Thoughts on pain med with a range

[Sitch321]

I'm curious to see what the feedback will be to this question. I've had some agree and some disagree.

Scenario: I have a patient who can get 5-10mg oxycodone q4h. Can I give her 5mg of oxycodone every 2h? She doesn't like to take the 10 all at once and her pain was very well controlled with 5mg every 2-3h. The oncoming nurse said we couldn't do that. But it's not overdosing. So long as she only gets 10mg total in a 4 hour period its all the same thing, is it not? I just make sure there's at least 4 hours between every other dose. So if she gets 5mg at 10 am and then works with PT and wants the other 5 at 11am, I now will until at least 2pm to give another 5. The daily max is the same: 24h/4 =6, and 6x10mg= 60mg/day. 24/2=12, and 12/5= 60mg.

What do you think??

[scottaprn]

Not if you know anything about pain management. The goal is to move the patient to a long acting med that they take twice a day, and use the short acting med for breakthrough, so they aren't needing to medicate q2 hours and have a more stable level of relief.

That's why we monitor how much breakthrough med is needed in 24 hours-the solution is to increase the long acting med to comfort, so the short acting med is needed less often.

Well don't I have the best luck that I can learn about pain management from someone as knowledgable as yourself.

So please enlighten me, oh wise one, from where you received your pain management certification. I am assuming a cracker jack box since I can't think of a single respected pain management certification or plan that doesn't have assessment of the patient as the first step.

For that matter can you name a single medical intervention that should begin without assessing the patient?

I can't wait to hear about your extensive pain management education and experience that has taught you that it is not necessary to know anything about the patient before prescribing a pain management protocol.

That way I will know to avoid wherever you learned this knowledge like the plague so that I can continue on with actually assessing patients and treating their pain appropriately for THEM.

The experience of pain is unique for every patient; therefore: treatment goals are tailored to the needs of the patient, controlling constant pain with Long acting opioids may be best, if less frequent dosing and sufficient pain relief allow them to resume some, if not all, normal activities; Other patients may find that Short acting opioids provide them with the same outcome and is more effective than a long acting opioid.

Argoff & Silvershein Mayo Clinic Proceedings 2009

[kbrn2002, ADN, RN]

This confusion is why we are pretty strict on how our providers are required to write range orders. The order can read 1 tab for pain rated 1-5, 2 tabs for pain rated 6-10 q 4 hrs or the order can read give 1 tab, if ineffective may repeat dose in 1 hour, dosing not to exceed 2 tabs q 4 hrs. The second option is being phased out so only those residents with an older order still have this as it can leave the time for the next allowed dose open to interpretation; is the next dose allowed at the 4 hour mark from the first tab, or the second? Of course substitute whatever drug/time range the MD orders, my numbers are for example only.

[quiltynurse56, LPN, LVN]

If this is found out, then your Board may charge you with diversion of narcotics, negligence, and willfully acting in a manner inconsistent with the practice of nursing. If you give it a little early, then you have made a med error- Not that big of a deal. If you consistently and willfully give it every three hours, then you are in BIG trouble. Not only are you putting your license at risk, but you also run the chance of getting to wear bracelets when the Gold Badge patrol rolls in.

If we are consistently giving q 3 hours, we do get the order changed from prn to scheduled.

[OCNRN63, RN]

Well don't I have the best luck that I can learn about pain management from someone as knowledgable as yourself.

So please enlighten me, oh wise one, from where you received your pain management certification. I am assuming a cracker jack box since I can't think of a single respected pain management certification or plan that doesn't have assessment of the patient as the first step.

For that matter can you name a single medical intervention that should begin without assessing the patient?

I can't wait to hear about your extensive pain management education and experience that has taught you that it is not necessary to know anything about the patient before prescribing a pain management protocol.

That way I will know to avoid wherever you learned this knowledge like the plague so that I can continue on with actually assessing patients and treating their pain appropriately for THEM.

Argoff & Silvershein Mayo Clinic Proceedings 2009

Hospice nurses are highly knowledgeable about pain management; it's what they do. When I worked in hospice, I had physicians ask me what my recommendations were.

See, that's the thing. When you work in hospice, you develop good working relationships with physicians. I never had any doctor speak as dismissively as you just did to a fellow nurse. (You are still a nurse, at the end of the day.)

It helps to know about your patient, e.g. religious or cultural considerations when trying to develop a successful plan of care for managing pain. It's not, however, the most important thing.

