Professional Nurse? Or "trained monkey" ?

My appy-pologies to MonkeyGirl. I simply use her moniker because it is an apt 'term' pertaining to the situation.

New rules at my hospital following JCAHO recommendations: If a PRN medication is ordered in a specified range (dosage or strength), it is not ok to administer a dosage less than what has been ordered.

For example: I have an order for: Morphine 3-5 mg IV every 2-3 hours for pain.

Now not only am I not allowed to exercise critical thinking and nursing judgment by figuring out how much medication my patient needs, I am also supposed to automatically interpret that medication order to read: "Morphine 3-5 mg IV every 2 hours for pain".

"So what, Spook?" you say. "It follows The Joint Commission (cue reverential music) recommendations on the very subject. In fact that med order that you gave as an example is cited by The Joint Commission (cue reverential music) as something to be avoided - you can see their recommendations here. Your organization is just following recommended policy".


So, if someone is ordered 6 mg Morphine IM for pain, I can't exercise my critical thinking skills and administer 4 mg because the patient may not need 6 mg (or maybe because 6 mg would be an unsafe dose. More on this later). Instead, I'm supposed to call the physician and request s/he lower the dose.

All medications carry side effects - why administer more than that which is required? Don't get me wrong, I don't think patients should sit around suffering in pain (not only is it inhumane, but constant pain slows down the recovery process). But to dose them 6 mg when 4 mg work just fine is just plain stupid.

"But Spook, you can always call the physician and have the dose lowered. Aren't you bothered with medication safety?"

Well, yes, I could call the physician. And it works fine for a couple hours. What if the patient starts reporting increased pain? Now I have to call again to get the dose increased! This seems fine and dandy on paper - but it's a fools errand in real life. I am yet to find a nurse in the trenches who agrees with this approach and implementation.

"But Spook, that's why they have dosing ranges".

Right and wrong. Dosing ranges exist - but no longer do we have (say for example) 'Morphine 4-8 mg IV'. Ranges are now supposed to be much narrower along the lines of 'Morphine 4-5 mg' or some such. I welcome folks to handle a single post-op patient on my floor with such narrow dosage strengths...

Remember earlier on in this post where I mentioned the fact that a patient may not need the dosage ordered? I once had an anesthesiologist order "6 mg Dilaudid IV push now and repeat in 10 minutes" .... for an 86 year old female with a hip replacement with a respiratory rate of 16. I repeated the order four times to clarify - and each time he was adamant it was right.

Needless to say, I didn't carry out the order. I exercised clinical judgment and gave the patient a bolus of Dilaudid 0.5 mg and it helped her immensely. Patient reported good pain relief and was resting comfortably within 30 minutes. I documented the hell out of that incident and also placed and incident report - and made sure the floor Director knew what happened.

Now technically, according to JCAHO - I'm not supposed to do that. I'm not supposed to administer less than the dosage ordered. While it's easily obvious in this situation as to why I shouldn't have followed recommendations; I use this example just to point out that a lot of times, it is not as clear cut in black or white. Precisely why Nurses are taught critical thinking and are allowed to exercise clinical judgment.

Ladies and Gents, unless I'm missing the big picture somewhere - all this new intrusion by The Joint Commission (cue reverential music) is simply eroding my authority as a trained medical professional. If I can't be trusted to exercise my judgment in determining the appropriate intervention and medication dosage for my patient - what the hell am I there for?


Might as well replace us with trained monkeys and be done with the whole deal.

And speaking of JCAHO, I have another post/rant lined up about it...

Of Pain Control, Teaching and Intimidation

For some strange, inexplicable reason, my internet access just died.

Just up and died.

And in just as strange fashion, it came back from the dead.

Totally bizarre.


Speaking of bizarre, ever have patients who complain about their pain being a "12/10", grimacing and carrying on, demand pain medication that-I-wanted-yesterday ?

Same patient who, upon bringing said pain medication, is found snoring away in bed with drool dribbling from mouth?

