Why so reluctant to give pain meds?

[Baubo516, RN]

Hello!

I just got off a busy night shift and I am feeling frustrated by one of the nurses I work with in regard to controlling a patient's pain.

Quick background on me - I am an LPN working as a CNA on a Rehab and Skilled unit at a hospital where they do not hire LPN's. I work homecare as an LPN. I will graduate from an ADN program in 3 weeks.

So...the issue I am wondering about is the reluctance to use the pain medications that the doctor has prescribed for a patient. We currently have a patient on our unit recovering from bilateral total knee replacement. She is female, 50's, a little heavy but not morbidly so, and she has a lot of pain. She is on our unit because she needs more time to recover and some PT to get these new knees working well enough to be safe at home. We put on her bil CPM machines at about 5am each morning. As a CNA, I make sure she is toileted before we do this, as we want her on the machines for 2 hours. I also think she should have pain meds about 30 minutes before CPM application, or right before if we are giving them IV.

For 2 nights in a row now, I have had the nurse assigned to this patient balk at the idea of giving her pain meds before putting on the CPM's. One of them gave her an oral pill at 4:30am, but when we got her up to the bathroom at 5:15am she was moaning in pain and talking about how much it hurt her to move. When she was back in bed at 0530, the nurse asked her about her pain, and said something like, "Do you want something for pain? I know you have been trying to get away from the IV meds," and then just went on with the interaction without giving the patient a chance to answer. As we were finishing up, the patient was still moaning and saying she hurt, and the nurse just said, "Call us if you need anything" and left the room. I followed her and told her that I thought the patient needed something because she was still moaning in pain. The nurse told me again how the patient had refused some pain meds earlier in the night when she was not in pain, and had been "playing on her computer" at another time, like this justified not giving pain meds. I guess I bugged the nurse enough because she did take her down some IV dilaudid.

Note: this patient has no documented history of addiction or any problems r/t opioid meds.

On the second night, before I ever saw the patient, I hear her nurse (a different nurse) complaining to the charge nurse about how the patient says she is having so much pain but that she (the nurse) does not want to give any IV pain meds. I know that patients have to adapt to using PO meds before they go home, but this lady is only up to 65 degrees on her CPMs - she is not going home that soon. I don't know how the pain med administration went for most of the night, but this time it was 5am when I went to toilet her before CPMs. Before I went, I asked the nurse if the pt had been given pain meds. She said she had her oral pill at 0330 (sorry, not sure what it was, but something like Norco), and then "something else" so she should be fine. But again, when we got her up to the bathroom she was moaning and continually saying how much her knees hurt. She had ice packs on when we walked in, and we put fresh ice packs on with the CPMs. It was 0520 when I approached her nurse and told her the patient was in pain and asking for pain medication. The nurse seemed very annoyed. But I think she did go down and give her something. I looked at her MAR and saw that the last thing she had been given was flexoril.

OK - so I know there are probably variables that I don't know about. Since I was working as an aide I did not read this patient's whole history. But I DID ask the nurse tonight WHY we shouldn't give her any pain meds and she said there are people who go home 2 days after knee surgery and they only use PO meds, and that by allowing her to use the IV meds we are letting her "go backwards" in her progress toward home. To me this is not a valid reason, as the patients who are healthy and strong enough to go home 2 days after surgery do not come to our unit. They come to our unit for pain control, recovery time and therapy to help them get stronger.

I guess I am looking for some insight, because I will be a new practicing RN soon and I feel that good pain management is important for these ortho patients if we want them to use their CPMs and do their therapies. I know we don't want respiratory depression, kidney problems, or people who are too dopey to get up in the morning. If the pain meds cause delirium I know we try to decrease doses or change meds. This lady has no therapy scheduled for today and breakfast doesn't come until 0745. She has had no confusion. Why are these nurses so hesitant to get her pain under control?

[Altra, BSN, RN]

Lots of variables, and we're not going to be able to speak for that nurse specifically. I do think I agree with avoidance of IV narcotics for rehab patients. In my experience, ortho post-op patients are generally transitioned off of IV meds within 24-36 hours after surgery.

[Esme12, ASN, BSN, RN]

I couldn't disagree more.....as I am just recovering from an emergent surgery. Pain is pain. I had nurses that empathized and gave me the meds as asked for/scheduled... and I had nurses that felt it was their personal journey to help me "tough it out" because you aren't going to go home on IV pain meds (although I was NPO and a fresh post op).

It is NOT the nurses job to insert her personal feeling and thoughts on how she feels best to carry out (or not carry out) the physicians orders. Nor is it her personal responsibility to withhold pain medication in order to "prevent" addiction because the pain meds are "addictive" all in my best (the patient) interest of course.

