FAQ Answers

How to I determine 'normal' sleep from opioid induced sedation?

Prompt recognition of opioid induced sedation will prevent clinically significant respiratory depression which can be potentially fatal. Patients at high risk for developing respiratory depression include those who

• Are opioid naïve, obese or taking other sedating medications, and
• Have a history of obstructive sleep apnea or other respiratory co-morbidities, e.g., COPD.

To identify opioid induced sedation you must be able to tell the difference between “sleep” and “sedation”.

• First, assess respiratory status, e.g., rate, depth, regularity. Is it at baseline?
  • New onset snoring or noisy breathing may indicate impending sedation
  • Decreased O2 saturation is a LATE sign of respiratory depression

  Arousal stimulates respiration, so access the respiratory status before arousing a sleeping patient.

• Then, assess ease of arousability when stimulated by things like your presence, a touch, or a conversation
  • The key for determining sedation is the ability to stay awake once aroused
  • Can the patient give a complete answer to a question

  If you aren’t sure if the patient is asleep or sedated, awaken the patient!

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Do I have to wake up a patient to reassess pain after pain medication?

It depends on the situation. Remember that

• Some patients who appear to be asleep may actually be oversedated. (See response to Question 1).
• Patients can sleep despite severe pain, e.g., due to exhaustion from unrelieved pain, or as a form of distraction.
• Not all patients who appear to be asleep are actually sleeping. They may be using deep breathing or relaxation techniques to try to reduce pain

Patients should be awakened for a pain score and sedation assessment until they have demonstrated an effective and safe response to their pain medications. Explain the reasons why this is necessary (e.g., harmful effects of unrelieved pain, dangers of over-sedation and respiratory depression).

Specific situation requiring reassessment include:

• Wide fluctuations in pain scores (ineffective pain management)
• Changes in the pain medication, dose or route
• Recent episodes of opioid induced sedation (unsafe side effect)

Criteria for allowing a patient to sleep following pan medication:

• Pain is controlled on stable doses of pain medication, e.g.,
  • No opioid related side effects, e.g., sedation
  • Pain goal consistently met following pain medication
• The patient has been educated on pain management options
  • Notify nurse when pain medication is needed
  • Have nurse awaken patient when next dose can be given
  • Should be considered when pain is relatively constant and the analgesic effect is known to wear off after a certain time

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I am doubting my patient's report of pain - What else could going on?  

• My patient is always asking for pain medications early - is the patient ‘drug seeking’ or ‘clock-watcher’?
  • Consider under-treatment of pain (pain-relief seeking instead of ‘drug-seeking)
    • Is the prescribed interval LONGER than the typical duration of the medication?
    • Are the pain medication orders LESS than what the patient takes at home?
  • When asking for a dose early, patients are often told how long until the next dose is due, e.g., “your next dose isn’t due for 2 hours.”  So …
    • They wait in pain for 2 hours, then ask for their medication
    • It may take another 15-30 minutes to get the medication.
    • Next time, the patient asks 30 minutes early so they can get their medication on time.
• My patient reports severe pain BUT doesn’t act like he/she is in pain (e.g., if a patient looks calm, or can laugh, sleep, eat, read, watch TV, go for a walk , etc – they can’t be having severe pain!)  
  • Pain can’t be proved or disproved; a self report of pain is the most reliable indicator of pain
  • Considerations about appearance/behaviors
    • Common “pain” behaviors (e.g., grimacing, crying, an unwillingness to move, etc)
      • May NOT be present with severe pain (especially with chronic pain)
      • Expecting to see these behaviors can contribute to manipulative behaviors
    • Laughter, sleeping, or reading can be forms of distraction from the pain
    • Cultural influences, e.g., isome patients are stoic, some value being a ‘good patient

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How do I administer a PRN pain medication with a dosing range e.g., 1-2 tablets; 2-4 mg?

A “PRN range order” (e.g., 1-2 tablets every 4 hours) means the nurse has a choice in dosage (e.g., 1 or 2 tablets) during the prescribed time interval (e.g., every 4 hours). When the total prescribed dose is given in split doses (e.g., 1 tablet, followed by a 2nd tablet one hour later), the next dosing interval is based on the time the first dose was given.
For example:

• New pain order: Norco 5/325 1-2 tablets PO every 4 hours PRN pain
• 0800: Mr. P reports a pain score of 6/10. He has never taken Norco before so you give 1 tablet.
  • FIRST dose (1 tablet) is given
• 0900: Pain = 5/10. He is awake/alert (Preventative Sedation Assessment score = 1, vital signs stable.
  • SECOND tablet is given 1 hour later.
• 1000: Pain = 2/10. Sedation score =1
• 1200: Pain = 5/10: Give 2 tablets of Norco because 1 tablet didn’t work last time. You should continue to give the dose that works until the pain has lessened OR opioid related side effects occur.
  • 2 tablets are given at 1200 – which is 4 hours after the 1st tablet (at 0800)

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Where can I find the Pain algorithms?

See Algorithms under "Resources - Charts / Tables / Algorithms" section.

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Why is it important to regularly review the Hourly Totals (boluses given [BG] and boluses attempted [BA] )?

Determining the best PCA intervention (e.g., patient education, administration of a clinician dose, increasing (or decreasing) the PCA dose, or doing nothing) for a patient requires assessing

• Hourly totals: the ratio of BG to BA
• Also consider: how many doses are given each hour compared to how many are allowed
• The pain intensity score
• Whether opioid related side effects are present

Example: Inadequate pain relief, no side effects, allowed up to 6 PCA injections/hour

• Patient A:
  • Receiving
    • 1 injection to less than 2-3 attempts and
    • At least 50% of allowed doses/hour (3 or more doses/hour)
  • Actions:
    • Relieve pain by giving a supplemental opioid dose AND
    • Increase PCA dose (need written order)
• Patient B:
  • Receiving:
    • 1 injection to less than 2-3 attempts and
    • Less than 50% of allowed doses (1 or 2 doses/hour)
  • Actions:
    • Relieve pan by giving a supplemental opioid dose
    • Patient educate on effectively using the PCA button
    • Reassess;
      • May need dose increase ln the future

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Why do we have to document on the Analgesic Flowsheet?

• It is currently the only place to record the hourly totals (BG and BA)
• It summarizes PCA order and subsequent management interventions, e.g., PCA dose changes, clinician administered bolus doses, total medication dose, in one place
• At a glance, all members of the healthcare team can get an idea of therapy effectiveness.
• It is currently the only place to record the hourly totals (BG and BA).

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Are family members, (e.g., parents/caregivers) allowed to press the PCA button for the patient?

NO - only the patient should press the button.

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How should I teach a patient to use the patient controlled analgesia button?

• Press the button before pain gets too bad and/or before a painful activity, e.g., physical therapy
• The pump will beep AFTER the dose is delivered. If it beeps right away, no dose was delivered – wait a few minutes and press the button again.
• If the pain is not relieved, notify the nurse

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How do I access the Hourly Totals on the Curlin pump? 

See Review Hourly Totals on "Curlin Pump" page.

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How do I change the time and date on the pump? 

The time / date can only be changed by Clinical Engineering. Send the pump to Central Service – be sure to include a note stating what needs to be done.

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