Non compliant and frequent flyer patients

muffie, RN · Nov 1, 2006

had a young father, fortyish, obese, noncompliant,diabetic,sleep apneic who didn't use his machine

had heart stents and did not finish his year of plavix

so the stents blocked and he went back to the cathlab and was "fixed-up"

at what cost?????

lsyorke, RN · Nov 1, 2006

I think you meant "subjective" pain, but I totally agree with your point. Pain is constantly undertreated. The goal of pain management is not to keep the patient on the lowest dose of painkillers possible; the goal is to adequately manage the pain so that the patient has improved quality of life.
I was reading an article about "pseudoaddiction", where patients behave like addicts (asking for stronger meds, exaggerated facial expressions, hoarding meds, etc.), because their very real pain is not getting treated adequately. If one is truly concerned, maybe a consult with a pain management specialist could benefit the patient, and, in turn, reduce the pt's need to frequent the hospital.
~Mel'

But what about those who have figured out the system of "they have to treat my pain" and that "pain" is a result of addiction?? This we don't see addressed. I understand and agree that pain is subjective, but this also has a downside of enabling the addict, obviously not in all cases, but we are seeing it more and more. The undertreating of pain IS a problem, but the overtreating is just as big a problem.

IMustBeCrazy · Nov 1, 2006

Non compliance is one thing, and it is a constant battle in all areas of healthcare to combat this problem.
Seeing someone as drug-seeking and having the attitude that goes with that viewpoint is really disturbing to me. Remember that we are taught that pain is objective, and now is considered to be the 5th vital sign! If someone is in the hospital and the physician prescribes pain relief in WHATEVER form, I fail to see how it is within our scope to withhold meds or reduce the dosage (for example, if the order reads 4-6mg, and the RN gives 4 based on his/her own conception of the patient's pain or lack of pain). The medicine is prescribed, in the amounts it is ordered, with phenergan or without, IV or otherwise.
I have seen this attitude in the clinical setting- usually in older (more experienced) nurses, but now it's obvious that the same attitudes are in younger, less experiences nurses.
Who are we to judge a person's pain, whether they've been in our hospital or unit 1 time or 100 times? The physician's job is to manage care, ours is to implement, using our critical thinking skills yes, but not to the extent that we refuse to carry out the MD's orders. Our attitudes need to be checked at the patient's door, IMO.

We have lately gotten a large population of meth or drug addicts that have figured if they 'voluntarily' enter themselves for suicidal ideation they get a free meal and bed and a servant (Nurses and CNA's) for two days! You can NOT assume they are not suicidal and help...but I do wonder about so many of these lately that after two days say "okay I am not suicial anymore...I want to go home now."

Absolutely there are those seeking "three hots and a cot" while claiming that they are suicidal. I can name several pts off the top of my head that will rip through their SSI benes and I'll see them around the end of the month. Like clockwork.

The problem arises as TriageRN_34 states, when the known drug seekers are admitted AND the MD's, KNOWING the hx does things like write orders for detox such as Ativan 2-4 mg PO q2hrs per CIWA.

I am extremely compassionate to patients, but neither will I be played for a fool. When I go in to assess pts and they have gross motor tremors and advocating hallucinations, then 30 sec later when I step into the hall I observe them calmly eating their lunch with no such tremor, not attending hallucinations, well...you get the point.

Same goes with pts that claim 10/10 pain, but their b/p never tops 110/70, other vitals perfect and the rest of their physical assessment is in line and they are walking down the hall socializing, laughing, etc. Of course I give pain meds, but you can be darn skippy that I'm dosing low if I have the right to do so per MD order.

Pompom · Nov 1, 2006

I have worked with some wonderful physicians that tell the patients that unless they are compliant no pain medications will be ordered. If they truly in pain the agree if not and just drug seeking they move down the road. Isn't it funny how all the druggies are allergic to toradol?

lsyorke, RN · Nov 1, 2006

Isn't it funny how all the druggies are allergic to toradol?

Or allergic to every single pain med except Demerol????

Sisukas · Nov 2, 2006

actually a person who is dependant on pain meds is more likely to need a higher dose due to a tolerance for that med. I would start at the high end of what the order is... and go from there. I believe everyone who says they have pain, but there is more to it than that. The pain scale itself is confusing and sometimes hard to gauge. Some pts I have seen say there pain in 9/10 one minute and they are sleeping soundly the next minute... so who knows if their 9 is like my 2. It is very subjective... but to deny someone meds also causes psychological distress which increases pain.

Try not to make whether the person is soundly asleep part of your pain assessment. Severe pain makes you so tired. When I had shingles a few years back, I fell asleep in pain and woke up in pain, and slept soundly too.

Multicollinearity, BSN, RN · Nov 2, 2006

I have worked with some wonderful physicians that tell the patients that unless they are compliant no pain medications will be ordered. If they truly in pain the agree if not and just drug seeking they move down the road. Isn't it funny how all the druggies are allergic to toradol?

Don't forget that *some* really are allergic to all NSAIDS which includes Toradol. It's called Samter's Triad.

http://en.wikipedia.org/wiki/Samter's_triad

Jennifer, RN · Nov 2, 2006

It is funny though that people are allergic to demerol, inapsine, compazine, zofran, stadol, morphine and toradol. They can take phenergan and dilaudid because that is all that works. Oh yeah, they have been taking motrin, but that hasn't helped and they took their last vicodin yesterday.

Sorry, I am a jaded ER nurse.

We see a lot of ff, a lot of diabetics. When they stop showing up, you wonder if they got arrested, moved or died. But you are thankful that they haven't been to the ER in a while.