I was less than 48 hours post op (I was in ICU) with a 16 inch midline abdominal incision (about 82 sutures), multiple lines and drains, art line, foley and NGT...no PCA... and was given "THE LOOK" and lecture about pain meds and "making yourself wait a bit longer" (in my best interest of course) because I was requesting q 1 hour pain Rx.....she would begrudgingly go and get 0.5 dilaudid and take as long as she possibly could to return to my room .... I was her only patient ( the order was 0.5 - 1mg moderate pain....1 - 2mg q 1 hour severe pain) yet she wanted me to get up and "do things for myself" so I could get better and go home.

First...if you want a patient to cough and deep breathe...medicate them. If you want them to ambulate... Medicate them. My nurse and I had an intellectual discussion about pain control and we came to an understanding...you medicate your patients.

Second..even patients with chronic pain issues and chronic pain Rx (I take 1/2 to one Vicodin (5mg) as needed daily) still experience acute pain and they deserve to be treated appropriately to have their pain as relieved as possible.

Even if a patient is "watching TV" or "Playing on the computer" is NO INDICATION that they are not experiencing pain. Some people shut down...others may behave opposite to what they are feeling and may be laughing or smiling...some people will employ distracting behaviors (like playing on the computer) to try to pass the time until someone will relieve their pain. Me personally... I am not my talkative self and will lie there with my eyes closed sending my mind to Hawaii...it by no means means I am "comfortable" so if I say I have pain and my B/P is elevated with a 130bpm heart rate...news flash....I am in pain.

I know all this pain scale stuff and relieving pain campaign generated a problem with a larger drug seeking patient population or demographic...however...patients need to have their pain relieved and have their moral character and dignity left intact.

A double knee replacement deserves more than a Flexaril. Maybe...just maybe...if this patients pain was better controlled she would be doing better with the CPM and on the road to going home.

[Esme12, ASN, BSN, RN]

OP...assess your patients. If they are not over sedated and are in pain.....medicate them.

[annie.rn]

I couldn't disagree more.....as I am just recovering from an emergent surgery. Pain is pain. I had nurses that empathized and gave me the meds as asked for/scheduled... and I had nurses that felt it was their personal journey to help me "tough it out" because you aren't going to go home on IV pain meds (although I was NPO and a fresh post op).

It is NOT the nurses job to insert her personal feeling and thoughts on how she feels best to carry out (or not carry out) the physicians orders. Nor is it her personal responsibility to withhold pain medication in order to "prevent" addiction because the pain meds are "addictive" all in my best (the patient) interest of course.

I was less than 48 hours post op (I was in ICU) with a 16 inch midline abdominal incision (about 82 sutures), multiple lines and drains, art line, foley and NGT...no PCA... and was given "THE LOOK" and lecture about pain meds and "making yourself wait a bit longer" (in my best interest of course) because I was requesting q 1 hour pain Rx.....she would begrudgingly go and get 0.5 dilaudid and take as long as she possibly could to return to my room .... I was her only patient ( the order was 0.5 - 1mg moderate pain....1 - 2mg q 1 hour severe pain) yet she wanted me to get up and "do things for myself" so I could get better and go home.

First...if you want a patient to cough and deep breathe...medicate them. If you want them to ambulate... Medicate them. My nurse and I had an intellectual discussion about pain control and we came to an understanding...you medicate your patients.

Second..even patients with chronic pain issues and chronic pain Rx (I take 1/2 to one Vicodin (5mg) as needed daily) still experience acute pain and they deserve to be treated appropriately to have their pain as relieved as possible.

Even if a patient is "watching TV" or "Playing on the computer" is NO INDICATION that they are not experiencing pain. Some people shut down...others may behave opposite to what they are feeling and may be laughing or smiling...some people will employ distracting behaviors (like playing on the computer) to try to pass the time until someone will relieve their pain. Me personally... I am not my talkative self and will lie there with my eyes closed sending my mind to Hawaii...it by no means means I am "comfortable" so if I say I have pain and my B/P is elevated with a 130bpm heart rate...news flash....I am in pain.

I know all this pain scale stuff and relieving pain campaign generated a problem with a larger drug seeking patient population or demographic...however...patients need to have their pain relieved and have their moral character and dignity left intact.

A double knee replacement deserves more than a Flexaril. Maybe...just maybe...if this patients pain was better controlled she would be doing better with the CPM and on the road to going home.

Esme sums it up beautifully. I couldn't agree more w/ her post.

[LibraSunCNM, BSN, MSN, CNM]

Agree 100% with Esme12. I have never really understood why some nurses do not understand pain control and feel that giving anyone narcotics will make them an addict.

Esme, they gave you a hard time immediately post-op?? If you don't need pain meds then, when do you need them?? You get anesthesia and then you're on your own, I guess.

Luckily I haven't worked with nurses like this, but I read about it a lot here on AN and it's upsetting to say the least. Use this as a learning opportunity to figure out how you as an RN will approach pain control differently than this nurse.

[canigraduate]

Thank you for asking this. It shows that you are critically thinking, compassionate, and you care more about your patient than your own philosophy.

