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?
I think it also depends which country you work in. I have found US hospitals really reluctant to medicate for pain, in situations that just would not occur anywhere else.
2 nights ago, a young lad in sickle crisis, just rolling around in agony when he arrived. In Europe we have a sickle crisis directive in the ER, give 10mg morphine subQ stat, and a further 10mg after 30 minutes. Once the pain is controlled, then find a vein and start fluids and a PCA.
Here (US), 2 nights ago, I asked 3 docs over 40 minutes to see this pt urgently and order something for pain. They did not want to know, and eventually sent a medical student to assess him.
Finally after I pestered them some more, I got an order for IV morphine 4mg.
So we have to delay meds for this poor kid while we find a vein. And then give a tiny dose which we know will do nothing.
I just don't see the compassion here that I see in other countries.
Skylark, how interesting. My current hospital has doctors that simply will not order enough pain medication. As for morphine, all we ever give is 2-4 mg, usually every 4 hrs. We give Dilaudid, too, but 0.5 to 2 mg, usually every 4-6 hrs. Our patients on oral pain med will get 5 mg of Norco; maybe 10 if they are lucky. My co-workers and I have discussed this many times, and cannot fathom why our doctors won't order more for pain. Only one of them is originally from the United States; the rest of our doctors are from other countries and immigrated here.
A quick addendum to all the great responses here. Be careful not to fall into the trap of thinking you know how much pain a patient should be in depending on how many days post-op the patient is. Pain disproportionate to the surgical procedure or disproportionate to where the pain "should be" based on comparison to a "normal" recovery can often be an indicator of badness dwelling within. To name a few things: infection, bleeding (retro-peritoneal bleeds have odd symptoms that can be overlooked), hematoma formation, hardware malfunction, compartment syndrome and blood clots. If you are unable to get the pain under control or if it is at a very high level when it should be trending down, a closer look needs to be taken as to the source. Some tests might be warranted to rule out complications. Also, if the pain is suddenly very different in quality or location, some red flags ought to start waving.
A quick addendum to all the great responses here. Be careful not to fall into the trap of thinking you know how much pain a patient should be in depending on how many days post-op the patient is. Pain disproportionate to the surgical procedure or disproportionate to where the pain "should be" based on comparison to a "normal" recovery can often be an indicator of badness dwelling within. To name a few things: infection, bleeding (retro-peritoneal bleeds have odd symptoms that can be overlooked), hematoma formation, hardware malfunction, compartment syndrome and blood clots. If you are unable to get the pain under control or if it is at a very high level when it should be trending down, a closer look needs to be taken as to the source. Some tests might be warranted to rule out complications. Also, if the pain is suddenly very different in quality or location, some red flags ought to start waving.
You're right!!
I'm sure we all agree that a lot of our patients are either completely faking pain, or just being dramatic and whiny. But I know that I don't want to be the nurse on duty that ignores someone's pain, since they "shouldn't still be hurting like that," only to find out something has gone wrong.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
I agree....then that needs to be taken up with the MD to order a more appropriate pain Rx and pain control.
Which brings another question...OP how many days post op was this patient. I know at a hospital I worked at they set the knees to the skilled floor POD #3.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
Boston....thanks for getting snippy!
I just wish they would use common sense....if the ppatient is asking early every time...here's a thought....MAYBE IT ISN'T ENOUGH or maybe CHANGE the drug! REASSESS YOUR PATIENT!
Jeeze....common sense...once they get done judging.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Personally, I am sick to death of the pain med debate. I read in the news that we are now getting a "new hydrocodone" with a hard, almost impenetrable shell, to reduce abuse. We will soon have to count tramadol, of all things. Both my daughter and I have severe arthritis. When mine flares, I can hardly walk. Some days I need Norco, some days I don't. I have never taken more than 10 mg in a 24 hr day before. I only work part-time because of the arthritis. I get tired of having to practically beg for pain relief. I have had 2 major GI bleeds and I am not supposed to take NSAIDS. Plain acetaminophen does nothing for the type of arthritic pain I have. Flexeril does nothing but put me to sleep. If I am in the hospital, and a nurse chooses to withhold my pain med, you can bet I will be on the phone with the doctor, the DON, etc. unless of course it is warranted.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
One nurse was holding my BIL pain meds, and taking his sweet time getting them as he lay dying from bone CA that was EVERYWHERE! because he could become addicted.
My sisters (I was in Boston), both nurses, informed him that he is dying and will be in heaven long before addiction is an issue.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
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).
After reading the above, and the OP I have to wonder, where in the heck did these nurses go to nursing school? It's shocking to me.
Also I have to assume that their performance evaluations (and thus raises) are NOT dependent
how well they do their jobs. Those facilities must not have RN surveyors walking around the hospital assessing patient's pain levels and marking down which nurses & physicians are not doing a good job with pain control and these marks are not being reflected in their performance evals.
Specializes in orthopedic/trauma, Informatics, diabetes.
tramadol is federal rule now (I have friend who has to go to the pharmacy to get it for her dog instead of the vet dispensing)
We are very generous in my hospital with the pain medications (non-ortho service pts, not so much). Our pts, unless contraindicated have 5-10mg oxy Q3H, a CR medication, and usually some IV breakthrough. We use PCAs to start, regional blocks on all joints and even ketamine drips if pain is not controlled. It is a serious issue. The residents learn early that when we ask, we mean it. We are very strong advocates for our patients
skylark, BSN, RN
636 Posts
I think it also depends which country you work in. I have found US hospitals really reluctant to medicate for pain, in situations that just would not occur anywhere else.
2 nights ago, a young lad in sickle crisis, just rolling around in agony when he arrived. In Europe we have a sickle crisis directive in the ER, give 10mg morphine subQ stat, and a further 10mg after 30 minutes. Once the pain is controlled, then find a vein and start fluids and a PCA.
Here (US), 2 nights ago, I asked 3 docs over 40 minutes to see this pt urgently and order something for pain. They did not want to know, and eventually sent a medical student to assess him.
Finally after I pestered them some more, I got an order for IV morphine 4mg.
So we have to delay meds for this poor kid while we find a vein. And then give a tiny dose which we know will do nothing.
I just don't see the compassion here that I see in other countries.