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?
yes you should give it to her. on the floor , and in your capacity as thr nurse, its a moot point whether shes full of it, faking it, whatever. its not your call if its ordered, you give it. its that simple. addiction counseling is not your role.
It sounds like the Vicodin is ordered PRN, is that the case? I think I'd be asking to get it changed to regular dosing rather than PRN, or see if it can be changed for something longer acting as a previous poster suggested. A regular dose of paracetamol (tylenol) may even help, depending on what sort of pain it is. Maybe her Fentanyl patch dose needs to be increased.
PRN dosing is not really supposed to be used for something that is actually being given regularly, it defeats the purpose, and the resident may do better knowing the pill will come - she may be asking for it 'early' because she's worried she won't get it otherwise or knows from experience that there is sometimes quite a delay between asking for the pill and actually receiving it. Regular dosing with times that are acceptable to the resident often takes away most of those issues. The medication can still be refused or withheld if necessary.
Chronic pain management can turn into a real control battle with the resident wanting to be in control of when they get their pain relief (and why wouldn't they?) and the staff wanting to be in control of deciding whether or not the resident needs it.
I get migraines and it took a lot of years but I've finally learned to take something at the first hint of a headache coming on, when I 'don't really need it'. If I wait until the pain is 'severe enough', nothing touches the headache.
Specializes in Trauma Surgery, Nursing Management.
First of all, I admire you for being torn, posing this question and seeking opinions. It shows that you care. You already know that pain is subjective, and you cannot make the assumption that this pt wants Vicodin because she seeks the 'buzz'.
Let's play a hypothetical game:
Suppose your mom was in an LTC facility. She is having chronic pain, yet it seems manageable. You find that she is not really herself, and it saddens you to see her decline. She is drowsy quite a bit, because being on narcs makes her drowsy to begin with, and having little interaction with others leads to boredom as well...so she sleeps. She is more than likely depressed, and lying in the bed all day DOES make your body hurt. You know that feeling you get when you sleep in a few hours more than you usually do--that achy feeling? Multiply that times 10. IT HURTS.
Your mom's nurse thinks that because she is sleeping a lot, that she must not be in pain. She decides to skip the next dose of Vicodin, because she thinks that your mom must be looking for a high. Your mom is clearly in no acute distress, right?
Doesn't this scenario kind of **** you off? On the one hand, we want to take a scientific approach to the way we practice as nurses. On the other hand, we can never remove ourselves from the humanitarian aspect of our practice. This is what makes our jobs so difficult sometimes-it is hard to discern black and white and we often work in grey areas. You must rely on your education, critical thinking and intuition, all the while ensuring the safety and well being of your patients.
Give the lady her Vicodin. Make her comfortable. In the grand scheme of things, it's not likely that she will turn into a junkie. She just wants to stop hurting.
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?
If I discovered a nurse had unilaterally decided to 'stretch out' the time before I received pain medication that was ordered by my physician, I'd file complaints with everyone from her employer to the BON.
I long ago decided that I am not the drug police. If they want it, and it's ordered, and it's time, and they have respirations above 12, they are getting it.
P.S. Have spoken to MD about it, his reasoning is she is not in that much pain. Daughters reasoning for not wanting an increase is if something happens that causes MORE pain, the drugs won't have an effect on her. I know.. I know..
I was taught in school as well, that pain is subjective .. but you sometimes get caught up in the "nursing" aspect once you're working as a nurse to question things. Having to wake her up, FIRMLY wake her up, made me question the validity of her reported pain.
I've called the doctor re: her requesting it early, and one time he's said it's ok to give it early. She's a newer pt to me, so I relied on the other nurses reports on her.
Thanks for the advice peeps.. eh hem, but a few of ya'll were a bit harsh. I appreciate those that weren't.