You are a rare treat!

[VANurse2010]

IV pain medications, in general, are not appropriate for the rehab setting. The whole point of rehab is to get the patient home (preferably off narcotics, although this isn't always possible). They need to be on a pain regimen that they can do at home, which does not include IV narcotics.

Edit: Esme - I respect your opinion, but there's a big difference between POD 0-2 in the ICU, and POD 14 in the rehab.

[canigraduate]

Not knowing this patient's history, I can only base my comment on the OP's description of unrelieved pain needs.

I understand the reluctance to give IV meds, but what I don't understand is why the oral dose hasn't been increased or the frequency increased since it is obviously ineffective.

Also, if the MD doesn't want you to give IV meds, it needs to be taken off the MAR.

My personal belief is that you need to use whatever tools you have to get the patient comfortable enough to function, and then talk with the doctor about what needs to change to get the patient ready for discharge.

I believe that making the patient suffer, in whatever setting, is cruel. The patient doesn't care what post op day it is if they aren't getting sufficient relief.

[Lev, MSN, RN, NP]

I currently work on a surgical floor that takes some ortho patients (I am leaving for ED next month). Pain management is huge especially with ortho and GI. Ortho so they can move and GI so they can breathe (and ambulate). That nurse was acting inappropriately. All patients get at the very least a PO narcotic (oxycodone is choice at my facility) a half to 1 hour before CPM. I have given dilaudid and oxycodone and put them on CPM right after. Dilaudid lasts maybe 1 hour. It is inappropriate to continue CPM if the patient is moaning in pain. That means it's time to stop. With or without pain meds. We will wean them off IV by alternating IV with PO. Some patients are afraid to try PO because they are scared we will take away IV altogether. By their day of discharge most patients are managed only on PO if anything. If they are having severe pain with activity IV dilaudid or morphine will be available for breakthrough pain or before therapy sessions (CPM is a therapy too). Esme is right - pain must be managed if you want your patient to ambulate, use the incentive spirometer, and feel better in general. Thank you for caring.

[FurBabyMom, MSN, RN]

When I worked on the stepdown/med/surg potpurri of various patients I used to work on, I never refused to medicate patients because I felt they must not be in pain (my personal feelings have no place in my work relationships with patients). There were several (2-3) where I assessed my patient, and based on assessment (sedation level, patient reported/description of pain, vitals - HR, BP, spot check vs continuous SpO2, any other factors as applicable), I temporarily held medications. I never simply held medications for a reason/refused to medicate and also refused to fix the problem. I would certainly never tell a patient they need to tough it out. I explained to my patients why it would be just a bit - that I was concerned about their safety, for example, their BP or oxygen level - and that my next step was to discuss the situation with their MD/NP/PA. I would call the provider, explain the patient's complaint and my assessment data and have some "request" to fix the situation. IV fluid bolus/IV fluid rate change? Continuous SpO2 monitoring (we could start it but had to have an order within an hour for SpO2 and tele)? Oxygen? While I had the provider on the phone, I asked for the order for narcan if it wasn't already an if needed order...(one hospital I've worked at it was auto ordered with IV pain meds, another it was not). Once I had an order to fix the problem I had with giving the meds, I pulled the meds, administered the medications, and started the additional intervention. And sometimes, there were times patients complained of pain drastically different than previous complaints (described it different etc) and sometimes, post op or post trauma/injury, those changes require being investigated too. Sometimes it's a referral for pain management, sometimes it could be an issue with a post op complication/etc. I would then reassess a little more frequently, and the whole process generally took all of about 5-10 minutes. I was generally in the room the first 5-10 minuted after giving the meds in question (IV push meds take a while to give properly, and there's generally always some "reason" to hang out - close enough to a re-assessment time to complete it, etc and closely monitor).

[BostonFNP, APRN]

Just a week or so ago I had a similar experience. I was rounding on a patient on a med-surg floor admitted with multiple compression fracture s/p a mechanical fall. I walked into the lovely elderly woman's room to find her writhing in pain. I asked her if she had a recent dose of her pain medication (0.2 of hydromorphone IV). She tells me she asked the nurse "about an hour ago but was too early". So I head out to the EMR/POE to check her last dosing time and up her frequency and find the order written for q4h with her previous dose given more than 6 hours before.

I find the attending RN and query her. She tells me she wasn't due yet. I told her I checked the MAR and she was long overdue for her prn. Then the nurse tells me "it was my judgement call not to administer it" so I grab the vitals sheet and show her an elevated BP and pulse, a RR of 24, and reported pain 8/10 twice in the past two hours. She then tells me "she is asking early every time and becoming an addict".

I very nearly lost it. I always try to treat the attending nurses with the upmost respect but this just demonstrated such bad decision making (as well as practicing outside of scope) that I got a little snippy. This is just not acceptable.

Sent from my iPhone.