With the large addiction problem and drug seeking behavior seen in our hospitals, why are PRN pain medication still written in a manner that solely relies on subjective data? Are there are negatives to writing PRN orders based on objective findings such as a low dose analgesic for guarding and a higher doses when tachycardia and hypotension is noted.
Posted Oct 5, 2015, 4:42 PM UTC
Pain is a subjective experience, and as such can only be measured subjectively. I honestly think that should be taught in medical and nursing school - to accept that people are in pain when they say they are.
That said, obvious there's secondary gain and drug seeking and obviously we shouldn't assumed that everyone who claims 10/10 pain needs dilaudid 2mg q2.
However, recognizing that the person is in pain and informing them that we must responsibly limit analgesia to avoid doing harm (whether that means Tylenol or morphine depending on the clinical scenario) is a more effective stance than trying to objectively measure pain.
I'm all for managing all pain, but IMHO narcotics should have some objective findings due to their propensity to be abused. Pain without objective findings (texting, eating, laughing, etc) can be managed with non-pharmacological medicine, NSAIDs or similar.
Well, that's what I'm saying.
I think we can recognize that pain is a subjective experience, but also recognize that subjective 10/10 pain while watching TV should be treated much less aggressively.
I think it's important for the provider - patient relationship to at least initially acknowledge that pain is subjective and not necessarily objectively measurable.
Amongst anesthesiologists, there were tasks of asking the patient how the pain interferes with their functions, what changes of activities, etc
There are pain scales for sedated/ventilated patients that rely on their facial expressions & agitation levels.
I'm a NP so I see both sides of this experience as a prescriber and floor nurse.
If a RN has a concern about an order they should bring it up to the prescriber. If you think analgesia is too much or too little talk to the person managing their pain. This is the same as any other medication.
In terms of being a prescriber I write numerical crap when I have to but I focus analgesia on correcting functional impairment in general. Analgesia is not about subjective pain scales, it's about allowing people to have reasonably peaceful meaningful lives.
Now out pt is a whole different animal.
PRNs need to be specific and objective. It is a joint commission requirement. However, HOTN and tachycardia are not specific to pain, and "guarded" can still be subjective (could two people come to different assessments on the same patient?). While pain scales are far from perfect and are subject to abuse (who isn't in 10 out of 10 pain, right?), they are still probably the best was to objectively identify pain severity.
But for intubated patients, infants, disabled patients we determine their pain score without subjective data.
No, we guess at it.
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Intubated is not specific for incapacitated. Exam findings have enough interrater variability to be effectively subjective. How does disabled mean incapacitated?
Why is a flight nurse administering prns? Alternative gig?
Disabled doesn't mean incapacited, I should have written non-verbal. But I'm sure you understand the large population of autistic, stroke, TBI, etc of I'm talking of.
You're right we don't give PRNs in flight, it was another thread on reddit that made me question why wasn't objectivity part of the assessment for PRNs. We have all had those pt, report 10/10 laughing, texting, up and out of bed and it kind of leaves nurses with no options -
I tend to touch base with my nurses often in those cases, more as moral support and to make sure we're on the same page. Patients like that get prn pain control with holding parameters including patient asleep/somnolent. If they can't stay awake between the time they ask for 10/10 pain med and the time the nurse goes to administer, them they don't get the med.