Rude Family Members: Just Venting!

DusktilDawn · Dec 4, 2005

I can tell from you, Dutchgirl, and Dusktildawn's comments, that hearing from someone who actually has PACU experience is in order here.
Not everyone in PACU needs additional pain meds while in the immediate recovery period. You can't just push pain meds just because they've had surgery.
This way of thinking could cause the patient to need to be re-intubated.
It's a tricky and unstable period of time right after anesthesia and waking up. BP, Resp. and O2 sats drop easily during this time.
Stretcher rides, transferring from stretcher to bed, and let's not forget how many patients suddenly put on the "crocodile tears" and drama once they leave PACU and see their family asking them if they are hurting.
You can't push narcs right before leaving and them zoom them out the door to the floor to prevent the discomfort of transferring and stretcher rides. It's not safe.
The condition of the patient when they are in PACU is completely different than when you get them on the floor.
And this is coming from a nurse who is all for maximum pain control.
PACU is just not the same.

I had a patient come to the floor post op colon resection. PACU had told me that he had not asked for anything for pain. Within minutes of being on the floor (I'm sure the stretcher ride didn't help) he was writhing with pain. I quickly gave him 6 mg of Morphine IV.

BTW at one facility I worked at I received patients that have told me that they requested pain medications in PACU only to be told by their PACU nurse "They will give something for pain when you get to the unit." This happpened because at this particular facility, if the PACU nurse had given them analgesics they would have had to monitor them an extra 15 minutes according to that facilities policies. It was not all PACU nurses at that this place that did this, it was only 1-2. I repeat: it was not all PACU nurses at this place that did this, it was only 1-2. I'm well aware that patients are supposed to met a certain criteria before they are considered stable enough to be transferred from PACU to the unit. In regards to my response to Dutchgirl's post, the pt had not asked for analgesics in PACU, the patient was writhing in pain on the unit after a colon resection, I question in this instance whether the PACU nurse based her decision in regards to analgesics on the fact that the patient did not request them.

Stretcher rides, transferring from stretcher to bed, and let's not forget how many patients suddenly put on the "crocodile tears" and drama once they leave PACU and see their family asking them if they are hurting.

I would expect that the patient would find some discomfort/pain during the transfer process. I don't expect them to arrive writhing in pain. Some patients may even be stoic in regards to pain, doesn't mean that they're not in pain, they may not be telling you that they are in pain.

You can't push narcs right before leaving and them zoom them out the door to the floor to prevent the discomfort of transferring and stretcher rides. It's not safe.
The condition of the patient when they are in PACU is completely different than when you get them on the floor.
And this is coming from a nurse who is all for maximum pain control.
PACU is just not the same.

No one said push narcs and zoom them out the door. If your all for maximum pain control, then does it not make sense that part of the criteria that patients meet prior to transfer to the unit be adequate pain control. Please tell me that as PACU nurse you assess pain in the recovery area and base that assessment on more than whether or not the patient's requests analgesics. The condition of the patient should not be completely different when you get them to the floor. Their condition should still be stable although the patient may experience addition pain and discomfort due to the transfer process.

Originally Posted by DutchgirlRN
I had a patient come to the floor post op colon resection. PACU had told me that he had not asked for anything for pain. Within minutes of being on the floor (I'm sure the stretcher ride didn't help) he was writhing with pain. I quickly gave him 6 mg of Morphine IV. A few minutes later his elderly mother comes to me and asks me how I dare give her son Morphine. She said I know you people only give people Morphine when they are ready to die. I know people who have received Morphine just before they died. I tried to be kind and explain it to her. She just wasn't buying it. I took her back into the room and explained it to her again and also to her son. He told his Mom to sit down and be quiet. I gave him a wink and with that I was out of the door. Gees, leave the work to the professionals. I wanted to ask her where she got her degree but I didn't want to be disrespectful.
Originally Posted by DusktilDawn
You know Dutchgirl, I do think the PACU nurse should have ASKED the patient if he needed pain medication prior to transfer. The whole situation may have been different if she did.
Our facility is planning on implementing a "Visitors Code of Conduct," some people just get way too out of hand.

This is Dutchgirl's post and my response. I'm not seeing where I said push analgesics in the immediate recovery period just because the patient had surgery. Perhaps I should have been more excruciatingly specific and stated "I do think the PACU nurse should have ASKED the patient if he needed pain medication prior to calling report, or at least within a reasonable time prior to transfer."

Sorry RN34TX, I do still question whether in this instance the PACU nurse fully assessed this patient's pain control or based her judgement on the lack of request for analgesics from the patient. "The patient didn't ask for pain medication therefore their pain must be controlled" shouldn't be the attitude of ANY nurse in regards to adequate pain control for our patients.

