IVDU pt kept asking for pain meds. Managment kept saying to just give it to her.

[ella2990]

I have a question, I'm a newbie nurse with only 2 years of experience. So, I work at a med/surg tele floor. I was assigned a pt who was very well known to be an IVDU and frequent flier. Pt was POD 7 from a spine surgery (totally forgot what the actual surgery was) and was getting pain med basically q1hr. She had orders for:

1. dilaudid PO 4mg q3hrs scheduled

2. dilaudid 2mg PO q4hrs PRN

3. diladid 2mg IV q2hrs for BTP PRN

4. oxycontin 10mg PO q12hrs scheduled

5. toradol 30mg IV q6hrs PRN

(**YES THERE ARE PAIN LEVEL PARAMETERS, but this pt is very manipulative and will do anything and I mean ANYTHING to get her beloved pain meds***)

So the nurse from previous shift was basically giving her pain meds every hour!! I did not feel that it was safe for her (and for my license) to be giving her all those pain med. It was a weekend and that particular surgeon who did her op was off. So I called their office and asked to for the on call dr. to be paged.

Dr. K came in to round on that pt, I told him my concern that Ms. so and so had been getting these kinds of pain meds basically every hour. The dr. was shocked when I told them all the kinds of pain meds and diff doses she was taking. He asked me who that pt was again and who was her primary ortho surgeon. I told him it's Dr. ***. Dr. K reacted very nonchalantly and said "Oh yeah she's known to our practice. She has high tolerance for pain meds since she's an IVDU. If she's still breathing just give it to her." I told him that her BP was low and his reply really caught me off guard, "I don't want to mess with whatever Dr. *** prescribe to her. Just wait for him to come back on Monday."

I was literally speechless!!! Pt's bp was already in the mid to low 90s, pt was not hooked up to tele.

Bottom line, I did not cater to her, I did not give her pain meds EVERY HOUR I made sure that atleast 2 hours has passed before I give her another pain meds. I explained her the legal side of nursing. Needless to say, she threw a **** show and threw the biggest tantrum a grown woman could every throw.

That pt filed a complaint against me to my director. My director talked to me and told me to just give her whatever MD ordered for her to have. I told her, NO it is my license on the line and not yours, if something were to happen to my pt it is not YOU AND YOUR LICENSE that would have to sit in front of the BON trying to explain why you did what you did. She said that it is very important that we earn pt's satisfaction.

I felt defeated and seemed like her priority was pt's satisfaction and not pt's and nurse's safety.

I told her and the charge nureses (whoever will be doing assigments) that I NEVER WANTED HER BACK as a pt.

DID I DO THE RIGHT THING? I MEAN I KNEW HER TOLERANCE FOR PAIN MEDS ARE HIGH GIVEN HER HX. BUT YOU REALLY NEVER KNOW WHAT WILL HAPPEN. 1 DAY SHE COULD BE FINE THE NEXT 2 FOR ALL I KNOW SHE'S OD from pain meds.

[5150rn2]

This bothers me. I have been mulling around how I want to respond to this for over a day now. I have started and deleted quite a few times and now I am just going to go for it. Remember, all I know about you, is what I've read here. I get the impression you were expecting people to commiserate with you and when that didn't happen you went to justifications to defend your actions vs owning it and learning from it.

you refer to this pt as "IVDU". That absolutely dehumanizes this pt. But this is a person. You know some facts about her, she is frequently hospitalized, she some very real medical issues, lives in an unstable environment and it sounds that it could be possible her pain is not being managed. Why? Because the "why" is the problem. Does she have a mental disorder? Is she homeless? What's the relationship with the boyfriend look like. Building a rapport and developing mutual trust will allow you to start fitting in the missing pieces. And once the "why" is addressed, if it can be you might starting seeing different outcomes. This is a great teaching opportunity( not a lecture) take an interest and provide her skills she can use. Realize as well you may repeat that conversation a number of times.. but for everyone's benefit be invested. Look past the the acronyms and see the person. Nursing is about compassion and caring not tasks and judging. I have worked with many nurses that go through the motions, get expected tasks done, they often think nurse translates to boss and their pts should just do as they are told. We are here to help and heal. People come to us to help them feel better. Please find your heart.

