Did you revise your care plan?

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Suggestions please!!!! How do you revise your plan of care when your known-frequent-flyer reports a pain level of 10 from before admission, clear up to the trip to the elevator at discharge? After all, he/she is still our patient until the car drives off.

***Note*** The patient states, "I told them when I left the last time, that I was still hurting."

Did you revise your care plan prior to the patient being wheeled out; do you just make reference to the prescription for pain meds IF they doctor will provide one on this visit; or do you just click the x in the upper right corner and forget about it since the patient is discharged and 'everybody knows his/her routine' and "oh,he/she's always in pain?"

[classicdame, MSN, EdD]

pain management is so tricky. For one thing, spiritual and emotional pain can actually HURT, and frequent flyers probably do have pain of some sort. I would create my plan so that the outcome would be reported by patient as "tolerable". If that is not possible we need to be thinking of what this patient needs after discharge - psych consult? pain management consult? Both??? Something is going on and the nurse does not have time or scope of practice to do behavioral management. Something has to break the cycle.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

pain management is so tricky. For one thing, spiritual and emotional pain can actually HURT, and frequent flyers probably do have pain of some sort. I would create my plan so that the outcome would be reported by patient as "tolerable". If that is not possible we need to be thinking of what this patient needs after discharge - psych consult? pain management consult? Both??? Something is going on and the nurse does not have time or scope of practice to do behavioral management. Something has to break the cycle.

I agree. I've seen referrals made to the pain clinic but is that effective in the cases where we unofficially 'know' the patient wants the IV stuff and will probably not benefit from such a referral and will most likely refuse to even go on a second visit once they realize it is not a clinic to go get a fix; and refuses voluntary behavioral therapy? Wow, that was a loaded question, I know. How do we get through to these patients when we've tried everything and said everything before we have to go back to the care plan and say, "Goal not met"?

I've been nursing for years and it is sad to say that, based on the fact that the patients call the shots nowadays, my goals are never met on the frequent flyers by the end of my shift and, as a night shift nurse, I've often wondered how the care plan was closed out when I return and that patient that was in excruciating pain when I left at 0730, was well enough to go home. As a dayshift nurse when I worked the cardiac floor, it was easy to end the care plan: Cath site clean and dry, no bleeding, pain, or edema; vitals WNL, patient in Sinus Rhythm....Goal Met!

In a world of 'they're not going to be satisfied so just give 'em the drugs and let 'em go', how do we actually initiate ADPIE as we know it instead of simply satisfying the patient for fear of repercussion, low scores, and lawsuits? Gotten completely off topic of careplan revision, haven't I? But then again, at discharge, sometimes the last thing we do or say to a patient might be an attorney's opening statement. God Bless Nurses!