SmilingBluEyes · Dec 4, 2005

Our PACU is just EXCELLENT about not sending up patients in too much pain. I really should thank them next time I see them----they have the PCA all set up and everything. I feel they are a real team of professionals and really do take care of our patients. I rarely get patients on my unit from PACU in much pain at all!

Yep a thank you is in order.

RN34TX · Dec 4, 2005

BTW at one facility I worked at I received patients that have told me that they requested pain medications in PACU only to be told by their PACU nurse "They will give something for pain when you get to the unit." This happpened because at this particular facility, if the PACU nurse had given them analgesics they would have had to monitor them an extra 15 minutes according to that facilities policies. It was not all PACU nurses at that this place that did this, it was only 1-2. I repeat: it was not all PACU nurses at this place that did this, it was only 1-2. I'm well aware that patients are supposed to met a certain criteria before they are considered stable enough to be transferred from PACU to the unit. In regards to my response to Dutchgirl's post, the pt had not asked for analgesics in PACU, the patient was writhing in pain on the unit after a colon resection, I question in this instance whether the PACU nurse based her decision in regards to analgesics on the fact that the patient did not request them.
I would expect that the patient would find some discomfort/pain during the transfer process. I don't expect them to arrive writhing in pain. Some patients may even be stoic in regards to pain, doesn't mean that they're not in pain, they may not be telling you that they are in pain.
No one said push narcs and zoom them out the door. If your all for maximum pain control, then does it not make sense that part of the criteria that patients meet prior to transfer to the unit be adequate pain control. Please tell me that as PACU nurse you assess pain in the recovery area and base that assessment on more than whether or not the patient's requests analgesics. The condition of the patient should not be completely different when you get them to the floor. Their condition should still be stable although the patient may experience addition pain and discomfort due to the transfer process.
This is Dutchgirl's post and my response. I'm not seeing where I said push analgesics in the immediate recovery period just because the patient had surgery. Perhaps I should have been more excruciatingly specific and stated "I do think the PACU nurse should have ASKED the patient if he needed pain medication prior to calling report, or at least within a reasonable time prior to transfer."
Sorry RN34TX, I do still question whether in this instance the PACU nurse fully assessed this patient's pain control or based her judgement on the lack of request for analgesics from the patient. "The patient didn't ask for pain medication therefore their pain must be controlled" shouldn't be the attitude of ANY nurse in regards to adequate pain control for our patients.

The point of my post wasn't to insult your nursing judgement or point of view, it was only for insight on the PACU side of it.

I was reading Dutchgirl's post about this and didn't see anything about whether or not the PACU nurse actually asked if the patient needed/wanted pain meds prior to transfer so that I'm still unclear about.

I was only going off of her comment about "within minutes of being on the floor, the patient was writhing in pain."

Some, not all, of the nurses that I send patients to have an unrealistic idea of how comfortable a patient can possibly be after surgery and when they're in pain on arrival. Some look at me as if the patient should be laughing and dancing or something right after surgery because they think that I have a multitude of drugs that I can constantly push to keep them comfortable and it's not that simple.

That's when I chimed in about transfers and stretcher rides (which Dutchgirl herself acknowledged) because you said that the whole thing could have been prevented if the PACU nurse would have asked the patient if they needed pain meds before transferring to the floor.

That's where we disagree and the point of my post.

You are correct that pain control is part of the criteria to be discharged from PACU to the floor. But patients can, and often will, report a tolerable pain level of 1-3 upon leaving PACU, only to tell the floor nurse that it is now at an 8 or 9 after the transfer, mostly due to the moving around in transit which does aggravate post-op pain.

I was trying to say that you can't have your patient telling you that their pain was a level 1 and then push more drugs in anticipation of the transfer, even if I waited a safe amount of time as you'd suggested. Even that type of move isn't safe.

My point is not to argue whether or not the PACU nurse asked the patient about pain level/meds, my point is that even if she did ask the patient and medicated him/her to your satisfaction, it still would not necessarily have "prevented the whole thing."

The best pain control methods, short of consious sedation or deeper, are not going to completely prevent the discomfort and pain involved in a transfer. We both agree on that, right?

Where we differ is in how much pain can be reasonably expected and/or controlled.

A patient rating pain at 1-2 upon leaving PACU, yes, can still be "writhing in pain" after a few bumps in the road and movement of transfer upon arrival to the floor.

Based on the limited info in this situation, it sounded like the patient did not arrive to the floor with a PCA. It is policy in our PACU that all patients that have PCA orders will have them set up and running by us before arrival to the floor. It works well.

