When nurses disagree about pain management...

  1. I work in an LTC. Most of our residents are quite young...most of them are under age 70. We have a few residents who have a long history of severe pain and receive narcotics on a regular basis. We have a new nurse who has been there less than a month who doesn't believe that they are in pain and is working to get their mediations reduced. One of the ladies has a long history of abdominal pain to to benign cysts and abcesses...she has had over 20 surgeries, but the cysts and abcesses continue to come back. Apparently, the cysts are back and causing her a great deal of pain. I have no idea if she is really hurting or not. There is no obvious change in vital signs, but she does become diaphoretic, guards her abdomen when she walks, and grimaces. So..since she stated she was getting no pain relief, I talked to her doctor, who increased her pain meds until she can see her surgeon on Monday. The new nurse is really upset that I did this. She told me that she does not believe for a minute that the resident is having that much pain and that when she is distracted by activities that she doesn't request pain meds. She makes the resident wait an 30-60 minutes before giving PRN meds that are due. She also told another nurse that I am just a sucker and that the residents can talk me into anything...she says that she is going to tuirn me in to the state.

    I'm not sure what to think about this...I really don't know if this lady is having that much pain or not. She acts like she is having that much pain, but she has a long history of narcotic use (abuse?) and is probably a good actresss. She is not sedated, gets very poor sleep, walks with a steady gait...I just don't know. I am starting to question whether I should be giving the meds or not...I am concerned that I am just feeding an addiction rather than trying to treat her pain...I am concerned that I may be putting my license in jeopardy. I would hope that if I were out of line in giving meds when residents say they are in pain, that someone would have said something to me by now, but maybe it just takes a new set of eyes to see that I am messing up.

    My manger is really no help...I've asked her point blank whether I am overmedicating the residents and I've never gotten an answer...she just says things like, "If you have an order, you should be OK."

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  2. 24 Comments

  3. by   caliotter3
    When I worked in LTC, I had many of your same concerns and those of the nurse you are discussing. In having nurse to nurse conversations with many of my colleagues, including supvrs, they told me that b/c this is a LTC situation, the same criteria for pain meds may not be as "followed to the T" as in a regular situation. They said that most of the MDs prescribe pain meds, particularly at noc, to help sleep, and the "addiction", "drug seeking" issues are not dogged out like your co-worker seems to want to do. Yes, in some instances, she may be correct, that dosages can very well be adjusted downward or PRNs more closely monitored, however, she should also take into consideration, that these people are in LTC, they are going nowhere, and have the right to be comfortable. What they perceive as comfortable, not our opinion of comfortable. And as far as being precise: if you assess properly and honestly, and see improper use of pain meds, then you should address this in the med rcds and this should be discussed w/supvrs and mgmt whether they want to address this in the care plan and take steps to make changes w/the MD. I am by no means advocating "close your eyes" or "wink" and do what everyone else is doing. I always took what ever action I thought was appropriate according to my assessment and documented accordingly.
  4. by   wooh
    I would rather medicate a person NOT in pain than not medicate a person that is in pain. Let this other nurse try to turn you into state, she'll just be drawing attention to her not properly medicating pain.
    If it's chronic pain, of course her VS don't change, and she can walk around. She's grown used to it. Doesn't mean she likes it or should have to stay in pain. And of course activities distract her. Doesn't mean she isn't hurting while she's doing them. Best course of action would be medicate her, then give her an activity to take her mind off things until it kicks in. Of course, that should be for breakthrough pain. If she's got chronic pain, she should be on something scheduled, easier to keep pain down than to get it down.
  5. by   classicdame
    Please spend some time on the internet and school library to research pain management. Perhaps you could do an inservice once you have accumulated the evidence. So many people are suffering needlessly. Thank you for being concerned.
  6. by   caliotter3
    Oh, and BTW, pain mgmt is a biggie when it comes to surveys and JCAHO inspections. In home hlth, we have pain mgmt very strictly monitored and addressed in our inservices and when our documentation is critiqued by our supvrs. Your nurse co-worker is asking for trouble if she is going around and creating pain undermedication issues for the facility. It does not take much for one or more of the more alert residents to speak up about any issue dealing with their care. They also have a strange habit of speaking up when they are encouraged to voice their concerns by the surveyors. Do what you think is right to take care of your residents!
  7. by   nursecher
    I am a student and we are being taught that pain is subjective, therefore; if the pt says they are in pain, then they are in pain!
  8. by   Anagray
    Sounds like the new nurse needs a little more experience with pain management. She may think she is actually doing something good for her patients, but of course, it is probably not so. The thing is..there is a doctor's order to give pain meds. If the patient says she is in pain - she is! It's not like LTC people are some crazy thrill seekers and want lortabs to get high.

    Nat
  9. by   Blackcat99
    When I worked in LTC, I always gave pain meds when patients asked for them. Pain is what the patient says it is. I remember one lady who was in a great deal of pain. One of the nurses, felt she was overmedicated because she didn't want to participate in the social activities. So that nurse called the doctor and got her pain medication reduced. When the patient's daughter came in, she was furious that her mother's pain med had been reduced. I called the doctor back and got the pain meds increased and so that nurse was mad at me.

