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LadysSolo 5,490 Views

Joined Dec 17, '06. Posts: 250 (72% Liked) Likes: 680

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  • Mar 27

    Quote from Lev <3
    I have dealt with many "Jakes" and I will dilute their pain medicine and push it over the recommended minutes.
    And I don't "flush it fast". When asked why, I tell them, like I would any other patient, that if I push the med too fast it could slow down their breathing enough that I might have to help them breathe, and I would rather not do that today if I don't have to. I used humor when appropriate and firm boundaries with people like Jake. Sometimes it worked, sometimes it didn't.

    This is a good article because I struggled with some of those feelings about addicts when I was a newer nurse.

  • Mar 27

    I have dealt with many "Jakes" and I will dilute their pain medicine and push it over the recommended minutes.

  • Mar 27

    The problem I have with all of the Jakes I treat is that many of them expect me to drop everything I'm doing all at once to give them their IV dilaudid and phenergan even if I am providing care to another patient. If it takes me more than two minutes (not an exaggeration), they pitch a fit. If I don't "push it fast" or if I dilute it, my practice and technique is questioned. If I refuse it due to them being hypotensive or difficult to arouse, I am nurse ratchet who doesn't care about their pain.

    They are so nauseous and in so much pain yet they can chow down on potato chips and starbucks despite being NPO. They claim that PO Dialudid doesn't "treat" their pain yet will ask for it one hour after getting their IVP of Dilaudid. That's interesting. I thought it didn't "work". And then, down the hall you'll have a patient ready to be discharged home with hospice already in the active stages of dying who fervently denies pain whenever I try to encourage him/her to let me medicate him/her.

    Don't get me wrong. I am professional and courteous to every Jake I encounter. If I know someone with undeniable pain is going to be discharged soon, I try to encourage them to move over to PO pain meds because we all know Dilaudid or Morphine IVP is not available at home. I cannot make someone change their ways and I cannot cure a drug addiction. If a pain med is ordered, I will give it if it is safe to do so. However, it is incredibly difficult not to resent these type of patients when they use manipulation to get their way and monopolize my time. I have other patients whose needs are just as important as Jake's.

  • Mar 27

    Drug seekers are a problem and sadly nobody wants to address it. "Pain is what the patient says it is" makes as much sense as "the customer is always right." No, the customer is not always right. The only problem with your scenario is you indicate Jake has recently had a surgical procedure. That causes pain. Change the scenario to "Jake presented to the ED having bumped his arm on his kitchen table, has no bruises, no fracture, nondislocation and was admitted because he screamed at the ED doc, called th nursing supervisor and heartened to sue if they didn't make him comfortable." Oddly enough, the hospitals which utilize carenplans don't get this as often.

  • Mar 27

    Jake is very sociable, and has a lot of …colorful friends who visit him in the hospital. He’s quite likable, because he’s intelligent, funny and clever. He’s not bad-looking, but at 35, his lifestyle is starting to take a toll on his looks.

    On this admission, Jake had an appendectomy. He also has a substance abuse disorder.

    Time: 1940. Right now, Jake is leaning against the doorjamb in the doorway of his room, looking up and down the hallway for me. He’s holding his cell phone in hand and repeatedly checking the time. Just to irritate me, I’m sure. He always calls for his pain meds before they’re due.
    Funny, I’ve yet to ever see him exhibit any outward signs of pain. On the contrary, Jake always appears relaxed, but his reported pain level is always a “ten.”

    Jake Lies

    Time: 1945. Only because I have to, I ask: “What’s your pain on a scale of one to ten?” He automatically answers “ten” without blinking an eye or looking up from Candy Crush. I might as well have asked, “Yo, Jake, what’s six plus four?”

    Jake Gets His Dilaudid

    Some patients always know exactly what time it is

    Time: 2005. Ok, Ok! It’s time. Reluctantly, I enter the room. My eyes roll as Jake scoots eagerly to the side of the bed nearest me and proffers his inner arm, exposing his antecubital saline lock. With his opposite hand, he pushes the sleeve of his patient gown up high and out of the way. His eyes are bright and his gaze is steadfastly fixed on the syringe in my hand.
    He watches intently as I swab his saline lock port with an alcohol wipe. He’s craving his fix. He swallows. He supervises as I pierce the rubber hub and finally inject the Dilaudid into his bloodstream. Then he asks me to “flush it fast.” I don’t respond or make eye contact. I flush the port and leave the room as quickly as I can.

