I have a patient who takes Vicodin one tablet every four hours for pain. She is also taking Neurontin and on a Fentanyl patch q72hrs.
My question/concern.. is. She is pretty much on the dot in asking for her Vicodin - often times she asks for it early, after two hours post my giving one to her. Many of the other nurses think she does not need this med, and is simply addicted, and wants it for the "buzz". I sometimes find myself believing this too, but I feel guilty for thinking she is faking the pain because who am I to know what she is feeling.
Sometimes, when she asks for her pill..and I bring it to her after the few minutes or so that it takes for the CNA to tell me she wants it, and for me to finish writing a sentence in my charting, open the lock box, document time etc... only to find her sleeping in her bed or chair, respirations wnl, no grimacing, diaphoresis, guarding or other s/s of pain, and I have to jostle her a few times to wake her to take the pill (she is very hard of hearing, which is why I jostle her). Those are the times when I think she is just addicted and wants a buzz.
The MD won't increase her dose, the daughter has stated that she thinks she doesn't need it, but this patient reports to me that she is in pain and well... I just can't decide how I feel. On one hand.. I do think she may have developed a tolerance to it and is indeed in pain, and on the other hand I think she wants a buzz.
Sometimes if she asks for a pain pill and I bring it in to her, only to find her sleeping, I'll walk back out and she won't call for one for another hour or two.
Can anyone please give me some insight on this.. should I give her the pain pill every time without question? Or should I try to stretch it longer in believing she is just seeking a buzz?
My experience with pain management in adults is limited to what I saw when I worked in the ER, and there was a lot of it. Was it chronic pain? Acute pain? Addiction? Drug seeking? Drug selling? Don't know. I gave what was ordered using my nursing judgment (there were some dilaudid orders for pancreatitis patients and sickle cell that made me very uncomfortable, and I could not bring myself to give it all at once), gave patient's their prescriptions, and left it at that. IMO, it is not our job to decide if someone is in true pain or not, but to report our observations, document what the patient reports and carry out orders as they were written safely, and report concerns of abuse, tolerance, etc to the ordering physician so that consults to psych, pain managment, palliative care, etc can be made if necessary. I have never witheld pain medication (even if I was rolling my eyes in disbelief that someone could have abdominal pain of 10/10 while eating Doritos, laughing and talking on their cell phone as I was getting it out of the pyxis) because I thought someone didn't need it, but have if I truely felt that it was unsafe to give (unarousable, decreased respiratory drive, periods of apnea ).
In the PICU, most of my patients were on fentanyl and versed drips, and I was more than happy to give them all the PRN doses that they needed of whatever they had ordered. The last thing that I wanted was an unplanned extubation. We would get teenagers who'd had surgery that required an ICU stay that would be very push happy with their PCA's (had one patient that pressed it 140+ times in a 12 hour shift) and would still say that they needed extra PRN's for breakthrough pain...no big deal (again, as long as it was safe to do so). I often found that they might have been bored or lonely and pushing the Wii to the bedside or turning on a movie to serve as a distraction or entertainment was just as, if not more effective at times. But that population was very different than that in a LTC facility.
IMO, pain is what the patient says it is - and if they insist that they are hurting after other nursing interventions or PRNs have failed, it's not my place to interpret what they report differently.
there are significant differences between s/s of chronic pain and acute, recent-onset pain. people with chronic pain severe enough to require a fentanyl patch almost never show the behavioral or vital sign changes we associate with severe acute pain.
as for asking "on the dot" for her vicodin ... it's what she's supposed to do. opioids are far more effective when they are used early, before the pain gets bad, than when they are used to "catch up" with pain that has been allowed to become severe.
another note: physical dependance on an opioid - tolerance - is not the same as addiction.
it's amazing to me how many nurses either do not get this or don't accept it.
You can usually tell who your drug seekers are going to be because they are frequent fliers on the unit or thier level of pain medication doesnt match the diagnosis or even the favorite, "Heres a list of things I cant take but I can take Dilauded 2mg" Lol?