The very same patient, who, the next day insists to the physician that s/he has had a "horrible night in pain", was "ignored by the nurse. He never gave me a damned thing for my pain!", and claims that the "Darvocet did nothing for my pain!" - despite having being found as above... snoring in bed with drool dribbling from the mouth?

Well, I'm sure some of you somewhere have met this patient.

I'm just talkin' because it seems that off late, 5 out of my load of 7 patients per night seem to be of this kind. The gorked-out-of-their-minds type who demand more and more meds and then wonder why the hell do they feel constipated, bloated, nauseated and "funny".

Speaking of constipated and funny - how about the ones who demand opiates because their "stomach hurts". Yeah, it hurts. It hurts because you've been doping yourself on so much pain meds that you've got "gas pains". Taking more morphine and lying in bed ain't gonna help - it's only gonna make it worse.

It is, of course, at this very point then that you are accused of being a "mean nurse". I think people in general don't like being told "No."

Don't get me wrong. I acknowledge that a hernia repair can be painful. Hell, someone just cut you up and sewed you back on. I know it hurts. And for some of you, it's probably the worst pain in your life. Alls I want folks to think about is that every med and every intervention carries consequences and risks. I find it distressing that so many think their post-op recovery is going to be "pain free" - even the ones who end up getting say fusion surgery from T1 to L4 vertebrae because of scoliosis.

Dude, you just had a 14 hour surgery where they ripped your back and built you a new one. Do you honestly think you are going to be pain free?

And of course, you have the concerned, worried family.

Concerned Girlfriend: "Can't you see he is in pain? Why don't you give him his Xanax?"
Spook: ('Ummm, yeah. Xanax for pain control on a post-op ACF guy. That'll work!') "Ummm. I'm sorry but I haven't assessed the patient yet. I need to see him and assess him before I can intervene".
Concerned Girlfriend: (annoyed) "But he's hurting real bad! How can you just sit around and do nothing?"
[I was faxing med orders to pharmacy. Unless pharmacy has med orders, I can't even pull out a Tylenol, much less the PCA and Dilaudid bolus per orders]
Spook: "Ma'm, I'm sorry but unless I assess his condition, I cannot and I will not intervene. He can end up having complications that could be potentially fatal. I'm not going to risk his life for wont of patience and time. I understand you are concerned about his pain, but you have to let me do my job."
Concerned Girlfriend: "That's so easy for you to say! I don't think you understand at all!" (Twirls on heel and walks away in a huff).

Barely 5 minutes after this conversation, patient has had a 1 mg bolus (instead of the 2 mg ordered) of Dilaudid, a PCA set up and explained and pain down to a 4 (and falling). All it took was 5 minutes - yes, I realise, 5 minutes of pain... but it was 5 minutes that potentially prevented a serious complication.

I actually like assisting family members in dealing with their loved ones illness - teaching is a secret passion of mine. Symptoms (such as pain, fever etc.) often tell a wide and varied story. Rather than jumping at the first sign of a symptom and attempting to "cure it", it's better to assess and think for a while. This is why, for example, I prefer to give Toradol to my hysterectomy patients rather than the Morphine ordered for their abdominal pain because it has been my experience that the anti-inflammatory action of Toradol kills their pain better than the masking-opiate effect of morphine. Also, if the Toradol doesn't work, I at least have the stronger dose of Morphine to fall back on.

Now if Concerned Girlfriend had given me 30 seconds of her time, I could have patiently explained me reasons to her. But she didn't and all it made for was an unpleasant experience necessitating a rant on my blog now.

Family members who follow you around with a notepad and pencil, jotting down everything and anything you do, waiting for you to make a "mistake" really get on my nerves. It destroys the atmosphere of mutual assistance and trust. Not helping anyone and least of all the patient. If you have an issue with the way I work, please pull me aside and bring it up to me. If we can't resolve it, I'll direct you to my boss.

But please. Please. Please, don't try to "intimidate me". It doesn't work. I don't get "intimidated into doing my best" - I just get royally pissed off.