pain management/pt upset

[sameasalways, ASN, RN]

I have only been nursing for 2 years but a few days ago I had something happen that really left me shaky and questioning things. I look forward to any advice. One of the post-op patients (orthopaedic) had an I/D of their elbow. It was the 2nd one done due in the week. I picked him up at shift change and he called out for pain. I looked at his pain meds and he had Demerol and Lortab. He had not been given Lortab since the day before. The report I got upon taking the patient did not address any issue about pain meds or issues with them. I was taught to stair-step pain meds and give the IV pain meds for breakthrough pain for a few different reasons which you are all probably all aware of. I went in before bringing pain meds and asked what his pain was on a scale of 0-10. He said "not really bad, its just my elbow and that is like a 7". I asked pt if there was a reason he had not taken any lortab since yesterday. He said shrugged it off saying "no...not really." . I asked him if it was because the lortab doesn't work and he said it doesn't work for him the way the demerol works. I brought him Lortab and I explained that we like to use the demerol for breakthrough pain and so that we can make sure the lortab is effective because if it isn't we need to get a different oral pain medication for him so he can be sent hom with a different oral pain med. He took the oral pain medication and at the same time his IV went bad. I was unable to flush it. while I was attempting to flush the IV I said "I hope I didn't come across wrong but I just wanna make sure that if the lortab doesn't work we can get you something different and because when you leave you won't have the IV pain meds available". He got very angry and told me that I need to start doing my job. I said, "sir, patient education is part of my job". He said, "you don't know how to handle MY pain!" I told him that alternating the oral with the IV med is standard practice. He said "you don't know how to handle my pain! have you ever had surgery before? huh? I was a CNA for years and if you aren't going to treat my pain I know what to do" I said "sir I never said I wasn't going to treat your pain. I just brought you something for pain" . Then he said something ( couldn't hear him as I was facing the computer documething his pain) about talking to the nurse supervisor. I asked him what he said and he said "nevermind! what kind of surgeries have you had? (yelling) and grabbing his leg saying he has had this and that done to his leg and elbow. I said "sir I don't appreciate your tone and yes I have had surgery before". He demanded "well what kind of surgeries?" I said I have had 3. And he said "yah well what kind!!!!". I said "That's really none of your business and I am not going to deal with this behavior". (he was yelling at me and acting very beligerant through all this). I left his room and immediately approached the charge nurse with this and I was actually shaking at the time almost crying. She said don't worry about it I will find someone else to take care of him. Well half an hour later a nurse tells me she is going to give him pain meds for me. I was confused and told her i just gave him pain meds. She said the charge nurse told her to give him IV pain meds. I said, Oh well he doesn't have an IV (I had told the charge nurse this) and she went in to the room said she would have to start one. I went on with other patients. She came out and I assumed it was taken care of. Then next thing I know the man is out pounding the counter with his fists yelling to the nurses statione (there wasn't a nurse there, only 2 doctors) that he wants his IV pain meds NOW. NOW! SOMEONE BETTER GET ME SOME NOW! and he slams his door shut. I was on the phone iwth the charge nurse who expressed frustration with me as I had already tried clarifying whether i was supposd to switch patients with the other nurse or what was going on because I thought we were switching but the other nurse said just to give IV pain meds. I told her what he had just done. 15 minutes later to 20 minutes later another nurse comes down and goes into the room. I said, "oh I think so so and so already was in there". she just shrugged and went in. I asked the the previous nurse what the other nurse was doing in there and she said "oh she had to start an IV..I wasn't going to try to start one on that angry man!". So Anyway, my question is, how should I have handled the fact that he hadn't had oral pain meds since the day before? I really don't want this to happen again. Also...if something like this happens and th patient becomes very upset and angry and beligerant with you, how do you react as a nurse? How should the charge nurse handle it? I feel like everything went wrong on so many levels over something that was ridiculously simple....I haven't had a patient react so angrily to me before over trying to assess how pain meds are working or not working for them. I often look back and honestly think I just should not have apologized if I came across the wrong way regarding trying the oral pain meds because for some reason that really set him off and that is when the behaviors started. I was told by the charge nurse just to give him his IV pain meds. I don't have a problem with that if that is what the patient wants..but I feel like the patient should know that if the oral pain meds aren't working we need to get them something else. (I of course told him that) but he was so angry it didn't matter. I feel like my charge and supervisor are just going to say "well if the pt wants iv pain meds give it to them" . Like I said, I don't hav ea problem with that, but I also want to know why from that patient so that if something can be fixed we can help the pain management issue more. I haven't had someone do this to me in this manner before. Thanks.

[AMCNurse]

I'm so sorry what a horrible situation. People can be so unreasonable at times. I think he was just majorly misunderstanding you. I don't understand how his pain wasn't really addressed before. I mean you always start with oral meds and then give IV meds. I think you did everything right and handled it well. I don't understand why his new IV wasn't started since the charge nurse knew about it. I would try not to dwell on it which I know is hard to do. I had a patient complain about me to the charge nurse recently. It really sucks. Keep your chin up I think you did nothing wrong and sometimes you can't make people happy no matter what you do.

[tokmom, BSN, RN]

For starters, he probably didn't feel listened to. Don't take this wrong, but charting at the computer and not looking at him probably gave him the impression you didn't care. Anytime I have a potential hot issue, I stop what I'm doing. I sit down next to the patient, give them eye contact and listen to them. You might not think you have enough time, but it takes less time to sit and listen to a pt then to diffuse something later on.

I would have given him IV to get on top of the pain. You knew the lortab wasn't the drug of choice. Granted his IV was bad, but I would have told him, I was going to restart the IV, get him something for pain that would work immediately and then tell him I was going to call the MD and see what we could do to switch him to something that worked better. Yes, in many cases, we only use IV for breakthrough, but rules are made to be broken and how fair is it to make him wait for a medication to kick in that won't give him much relief in the first place?

The education you gave probably came across as a lecture to him. He sounds like he was starting to wind up at that time.

Once pts are in mid tantrum, it is a difficult situation. I tell pt's I won't stay in a room and listen to them if they are going to be rude. However, they have my full attention (as I'm sitting down)if they can be civil and we can work this out. I then ask the pt what they want and how can I make the situation better. I might get their request with an angry tone, but I echo what they have said and look interested. It really can diffuse the situation.

As a charge I get pulled into angry family member issues a lot. It's so frustrating. If the nurse would have spoken less and listened more, many times it could have been avoided. Of course, not all times. Some pt's and family can be complete butt heads, but even then you can keep the relationship on an even keel throughout the stay if you listen to their needs. If they ask for something unreasonable, tell them you cannot do that for XYZ reason, but replace it with something that can be done.