I'm honestly somewhat torn in said situation @ times. I've definitely entered a pt room who has asked my "tech" (to ask me) for pain meds only to find them sleeping. In this case, I will never wake them up to administer the med. However, if they should put the call light on again, I answer it myself so there is no confusion as to whether or not the tech relayed the message and I can provide my explanation as to why I didnt administer the med. I usually administer pain med shortly after. I have found many times in this cellular/technilogical age that setting an alarm q4 (or whatever the freq may be) is not uncommon. It annoys the **** outta me when I come in and find them sleeping! I work in trauma/trauma step down in Atlantic City. I know pain is real. I also know addiction is real (esp in this city). I often wonder whether I'm helping these ppl or contributing to the problem. My fears are not eased by having an "order"
p.s. have spoken to md about it, his reasoning is she is not in that much pain. daughters reasoning for not wanting an increase is if something happens that causes more pain, the drugs won't have an effect on her. i know.. i know..
i was taught in school as well, that pain is subjective .. but you sometimes get caught up in the "nursing" aspect once you're working as a nurse to question things. having to wake her up, firmly wake her up, made me question the validity of her reported pain.
i've called the doctor re: her requesting it early, and one time he's said it's ok to give it early. she's a newer pt to me, so i relied on the other nurses reports on her.
thanks for the advice peeps.. eh hem, but a few of ya'll were a bit harsh. i appreciate those that weren't.
is this doc prescribing fentanyl for 'not that much pain'? does he have a clue about long term pain care management??
as far as the one vicodin-- i worked drug/alcohol rehab....70 vicodin a day was fairly common :) and the primary reason was for the buzz...most didn't even talk about pain (some did).
if the vital signs are consistent (some people have normally low bps and don't have tachycardia anymore because being in constant pain is their normal. they've adjusted.
imo, it is always better to medicate someone than take the chance they're being left to have unnecessary pain. most pain patients know that "pain free" isn't even an option. they just want tolerable. :) if a lousy 5mg of hydrocodone every 4 hours takes care of it (and keeps it from being worse d/t not getting it- then having to 'catch up'), she needs it :)
When you get yourself caught up in this judging of real vs addicted pain, you are spending your own emotional energy on an issue that you have very little control. If when giving the pain meds, if you feel suspious, contact the doctor or your supervisor. There is a lot better things to spend your emtional resources on. Instead of getting upset every time these one or two or more pts want a pill, just do it and leave the emtions out of it. You will feel better, and you will be following doctors orders. You don't have to judge everyone's right to recieve an order. Use common sense - sure.
There are so many emotional traps to get yourself bogged down in, - save yourself for your family and freinds. Don't spend all your emotional chips at work and have nothing left for later.
Because you may find that you - yourself are getting a buzz off of all the chaos of work, and that you look forward to the adeneral (sp) rush of the work day, rather than the calm sometimes repeative nature of homelife.
Specializes in LDRP, Medical, Surgical, Pediatrics.
It happens all the time...most patients with chronic pain do become addicted to their medications, but I always try to remember..."this is not rehab". it is irritating, we have patients that set their alarms on their cell phones so they will wake up in time for the next dose of pain med. if i find the patient asleep when i go back to the room i wait until they wake up again then give it to them.
It happens all the time...most patients with chronic pain do become addicted to their medications, but I always try to remember..."this is not rehab". it is irritating, we have patients that set their alarms on their cell phones so they will wake up in time for the next dose of pain med. if i find the patient asleep when i go back to the room i wait until they wake up again then give it to them.
Not true. :) The addiction rate among chronic pain patients taking opiates is between 1-4%. :) Dependence and tolerance are physical responses to opiates; not psychological addiction. 95-99% of patients taking opiates do not get a 'high'.....they get relief... and %100 of the grief over the 1-4%.
Staying ahead of the pain helps keep the amount needed to a minimum. Waiting too long requires more meds, or something stronger to get "caught up". I'm not advocating waking someone up- but for some patients, it is really important to not let the pain get "too bad". And that is totally subjective. THAT is hard to deal with, since nursing (and medicine in general) wants concrete "proof" of something to believe it exists. So, patients go unmedicated.
I think the subjective part of pain is probably the biggest problem in understanding pain management. Chronic pain patients don't have the acute pain vital sign changes, their fight or flight is always on, and has reset their "normal".
But you're absolutely right- acute care is no place to be messing around with detox and rehab :) First- it's temporary at best- and, second- if there are painful diagnoses or procedures, it's cruel.
RNOTODAY, BSN, RN
1,116 Posts
yes you should give it to her. on the floor , and in your capacity as thr nurse, its a moot point whether shes full of it, faking it, whatever. its not your call if its ordered, you give it. its that simple. addiction counseling is not your role.