advance everyone, and may you all have a safe, sane, and love filled holiday!

[UM Review RN, ASN, RN]

Also, when asked, all these pt's rated their pain a "10", which I didn't see in my assessment. They were sleeping or resting quietly, vs wnl, no other s/sx of distress.

Pain is what the patient says it is. Bottom line, you have to treat it. Sure, you can try other interventions, and it's commendable of you to do so, but in the end, if the patient is still c/o pain, you have to give that pill.

I usually ask patients to wait a half-hour to an hour after giving a pain pill before I'll give a sleeper or anti-anx myself, and if I'm not comfortable, I don't give it. But document why. Anxiety is something that's perceived only while awake, while pain is not, so I think it'd be OK to document that patient doesn't appear to be anxious since Patient was snoring and roused with difficulty. If someone's BP is hovering below 90 systolic, you might hesitate with good reason before giving Xanax and Ambien with that Percocet.

[JohnBearPA]

Thanks Angie. I realize that the pt's pain is always what they rate it at, since I have no way of knowing myself, and always treat it according to what the pt rates the severity at, but also always have tried other interventions first.

I didn't give the pain, anti-anx, and sleepers all at the same time yesterday, waiting at least 20 minutes between each, which peed off alot of pt's! LOL I'm sure the pt's will complain about this to the sup today. I just wanted an opinion r/t to my actions, so I had some positive reinforcement to back me up when and if I get called in on how I admin'd these meds yesterday. Thanks for telling me what I already knew. It makes such a difference to hear what you think is the right way to do something coming out of someone elses mouth sometimes!

[SuesquatchRN, BSN, RN]

I would give them. But then, I have nothing against people using drugs.

[Midwest4me]

No--DON'T "just go along". Keep doing what you're doing(being a responsible nurse); i.e., assessing the pt and trying alternative interventions---repositioning, heat, massage, image therapy--(pending pt cooperation/acceptance)before giving the prn meds.

[JohnBearPA]

Thanks again for the input everyone. I seem to work with the kind of nurses mentioned in another post about med passes, and I won't just do what they do when I know it's wrong. Not just because it could cost me my license, but because I advocate for the pt's whenever I can. I just really needed to hear someone tell me to stick to my guns, do it the right way, not the popular way.

[Tweety, BSN, RN]

Never do anything you're not comfortable with or your inner voice tells you is wrong. Stick to you guns. :)

As was mentioned, not medicating for a patient that states 10/10 even though they have no outward s/s will get you in more trouble than medicating them.

[carol72]

JohnBear I like your approach with respect to PRN meds. I agree, this means PRN.

[ginger58, ASN, RN]

"...when asked, all these pt's rated their pain a "10", which I didn't see in my assessment. They were sleeping or resting quietly, vs wnl, no other s/sx of distress."

I congratulate you for trying other modes of pain control, relaxation. I admit I have a tainted view working in palliative care. WHO brought forward pain as the 5th vital sign for a reason. We are taught to take the pt. report as what the pain is. Many people with chronic pain laugh, talk on the phone, sleep, or whatever. These actions don't mean they're not having pain. If you get a 10/10 report and don't act on it you will be in trouble with the State.

If you're concerned about the patient ask for doc for his/her input on the origin of pain. Addiction happens to 0.1% of people. Addiction has its own set of behaviors.

People have pain for various reasons--it doesn't have to be due to a broken bone, cancer, etc.

[HappyNurse2005, RN]

I'd be pissed if I asked for my meds and you didnt give it to me. now, if they are slurring their speech, have low bp, low resps,etc then i can see. but, pain is pain. who said you get to decide if they are in pain or not? anxious or not? and if you wake them up for pills like you said you did, mayb e they know they'll need an ambien to get back to sleep.

you're the new guy here. you don't know these folks....if htey need it, they need it. if they say they do, then they do.

[caliotter3]

You said it all when you stated how much you need your job. I had almost the exact same experience with my first full time position in a LTC facility as an LVN, on the night shift. I would come in for noc shift and certain call lights would be ringing to break the electrical system for the residents to get their drugs. The CNA's would come and tell me, I couldn't even finish getting report from the offgoing nurse. It got under my skin after awhile. One of the little old ladies refused to utter a word when I repeatedly asked her to verbalize pain, point to the area of pain, or show any kind of objective or subjective need for her prn pain med. It did not take long for me to figure things out and the CNA's knew too. So I would tell the resident exactly what I was charting, and why I was charting it. And I got the same if looks could kill expression on her face every time. I also made it known to her when I was by necessity, called to a higher priority situation first. I charted everything to the best of my ability, each shift. I discussed this situation with my co-workers, who were more experienced than I was at the time. Some of them told me that MD's would prescribe vicodin as a "sleeper" at the other facility where they worked. So my question to them was, "Well, since Dr. So and So is the MD for this patient why doesn't he just prescribe the med the same way?" "Why doesn't anybody see that this happen?" A talk with the supervisors elicited the same inaction. You know you, as an individual, can only do so much. You are not Florence N. reincarnated. Continue to do what is right. Do not waste energy trying to change everything, unless you have that energy to change one situation at a time. When you get a chance, try to talk to the doctor about the patient, and their response to treatments, interventions, and medications, but insure that your documentation backs up your assertions. And always remember, you need that job, so don't expect to be able to accomplish everything by yourself. You will suffer for it in the long run. I know. I've been there, done that.

[nurseangel47]

This is the norm for all LTC residents who are alert, oriented, and hence, demanding enough for their "expected" meds. Some of them are addicts. They have no life. I didn't mind giving them benzos., tranquilizers, narcotics all in one fell swoop because I knew them and knew they were immune to the potential resp depression that could occur or addiction problem that had already occurred (not my problem....don't blame them...they are there to die and they know it...give 'em their pills!)....

Not a bad attitude here. Just the plain facts as I see them. I've been a nurse for a very long time. Given this particular issue a lot of thought. Talked with nursing management/docs etc. about this particular thing.

No, I wouldn't feel badly about giving them those hs prns at all...