I understand your frustration. Every Med/Surg floor I ever worked, the PACU never even glanced at the floor orders. They didn't think that floor orders were their concern. I often received patients that got a ton of morphine and fentanyl in PACU and they'd send them to me with nothing but tylenol ordered for post-op pain! Thanks guys! Now I have a screaming and crying patient and the doctor still hasn't returned my page!

Our PACU also requires that we look over floor orders and if the MD forgot to order pain meds for the floor, we must call and get something ordered before sending them up, whether they are currently in pain or not.

DusktilDawn · Dec 4, 2005

Some, not all, of the nurses that I send patients to have an unrealistic idea of how comfortable a patient can possibly be after surgery and when they're in pain on arrival. Some look at me as if the patient should be laughing and dancing or something right after surgery because they think that I have a multitude of drugs that I can constantly push to keep them comfortable and it's not that simple.

Usually in my experience, it tends to be the patient or the family that will have an unrealistic idea in regards to post-op pain control. I certainly hope they don't arrive laughing and dancing, of course it would be amusing to see:lol2: (just kidding).

That's when I chimed in about transfers and stretcher rides (which Dutchgirl herself acknowledged) because you said that the whole thing could have been prevented if the PACU nurse would have asked the patient if they needed pain meds before transferring to the floor.
That's where we disagree and the point of my post.

I stated that the whole situation may have been different if she had asked the patient if he needed pain medication, not that it would have been prevented. The PACU nurse relayed that the patient had not asked for analgesics, what I question is was that her only criteria in regards to pain control for this patient. If that was the case, then yes, the situation may have been different. I don't think we are necessarily in disagreement here.

I was trying to say that you can't have your patient telling you that their pain was a level 1 and then push more drugs in anticipation of the transfer, even if I waited a safe amount of time as you'd suggested. Even that type of move isn't safe.

I think we can agree that if a patient is rating their pain at a level 1 that they are adequately controlled. If a patient is rating their pain a level 1, chances are they will not be asking for analgesics. I didn't suggested giving analgesics in anticipation of the transfer. Believe me, I don't want patient's arriving comatose. Most patients who do experience additional pain and discomfort from transfers will usually experience a decrease in pain/discomfort after they are settled into their bed.

The best pain control methods, short of consious sedation or deeper, are not going to completely prevent the discomfort and pain involved in a transfer. We both agree on that, right?
Where we differ is in how much pain can be reasonably expected and/or controlled.
A patient rating pain at 1-2 upon leaving PACU, yes, can still be "writhing in pain" after a few bumps in the road and movement of transfer upon arrival to the floor.

I doubt that we do differ on how much pain can be reasonably be expected and/or controlled. Rarely do I receive a patient writhing in pain, but it has happened. It tends to be the exception.

After reading your post RN34TX, we are actually very much alike in regards to post-op pain control.:icon_hug:

HillaryC, RN, CRNA · Dec 4, 2005

Tonight....
Patient in room with severe chest pain getting prepped for emergent cath lab, meanwhile family insisting patient lips are dry- when can he get some carmex? He's hungry- hasn't eaten all day, when are you going to feed him? Just look at his toenails! When will you trim those? Louder....Where is that carmex? Family insisting I should tell them where to find the *!# carmex in the clean utility since I'm too busy piddling around with patient's drips and meds and consent form. Then, during all the riff raff, family of patient next door pokes head around curtain wanting fresh ice for thier family member's creatine clearance container (which had half-melted but was still plenty cold!)
YIKES!

I know some people on this site think that the Center for Nursing Advocacy (nursingadvocacy.org) is a little over the top, but I really believe that the way nursing is portrayed in the media plays a big role in how patients and visitors treat us. Most TV shows either have nameless nurses in the background or have nurses whose primary responsibilities are giving baths, emptying bedpans, and getting ice water for patients (and often visitors). I can't think of a show that isn't guilty of showing physicians doing at least some of what nurses do in real life. I guess we shouldn't be too surprised then when visitors don't get that we have more pressing things to take care of before we can worry about lip balm or toenail trimming.

Marie_LPN, RN, LPN, RN · Dec 4, 2005

I can tell from you, Dutchgirl, and Dusktildawn's comments, that hearing from someone who actually has PACU experience is in order here.
Not everyone in PACU needs additional pain meds while in the immediate recovery period. You can't just push pain meds just because they've had surgery.
This way of thinking could cause the patient to need to be re-intubated.
It's a tricky and unstable period of time right after anesthesia and waking up. BP, Resp. and O2 sats drop easily during this time.
Stretcher rides, transferring from stretcher to bed, and let's not forget how many patients suddenly put on the "crocodile tears" and drama once they leave PACU and see their family asking them if they are hurting.
You can't push narcs right before leaving and them zoom them out the door to the floor to prevent the discomfort of transferring and stretcher rides. It's not safe.
The condition of the patient when they are in PACU is completely different than when you get them on the floor.
And this is coming from a nurse who is all for maximum pain control.
PACU is just not the same.