Your previous comment was vague, so I can see why she responded the way she did.

[imintrouble, BSN, RN]

Here's where I get stuck. I hope this makes more sense than my last post.

"Sue" gets 5mg at 1500

She wants another 5mg at 1700

At 1900, when I come on, she want the whole 10mg because her pain is 10/10.

Her last removed pain med dose has only been 2 hrs. The parameter is 4 hrs. She's been getting pain med very 2 hours and she doesn't understand why I won't give it too.

If I give the full dose of 10 mg at 1900, aren't I making a med error? Or am I over thinking this whole thing?

[scottaprn]

Hospice nurses are highly knowledgeable about pain management; it's what they do. When I worked in hospice, I had physicians ask me what my recommendations were.

See, that's the thing. When you work in hospice, you develop good working relationships with physicians. I never had any doctor speak as dismissively as you just did to a fellow nurse. (You are still a nurse, at the end of the day.)

It helps to know about your patient, e.g. religious or cultural considerations when trying to develop a successful plan of care for managing pain. It's not, however, the most important thing.

Your previous comment was vague, so I can see why she responded the way she did.

Yes I am proud to be an advanced practice nurse.

And if you think that

Wouldn't it seem prudent to actually know things about the patient and situation before making a blanket statement about their pain medication regimen?

is vague I will be more than pleased to help you with your reading comprehension.

Wouldn't it be prudent (prudent means acting with or showing care towards the future) to actually know something about the patient (like an assessment, diagnosis, past pain control treatment and their efficacy would fall under "actually knowing something about the patient") before making a blanket statement about their pain medication regimen (For example expressing a belief that there is a magical level at which everyone needs to be on a long acting opioid). Hopefully, knocking it down a few grade levels will allow it to be less vague for you.

Here is the thing. A patient who is in pain needs to have their pain assessed and treated in the manner that is correct for them- that is the basis of pain management (something I supposedly know nothing about per the poster). Treating the patients pain may mean long acting opioids or it may mean short acting opioids or it may not mean an opioid at all. The decision does not belong to a keyboard warrior with imaginary powers- whether they are a hospice nurse, a nurse practitioner or a physician.

For the poster to tell me I don't know anything about pain management because the poster believes the only correct treatment for the patient is a long acting opioid based on no knowledge of the patient at all is absurd. For all the poster knows the patient may have failed a trial of long acting opioids- but the poster doesn't know that because she doesn't know anything about the patient.

If a nurse calls me about a patient and they haven't assessed them I tell them to call me when they have made an assessment. This is as bad as Terry Schiavo being diagnosed by physicians on CNN off a ten second video clip.

Let me reiterate that no professional pain medicine guidelines suggest interventions or changes to interventions without assessing the patient. Period. End of story. Yet the poster tells me I don't know anything about pain management when she is making recommendations with no assessment. She has proven herself the fool.

And if you think I am dismissive to nurses who show ignorance like was just demonstrated you are correct. It is an embarrassment to the profession when a nurse suggest interventions and claims to be an expert of pain management when she doesn't think it is necessary to know things about the patient before recommending a treatment plan. I can't think of a way to harm the profession more than to publicly demonstrate ignorance.

Do you ever wonder why nursing doesn't advance as a profession at a faster pace? Part of the reason why is because we tolerate and accept stupid statements like the poster made. At least when the resident says something stupid in rounds they get corrected. On the nursing side we get other nurses supporting stupid ideas.

And if you don't think that the physicians are every bit as dismissive as I just was to baseless suggestions get a badge to the surgeon's lounge and hang out and see what stories you hear.

So just to hit the highlights so we aren't to vague. ASSESS THE PATIENT BEFORE YOU MAKE BLANKET STATEMENTS ABOUT HOW THEY SHOULD BE CARED FOR. Also, don't claim that someone doesn't understand a topic on which they can run circles around you.

[Guest219794]

If this is found out, then your Board may charge you with diversion of narcotics, negligence, and willfully acting in a manner inconsistent with the practice of nursing. If you give it a little early, then you have made a med error- Not that big of a deal. If you consistently and willfully give it every three hours, then you are in BIG trouble. Not only are you putting your license at risk, but you also run the chance of getting to wear bracelets when the Gold Badge patrol rolls in.

Can you cite any examples of somebody losing a license or being arrested for the practice described?

A lot of people on this board seem to believe that The Board of Nursing is some kind of bogeyman, but when I look at why people get disciplined, it is never for anything like this. And getting arrested for possibly misinterpreting an order in a manner that is no harm to the patient? Nah.

