Yes, I did think of compartment syndrome. I was really glad for my clinical rotation on ortho! There were no s/s, and this pain issue had been an issue since prior to her surgery. She had been verbally abusive prior to her surgery as well, so her comments that she was "homicidal" and that the charge nurse had almost gotten "kicked in the head" were not a new behavior.
I forgot to document a couple of findings in my nursing notes, and I was thinking of going in and doing a late entry today. I'm not sure how appropriate that is, but I really want to CMA here. This lady had been complaining that we weren't doing enough for her for days, and had even alleged discrimination and demanded to talk to the charge nurse.
One of the findings was that even after I explained how the PCA works for the third or fourth time, the history showed that in the nine to ten o clock hour, she had only pressed the button four times and received three injections. She could have had six. It is my understanding that most of the time, people in a lot of pain will press the button quite frequently, and in doing so, will get their max hourly dose. She was not getting all the med she could, and in fact, was only getting half, because she was not pressing the button enough. I did explain this to her. She kept saying she didn't want the PCA because she didn't believe it would work, and she wanted us to do all her pain meds IV push. At one point she tossed her PCA button aside and refused to use it. I told her that she is not getting all the med she can from the PCA because she is not pushing the button enough, and I implored her to spend the next hour pushing the button as many times as she wanted, and that when she was getting the maximum dose, if her pain was not relieved, we would go on to the next step.
When I tiptoed in to check on her (didn't want her to know she had an audience in case that changed her behavior), she was lying quietly with a washcloth on her forehead. It wasn't until change of shift that she started stirring and fussing again.
Now I'm not saying she wasn't in pain. I do believe she was. But I also believe there were other factors involved including noncompliance with the PCA. She was cognitively and physically able to use the PCA, but psychologically, something was preventing her from accepting it.
You know, it's funny, because it was explained to her twice, once by another nurse, and once by me, that the PCA gives her control over her pain medication. Both times, she would start arguing about how if she had control, she wouldn't be there in the first place, or she would tearfully change the subject completely. I don't think she wanted control over the PCA; I think she wanted control over the nurses. I think she really wanted to be fussed over. I'm not denying that she was in pain; I really think she was. But I also think she was playing games that were interfering with effective pain control.
I'll be curious to find out what happened. Hopefully she got transferred to ortho today. They are far more equipped to handle post op pain, and their protocols give them far more flexibility in choosing an approach that works for the patient. Maybe they got a doctor's order for PRN ativan too.
Of course, it all becomes so clear at three am when I'm trying to sleep, not when I'm actually in the middle of this situation.