[5150rn2]

@jkl33 Perfectly put. I really hope as you do, that this becomes a lesson learned and another step toward being a terrific nurse

[JKL33]

Pain is subjective. One of my nursing school clinical rotations was a pain managment seminar. People are afraid of pain meds for chronic pain sufferers. She gave us the acronym BABWACTO for managing chronic pain patients. Breakthrough pain dose, Around the clock dosing, Bowels (constipation), WHO ladder, Adjust dose if current dose not helping, Change med if not helping anymore, Time to allow PRN with scheduled, Orders. She had a patient who was on 3,000mg of dilaudid a day after a lengthy battle with spine issues, including several surgeries. When that pt had to go to the ER, the ER refused to administer that dose so the pt was lying there in pain on top of the ailment that brought them to the ER to begin with! It is not up to us to determine if someone is truly in pain or not. It's hard for us to comprehend that because we are so scared of decreased respiratory rate on pain meds, but for a chronic pain sufferer they've built up that tolerance to it.

All that said, there are also situations where other providers do not concur with the course of treatment and are under NO obligation to order it themselves. If you've been in an accident we would try to consider the amount of medication you might require based on your baseline. If your back hurts more than usual despite your 3000 mg of dilaudid, that's a different story. Pain is what the patient says it is but we have to acknowledge that there are different ways to skin a cat, some of which are far healthier and much less risky. A provider is under no obligation to continue something merely by the fact that someone has already started it.

[KRVRN, BSN, RN]

OP, I see you've mentioned "****show" and "tantrum" more than once. If the pt were polite, yet insistent would you feel differently?

[JKL33]

We don't have very honest conversations about pain, do we.

[catsmeow1972, BSN, RN]

While i am not usually a big fan of writing on the whiteboard, the time for the next dose of PRN meds , for the ones that have addiction issues or are manipulative enough to try and sway me, i will do the bargain thing. Don't try to game me and i will do what i can within the scope of my orders to keep you comfortable.

Even if i know dang well that I am being played, i don't have time nor is it the place to do rehab. So long as the person is not exhibiting unsafe LOC or Spo2, etc. I'll give'em the meds.

Then there is the altogether different issue of enabling family. I recently had a husband that called out saying "she needs her pain meds" it does happen to be just past Dilaudid o'clock and these people had refused D/C home with pain management for 4 days now. I go in to assess and she is stone cold asleep, sawing logs. Erm, sorry too sedated for me to be handing her narcs.

[Libby1987]

Careful with HIPAA here. You're giving enough history for someone (probably another nurse at your facility) to ID who you're talking about.

I agree.

I stopped reading on page 3 but if I were worried about my license, I'd be considering how much detail you've provided.

[FrostedCupCaitRN]

I actually made an account specifically to respond to this thread.

First of all- Yes honey, you were extremely biased. You allowed your personal opinions on drug use to cloud your "clinical judgment" (which is severely lacking).

2nd- Excuse my language, but it is non of your damn business what that patient does in her personal life. Everyone has a vice. Some people drink wine, some smoke cigarettes, some pop pills...whatever. Their life, not yours.

3rd- You are not, I'm assuming, a physician. You are not a surgeon. You are not an addiction specialist. If a physician has ordered medications to be given, you give them. Unless the order is completely wrong. It is not up to you to decide what the patient needs or doesn't need.

4th- Your job is to assess vital signs, pain included. If your patient says she was in pain, then she was. If her RR, HR and BP were normal and she was asymptomatic, there was absolutely no reason for you to alter the medication schedule that the DOCTOR ORDERED. None.

You were 100% wrong. Use this as a learning experience and don't make the same mistake again. I'm not preaching from my high horse. I made that same mistake as a new nurse. And looking back, I feel terrible that I caused another human being unnecessary suffering. We should thank our lucky stars that pain medication exists. If we can alleviate the suffering of our fellow humans, that is what we should do!

So please don't allow this to break your spirit. Just learn and make a better effort next time.

Sincerely,

Cait

5 years of ICU

4 years of pediatrics

4 years of terminal pediatrics