    I also remember another nurse who told me that a certain patient was always faking and didn't need any pain meds at all. This nurse confronted this alert,oriented patient about her pain meds. This alert patient got furious and reported this nurse to the director of nurses. This nurse got fired for under medicating this patient. This nurse was also reported to the Washington state board of nursing.
  10. by   fultzymom
    One rule this new nurse needs to remember is that pain is a subjective thing and yes sometimes having an activity or something else to do can distract you for a little while. (Think of how they try to distract a woman in labor by giving her something to focus on, ect.) But as nurses we are not allowed to medicate for pain based on whether we believe the patient is in pain or not. If she turned you in to the BON, she might get reminded of this. If if is time and the patient is requesting the medication, you have to give it. In the elderly, you generally do not need to worry about addiction issues. It would not hurt to try non-medication approaches but bottom line is you have to give it as long as it is within the doctors orders and you can tell you are not oversedating them.
  11. by   txspadequeenRN
    This drives me crazy!!!! Tell that nurse to go ahead and turn you over to the state and you will be right there waiting when they come to report how long she makes the patient with chronic pain wait for meds and about how hard she is working to have them reduced based on her own thinking... I would tell her that you know this patient much better than she does and regardless of what she thinks if the patient say's she is in pain then she is... Every time she works on getting a reduction in her meds I would be right there to counteract that.....She is not doing that patient justice and there ain't no way she would be dishing out that crappola on my floor!!!!
  12. by   txspadequeenRN
    dont mean to sound so aggressive, this baby is making me act like the first cousin to the devil....
  13. by   Antikigirl
    Heck guys...still story of my life in hospital (worked LTC/ALF for 4 years)...

    In the OP story...you don't get more from less...so what in the heck was she thinking!? Sadly once your receptors get use to a med..time to jack it up or change...if we had another solution that would be a nobel prize winner plus! Sadly no, and the side effects are still the same...so it is the point of side effects vs pain control...just like other meds having to balance or comprimise on one or the other...

    Good for the OP for being a pt advocate and sticking to her thoughts of what was right and just! Too bad the other got upset...but that is actually her probelm, not yours or the patients....her probelm for not knowing meds, the way they work, how to balance side effects, and how to CORRECTLY talk to the MD about these issues!

    I know my pain meds...I wanted to since I became an RN student. I wanted to know them inside and out so that I could be smart about them, understand when and why they are used, and be able to educate and even quell myths! I knew this was a hot point in nursing...no way was I going to get stuck with my pants half on with this subject!

    Have I had to argue...oh holly heck yes...who turns out being right...me! Who had helped MD's with pain management...me, and it makes them ticked when I know more then they know..which is an incentive I actually use for my and my pts benfit! A/P folks..it is that simple!

    Good luck to all...not easy, and I will never be without challenges in this arena, and nor will anyone else. Just keep your mind straight, ducks in a row, so when you have to debate or converse, you know what you are talking about!
  14. by   Antikigirl
    OH btw, on pain being pain...yes and no. If you have someone that is not able to make medical choices for themselves they are not in the right state of mind also to make pain assessments. So going only by word of mouth is incorrect. Go by symptoms too! Read that body folks...don't automatically say NO they aren't because they are sleeping..watch them as they sleep..are they twitching, do they look exausted from pain and passed out? Lots to consider!

    Body language for me is key to pain..when I am in pain (which I have a high tolenance to and don't like meds myself)...my left ankle moves alot! Don't know why..but if that sucker gets moving...it will increase to the leg and eventually me clawing like I am trying to leave my body with skin and such behind! (when I am at a 10...it is serious...I loose my mind at 8!).

    Some stoic people also show pain...showing expressions is a key to a stoic pt, twitch, blinking, not being able to sit in one position for more than a few minutes! Even post stroke pts show signs!

    Learn your pt, learn their 'tells' (like in poker! You can tell)...and try to help..that is all we can do!

    But to automatically assume a patient is in pain because they say so...naaaa...I don't go by that alone. I mean...would I assess someones cardiac condition by them saying only "I don't have chest pain"...NO! So pain is no different..you just have to be a bit more open to signs!

    Also there are cultural stereotypes for pain as well...watch for those! Some maternal women don't want themselves to be seen as weak and unable to care for their loved ones and will hide it no matter how it hurts. Some men would rather walk that admit they have a broken hip! Watch for that too..it is all part of the story! Heck, even people with low tolerence will seem like they are in pain all the darn time and say such, but there is a point where pain relief is hazzardous...so you have to be careful!

    I will typically have a small convo on pain with pts..see what their history is...best way to tell if something is wrong...see the way it has been so far for them! AND I discuss a pain plan WITH the pt doing comprimise for best results always having them know that I can add or subtact as they need! That takes care of some of the anxiety..which is a large part of the pain path!
    Last edit by Antikigirl on Feb 15, '07

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