Thank you. Things can most certainly change in that 5 minute bumpy ride to the floor. You can give a pt. a dose of what's ordered, re-assess them, they are fine, but soon as the hit the floor, severe pain ensues.

And plus, in our PACU, the pts. don't move much, then all the sudden you're running over the grooves on the elevators, bumping against the doorway trying to get a stretcher in a skinny doorway, THEN moving the pt. to the bed.

And THEN PACU gets to hear from some of the floor nurses about how evil they were for "transporting a pt. all the way up here in that kind of pain. That's just cruel."

And the family complaining neglect when the pt. complains of soreness.

Not to mention, as previously noted, a dose of narcs on the way out the door can spell a disaster in the elevator ride to the floor. A code on the elevator? Fun, fun, fun.

Marie_LPN, RN, LPN, RN · Dec 4, 2005

Visiting hours are only visiting hours if they are enforced. But then again, sometimes it is really nice to have Sister Sue sit with her confused Great Aunt. Its a toss up for sure.

Yeah, you've got a few that stay with confused pts., but then, i'll never forget that night, a routine post-op abd hysterectomy pt. have FOUR people sleeping in her room. Looked like a bunch of cats laying everywhere. Junk food all over the place, messy, etc. And rude on top of it.

But, hey, good ol' customer service, certainly can't ruffle feathers, ya know. :rolleyes:

nurseman99 · Dec 4, 2005

unfortunately many family members know the old adage that the sqeeky wheel gets the grease.i'm not saying that being a male nurse is by any means makes me better off, but the fact that i;m bald,over 200lbs and have that jack nicholson grin makes pt;s family less inclined to verbally berate me.i believe most family;s that go after the nurses for every little thing are mostly either guilt ridden or clueless as to what we actually do in our 8 or 12hr shift.they feel if they bully us then their family member will get more attention then the next pt will.i always put an end to that quickly.i take them aside and give them my speech on priority and policy.for example,i hate when someone's meds are do at 9pm.it;s 930pm.you are busy as all heck.the family is riding you like a new pony.i explain to them all 8hr meds as well as q6hr/q12hr meds can be given 45minutes either way early or late.when proper info is given they seem to calm down.if not ,that;s thankfully where the charge nurse can come in and tell the family they should be thankful for having a nurse who goes far beyond the extra mile for his pt;s.i no longer let familys get the best of me.i guess 12yrs in the business you realize for every nutty family member there is a dozen who really appreciate what we do.fyi;please forgive my grammer and typing.i type with 1 finger,and less than 30wpm.

Marie_LPN, RN, LPN, RN · Dec 4, 2005

I don't care if i'm wearing a frilly pink tutu, and a tiara, that doesn't make me more of a target for family member. What would make me more of a target is management that doesn't back up their nurses, who do anything to get the family to pipe down, even at the expense of the nurse..

nurseman99 · Dec 4, 2005

although i do agree that management has a poor hx in helping nurses with their struggles r/t families,i am convinced in my many yrs in my hospital that families are much more intimidating and bothersome to the younger looking nurses than they are to the more seasoned male and female nurses.any nurse new or old needs for their visitors to know that you as the primary nurse is in control of the situation and/or needs of the pt at any given time.if they do,they are less inclined to be a "pest" and will let you go on with your job.

LeahJet, ASN, RN · Dec 6, 2005

I don't care if i'm wearing a frilly pink tutu, and a tiara, that doesn't make me more of a target for family member..

hehehe...that just struck me as funny.:chuckle

luvkitties · Dec 6, 2005

While it's all warm and fuzzy to talk about putting yourself in someone elses' shoes and to be all therapeutic..... there are some people that are just JERKS.
I have kind of an off beat way of dealing with people like that.
For instance, one night while in the ER, a co-worker asked me to go and try to start an IV on a very obese dehydrated diabetic woman. She had only tried once and couldn't even see anything else to stick. The minute I walk in the room, the daughter goes off on me. "Well lets see if YOU know what you are doing...you only have ONE try....I don't know WHERE you people learned to start IV's..." Just on and on ......
I looked her right in the eye and say, "Well aren't YOU a sweet thing?" with my southern accent and a sweet smile. The taken aback look on that woman's face was priceless. She had no idea how to respond. She just shut up right then and there.
See, the secret is to say things that would make the person look absolutely ridiculous if they tried to report you. "That nurse said I was a sweet thing!!"
This is good for me because I get to get my point across and have fun doing it with a minimal risk of being complained about. I used to walk out of the rooms fuming...now I have a satisfied smile.:)

I absolutely LOVED how you handled that...I just love it when they shut up, don't you? :chuckle