Now that I'm starting to get a handle on how the workflow in our facility is structured, I'm starting to look at things with more of a critical eye.

One thing I wrote down in my little black moleskin to check up on later is records of narcotic use.

Pain control is something that my education taught me to take very seriously. It's a tricky subject. All we really have to go on most of the time is the patient's own reporting of pain. What level of pain they're experiencing, what level of pain is bearable, what level of pain interferes with physical therapy and the recovery process.

Too little analgesia, and you risk increases in stress hormones (most notably cortisol), non-compliance with physical therapy regimen, and general overall grouchiness. Too -much- analgesia and you'll find that the orders for PRN vicodin or percoset or whatever are no longer adequate to control pain. Now you've got tolerance problems, along with the constipation and apathy that typically accompanies high levels of opioid analgesia.

Since we chart everything by hand, there are no helpful reminders to let the floor nurse know when their patient is coming dangerously close to that 4 gram/day barrier that tylenol presents us with (which is mixed together in many of the combination opiate/non-opiate analgesics (like vicodin, which may contain half a gram of tylenol per pill).

I've started to look through these records very carefully, prompted by an encounter with one of my residents. I was called to her bedside by an aide who noticed that her blood pressure was much lower than usual, somewhere around 80/40. Considering all the factors that might be in play, a few things came up. Diuretic use. Anti-hypertension medication. Lack of ambulation outside of therapy. Then there was the opiate use.

I looked through her as-needed-medication records and found that nearly -everyone- who had administered PRN pain medication to her had been giving her the maximum dose, meant for severe pain. The resident's pain was never recorded any higher than 3/10.

I sat down with the resident after her family had stepped outside and had a talk with them. This is never an easy discussion to have with someone, but once you notice that they're in danger of spending way more time in a facility than they have to, you have to say -something-.

I started off talking about the resident's blood pressure, and what we were planning on doing about it. When I started to talk about pain coverage, she started to get noticeably anxious, wringing her hands and making all of those familiar anxiety body movements. I -knew- she was being overmedicated for pain. I didn't need any more info from her to determine that. I know amputation sites can be painful, but after the site is well-healed and benign, 'round the clock administration of the maximum amount of PRN pain medication should not be necessary.

Following the advice of a good friend of mine (who's a retired psych nurse), I was completely matter-of-fact about everything and used a lot of open-ended questions. I found that the resident would overstate their pain because they were afraid of the pain increasing later. This was a good find, since it gave me a platform from which to launch into some much-needed teaching about the effects of pain medication (both desired and adverse), and how we could work together to keep her blood pressure within normal limits and get her out of here and back in her home in a timely fashion.

Next time I come in to work, I expect to see more initials in the 1-gtt field instead of all of them being in the 2-gtt field. More importantly, however, since I'm in a supervisory role, I have to make sure the rest of the team is on the same page. I documented some of my concerns and made sure the oncoming shift was aware of what we had discussed, I guess I'll see when I'm in next if that was enough.

PRN pain medication can truly be an insidious thing. Speaking with the spouse of one of the residents, they related to me how they were once in a skilled nursing facility for some kind of joint issue. In their pleasant, understated, european way, they said "after just a few days, I was quite looking forward to those pills".


This is an area where I think my education has served me well, by imprinting on me the importance of frequent and detailed pain assessments. It's been difficult to fold in everything I've learned during my training in a medical/surgical setting into long-term/rehab, mostly because there's just so much going on! I thought med/surg was a busy environment, but when you have 17-37 patients at a time instead of 4 or 5, it's not always easy to see where you should be spending all your time.

With that kind of patient load, I can see how it would be easy to gloss over the critical thinking aspect of pro-re-nata pain medication administration, especially when the director of nursing is telling me things like I have to "encourage the LPNs to think critically".

On the rehab side, requests for pain medications are frequent, and pose a challenge to getting all of the tasks done on time. On the long-term care side, pain assessments are even more challenging due to the altered thought processes of the residents.

On either side, I end up staying late. Maybe part of it is being new, maybe part of it is having been educated more recently, but when one of the aides (or nurses) tells me someone is requesting pain medication, my training dictates that I need to go in there and do a pain assessment before pouring medications for anyone.

I see where the experienced nurses are increasing their time-efficiency by cutting out certain steps and playing around with the ordering of tasks, I just don't always agree with where or how they do that. Of course, I'm learning a lot from them about what I -can- cut out and what I -can- do to use my time more efficiently, I just have to remember to think carefully and remember my training.

As much as I felt that the lectures in nursing school were mostly useless (mainly just reiterating what we were responsible for in the reading already), the lessons I've learned from my clinical instructors will end up making a big difference. Even things that took me a while to master (or maybe especially those things) like IV medication administration and aseptic technique...I came out of the program feeling like I was marginal at best at some of those skills, but now that I've entered the workforce I realize..hey, I CAN do this! In fact, I can do it well enough to be in the position of reminding and teaching -other- people how to do it!

I'm still loving my co-workers. I made the mistake of letting slip what bar I hang out at. Now I'm forever looking over my shoulder, expecting to see the Director of Nursing and the Minimum-Data-Set Nurse walk in. Hah.

1 comment:

Strong One said...

You can't be everywhere for everyone.
PRN opiate dispensing always has a great need for continuing education.

Best of luck.