[MunoRN, RN]

It is practicing outside of your scope of practice (inconsistent).

The med is to be given the way the doctor ordered it.

I can't think of anything to say except that you really need to invest in some liability insurance.

If this is found out, then your Board may charge you with diversion of narcotics, negligence, and willfully acting in a manner inconsistent with the practice of nursing. If you give it a little early, then you have made a med error- Not that big of a deal. If you consistently and willfully give it every three hours, then you are in BIG trouble. Not only are you putting your license at risk, but you also run the chance of getting to wear bracelets when the Gold Badge patrol rolls in.

Other than 'wildly misinformed' I'm not really sure what to make of this. I actually am involved in our surveys and have discussed this specifically with out BON surveyors and you've got a completely opposite understanding of what the BON, at least in my state, expects.

In their survey binder, they include the positions statements of two pain management groups as the basis of what they would like to see. This includes two basic rules, the first is that pain med dosages should not be based on a standardized numerical scale, and the other is that the purpose of a range order is to indicate what the maximum dose of medication is to be over a certain time period. Nurses should not be encouraged to start with a higher dose out of concern the smaller dose won't be sufficient and will have to wait, nor should patients be required to unnecessarily wait out a frequency period within pain despite not having received the allowed dose.

What is the rationale for the way you are saying it should be done?

[Jensmom7, BSN, RN]

Well don't I have the best luck that I can learn about pain management from someone as knowledgable as yourself.

So please enlighten me, oh wise one, from where you received your pain management certification. I am assuming a cracker jack box since I can't think of a single respected pain management certification or plan that doesn't have assessment of the patient as the first step.

For that matter can you name a single medical intervention that should begin without assessing the patient?

I can't wait to hear about your extensive pain management education and experience that has taught you that it is not necessary to know anything about the patient before prescribing a pain management protocol.

That way I will know to avoid wherever you learned this knowledge like the plague so that I can continue on with actually assessing patients and treating their pain appropriately for THEM.

Argoff & Silvershein Mayo Clinic Proceedings 2009

No need to get snippy. Of course pain management starts with assessment. I believe I was talking about the general objective of pain management. I could have gone on for pages about what meds work best with what type of pain, and why, but that wasn't necessary here.

And, I did say monitoring level of pain and titration of meds based on the total amount of breakthrough meds used in 24 hours are important aspects of effective pain management. Are those not assessments?

Oh, as for my knowledge? I'm a Hospice Nurse. We kind of deal in pain management.

Now that I've answered you nicely, I'm going to go on my way, and not let you get under my skin, no matter how argumentative and nasty you get.

[calivianya, BSN, RN]

Here's where I get stuck. I hope this makes more sense than my last post.

"Sue" gets 5mg at 1500

She wants another 5mg at 1700

At 1900, when I come on, she want the whole 10mg because her pain is 10/10.

Her last removed pain med dose has only been 2 hrs. The parameter is 4 hrs. She's been getting pain med very 2 hours and she doesn't understand why I won't give it too.

If I give the full dose of 10 mg at 1900, aren't I making a med error? Or am I over thinking this whole thing?

That is really sticky. I would probably call the provider over that one.

[BuckyBadgerRN, ASN, RN]

Nope, you have to give AS WRITTEN. Your tweaking the order because it controls the pain better is not allowed. Get your MD to re-write it, but don't deviate from what is written!

[trinitymaster]

Other than 'wildly misinformed' I'm not really sure what to make of this. I actually am involved in our surveys and have discussed this specifically with out BON surveyors and you've got a completely opposite understanding of what the BON, at least in my state, expects.

In their survey binder, they include the positions statements of two pain management groups as the basis of what they would like to see. This includes two basic rules, the first is that pain med dosages should not be based on a standardized numerical scale, and the other is that the purpose of a range order is to indicate what the maximum dose of medication is to be over a certain time period. Nurses should not be encouraged to start with a higher dose out of concern the smaller dose won't be sufficient and will have to wait, nor should patients be required to unnecessarily wait out a frequency period within pain despite not having received the allowed dose.

What is the rationale for the way you are saying it should be done?

What position statement says that you can deviate from a physicians order? The op

desired input on whether you could give additional pain medicine after only waiting for 1/2 of the prescribed interval.

It does not matter that we don't think that we should wait until the prescribed interval has passed to give an additional dose of pain medicine. We can't do it. It's called trafficking in a controlled substance.