In the ER, we send a lot of ff home. Rarely do we admit, unless, like TazziRN said, they are unstable. In fact, it is amazing how many pts we do send home.

AU-RN · Nov 6, 2007

i cant even begin to get into a discussion on how much I HATE druggies and how they along with doctors and nurses who give them their fixes are running our healthcare system into the ground.

I was shocked the other day when i mentioned to an (apparent) new nurse that he should give 12.5 mg of Phenergan instead of the ordered 25mg b/c phenergan is so sedating, irritating to the veins and the pt would be safer on starting out on a lower dose (and also b/c they werent showing any symptoms of nausea) and then if they still really needed the other 12.5mg ...well it would be there to give. The guys looked wide eyed at me and said "you cant do that...oh my gosh you HAVE to give what the dr ordered!"....I turned my head so fast almost like the girl in the Exorcist and said "of course you can give less...you just cant give more....there are several factors involved in deciding to give a pt less narcs/phenergan thats ordered."

I worked on an infection floor for years and saw more druggies their then on any floor EVER! They know exactly how to make themselves more sick so they can be admitted into the hospital for ABX and of course....dilaudid/phenergan. B/c you cant argue with a fever and a high WBC right? Had one FF that was such a you know what that the ENTIRE hospital knew her by name and everyone HATED her guts b/c of her rudeness and extreme drug seeking behavior. Every infection DR on the floor over time refused to be consulted to treat her b/c she would yell at them and argue for more narcs. Well, guess what happened to her....found dead in the the hospital room with syringes/vials next to her where she had OD'd through her central line. In a way alot of people were well.....relieved. She was the rudest pt ive had in my entire nursing career. She stood yelling at me during a situation where another pt was about to code b/c "im a pt too, and i shouldnt be made to feel guilty b/c i need my meds!" As shes instructing everyone on exactly which meds "work" and in which combination and even as far as "how" to give it...you know the old "oh, you have to flush behind the meds!".........

So, I have NO compassion or time for druggies....im so straight forward with them and the stupid dr's that keep prescribing the narcs to them that the pts end up requesting for me not to be there nurse...which I find hilarious b/c I wont give in and give the narcs "early"...when its not time yet......or b/c I give them the smallest amount able to give...and guess what...they dont know the difference.

Nursebarebari · Nov 7, 2007

i had a patient, non compliant, frequent flyer. refused blood work, refused heparin shot. nasty attitude, argumentative. manipulative.
no one wants to take care of these kind of patients. other nurses and i were joking around saying let's make a log book of the names of those kind of patients so we can fill up the rooms with other patients and other floor will take these patients.. , i wish we can do that
i wonder why they keep admitting those kind of patients if they will be non compliant with their health care anyway?
i say for those kind of patients who shows up in er, treat them and send them home!
they take our time and energy w/c could have been given more to the patients that really need our help.
your thoughts?

they keep admitting them for the money

al7139, ASN, RN · Nov 10, 2007

As a new RN, It's hard for me sometimes when I see the obvious drug seeking behaviors of a pt. I have been taught that pain is part of the vital signs assessment, but I have a hard time with the HIV+, HEP+, known IV drug user here for whatever who can tell me to the second when their next dose of pain meds are due. I don't deny they are in pain..after all they are there to be treated for an infection, or heart problem, etc. I just have a hard time with the pts demanding pain meds all the time. Saying that 1-2mg of dilaudid did not diminish their pain (equivalent to larger doses of morphine), and demanding that I call the doc at 11pm at night to get a higher dose when I know that they are drug addicts.

On the other hand, I have no problem calling a doc at 11pm at night for a pt who is having breakthrough pain in spite of the regimen to get them relief.

I think that after awhile you can tell who is drug seeking and who is not.

I never want to disregard anyones pain, but you can tell who needs addiction counseling and who really hurts.

AND, to really play devil's advocate here, there are some pts who are known drug addicts, who have a disease processs that really is painful and they may need higher doses of pain meds than the "normal" patient.

So, who's to say? I have been taught that the patients assessment of pain is the way you determine what to give. So document your concerns, but treat all your patients the same, no matter their background.

Yes it's frustrating, but remember this: If the addict does not want help you cannot make them get it. Denial is a huge monkey on their backs. THey have to want to get clean, and even though we can educate, we cannot save the world. That does not mean we should just give drugs without questioning, but we cannot legally withhold drugs b/c the pt has the right to be treated regardless of their history.

Amy

**canoehead, BSN, RN** · Nov 10, 2007

"of course you can give less...you just cant give more....there are several factors involved in deciding to give a pt less narcs/phenergan thats ordered."

Nope, if the doc gives a range you can give on the lower end of that scale but you cannot go outside the range. Of course if you disagree with the dose altogether you can call and get a new order, or decline to give it for patient safety reasons. If you DON'T give the med when stated parameters are present you must notify the physician.

But I disagree with the person who said we must abide by the patient's statement of pain intensity and give the maximum dose when pt states a 10/10. We can chart responses to meds, and if I know 10mg will leave the patient asleep and unable to do ADL's, while 5mg will allow interaction during visiting hours, use of an incentive spirometer, and a RR>12, I will give 5mg. That said, I also know the benefit of total pain relief, usually at nighttime for a good sleep. We have to individualize our approach to fit our patient needs.

I think it's impossible to tell the difference between recreational drug use and therapeutic pain relief from the outside. Some situations are clearly at one end or the other of the spectrum, and we can react accordingly. I like to think that since less than 5% of our ER patients trigger my drugseeker radar that I'm erring on the side of pain relief. Even among the 5% I want them to feel a lot better, but perhaps not blissed-out-wonderful when they leave the ER.