Allergies to toradol, morphine, ultram, reglan, and zofran...and phenergan and dilaudid cause itching so please give them with IV benadryl as well?
I have only had ONE patient that I thought was truly drug seeking. This was the guy who had 2mg of Dilaudid every 2 hours and told me that "my IV site stings when you hang it over 20 minutes, so please push it instead." I work with vascular patients, so chronic pain is a very real thing on my floor and with the difficult patients I usually have a conversation at the beginning of my shift about whether they would like to be woken up for their pain meds or not. There is nothing worse then having a patient wake up at 5 am in excruciating pain because they haven't gotten their meds for 6 hours. Then you have to give them IV pain meds, which honestly can hold up a discharge. One Vicodin every 4 hours? Not a big deal, I would be surprised if it is even helping her pain (depending on what type of pain she is having).
Specializes in LTC, Disease Management, smoking Cessati.
Give it to her.
Clearly she has chronic pain if she has a Fentanyl patch. And really, who cares if she gets a little "buzz" from her ONE stinkin Vicodin pill? It's not our job to impose our morals on our patients.
Amen! and I seriously doubt that, if she has been on it long enough one Vicodin is NOT going to give her a "BUZZ"..... and if it makes her feel better who cares....
One Vicodin every four hours is nothing. If she's also on Fentanyl and neurontin she has some legitimate pain issues. I'm actually a little surprised that she's only getting one vicodin and not more, or some other type of prn pain med.
It also sounds like she is trying to be responsible about respecting the Q4 dosing schedule.
But if she is asking for more than her Q4 vicodin, it's possible that her pain management needs to be re-evaluated. Do you know why the doc doesn't want to increase it? Does it make her confused or sedated? Is there some other concern? Has she tried other pain meds in the past?
Chronic pain sufferers need to have their pain meds tweaked every now and then, the same as patients on insulin, anti-hypertensives, psych meds, diuretics, potassium, etc. etc. The difference with those meds is that you can use objective data to support those decisions, whereas pain is subjective.
It's our responsibility as nurses to be able to read our patients' cues well enough to convince the doc to take a new look at the problem.
Your next best action here would be to get a sense of why the doc has her on one vicodin, and maybe discuss with him/her the patient's increasing needs and whether other options might need to be considered.
This patient is not asking for the Vicodin for pain control or a buzz. It is a drop in the bucket compared to what she is receiving.
It is her attempt at control of her illness. Whereas ,a few vicodin sprinkled in during the day may not cause any side effects... the real issues need to be addressed.
Has the pain team or a psychiatrist been consulted?
This patient needs a comprehensive look at her and her pain/ psych issues.
If it's ordered, and a patient wants it, I give it. I won't do 4mg dilaudid to a pt who is being discharged in an hour who just wants "one more dose" before we take the IV out, because they will not be going home with any dilaudid.
Who am I to judge whether an elderly woman is actually in pain or addicted? If the patient says pain, they have pain. Period.
). 
We would get teenagers who'd had surgery that required an ICU stay that would be very push happy with their PCA's (had one patient that pressed it 140+ times in a 12 hour shift) and would still say that they needed extra PRN's for breakthrough pain...no big deal (again, as long as it was safe to do so). I often found that they might have been bored or lonely and pushing the Wii to the bedside or turning on a movie to serve as a distraction or entertainment was just as, if not more effective at times. But that population was very different than that in a LTC facility.
DookieMeisterRN
315 Posts
1. Another thing to consider is that fentanyl patches don't relieve all types of pain.
2. A major side effect with all narcotics is drowsiness for most people. Despite being drowsy though you can STILL be in pain.
3. Look at your residents MARs, how many on antidepressants?
4. I know when I'm elderly and if ever in a LTC facility I will want to be comfortable and respected not be made to feel like a drug addict.