    I’m feeling repulsed. Did I say repulsed? Yes. I’ll be honest here. You may stop reading now, you may be shocked, you may unfollow me. But I know that if I feel this way…I can’t be the only one.

    More on How I Feel

    Dirty. Tarnished, as if I’m complicit in Jake’s addiction. I’m pushing IV drugs on an IV drug user? Really? That’s not what nurses do!
    I’m angry.

    • Angry because I feel manipulated and used
    • Angry because Jake’s not playing by My Rules
    • Angry because I’m a tight-lipped, mean nurse with Jake. Not the compassionate angel of mercy I prefer to think of myself as! I hate when that happens, JAKE!!
    • Angry because I’m angry
      I’m a tight-lipped, mean nurse with Jake, the drug addict

    What about the Rules? I’m playing by the: “What the Patient Reports as Pain is the Gold Standard” Rule Book. And Jake’s Rules? No rules. He’s just playing me for a fool. Or so it feels.

    Take a Deep Breath and Repeat

    I don’t like how I feel. So, for a minute, let’s just step back from Jake and the floor and review some pain management terms.


    Tolerance is a normal physiological response to exposure to a substance over time. Think coffee. You require more caffeine to realize the effects you enjoyed when you first started using, I mean, drinking, coffee. There’s:

    • Tolerance to side effects can include sedation or nausea, (opiates) and
    • Tolerance to analgesic effects, which requires higher doses to achieve pain relief

    I need my coffee strong, please!

    Jake has tolerance to both. “Normal” doses of pain medication will not relieve Jake’s post-op pain. Dilaudid one mg IV for Jake is like a lukewarm, watery, half cup of coffee is to me. Due to tolerance, Jake needs more pain medication, not less.


    Physical dependence develops with repeated exposure to opioids.
    “Tolerance, withdrawal, and physiologic dependence are expected responses to opioids …and are not by themselves indicative of addiction.” American Society of Pain Management Nurses (ASPMN) Position Statement on Pain Management in Patients with Substance Abuse Disorders, 2012

    Many respectable, functioning members of society live with chronic pain that’s managed by some form of opiate. Given enough time and drug, they become physically dependent. Dependence in and of itself does not constitute addiction.


    According to the American Society of Addiction Medication (ASAM), addiction is “A chronic, primary disease of (the) brain…characterized by inability to abstain.” People with active addictions can’t control their cravings or impulses.
    Here’s the thing- patients with active addiction have pain, too. Perhaps even more pain than other people undergoing the same procedure. There’s a phenomena known as opioid-induced hyperalgesia, in which patients dependent on opioids have increased pain despite increasing doses of meds.

    What Else ASPMN Tells Us

    The (ASPMN) Position statement further says:
    “Patients with substance abuse disorders and pain have the right to be treated with dignity, respect, and the same quality of pain assessment as all other patients.

    So when Jake, the post-op substance abuser, asks for his pain meds, it’s complicated.

    It’s easier to dismiss Jake as a drug user than to sort this all out

    Added to the problem is that few providers are schooled in managing pain in patients addicted to opiates. Dr. McSurgeon will most likely order his one size fits all post-op pain management order set.

    Here are somethings I’ve learned to reduce my frustration:

    Six Resolutions that Help Me Cope with Patients with Substance Abuse Disorder

    I will check my judgmental attitude. I remind myself that I don’t know how Jake got to this place. I don’t know his story, all the factors and forces that led to his addiction. Was he a cute little boy?
    Did someone hurt him? Did his father leave him? I’m not saying that any of these are an excuse to use drugs. I myself didn’t have a stellar childhood, and I don’t use drugs. But reminding myself that I haven’t walked in Jake’s shoes instantly changes my perspective and helps me be less judgmental.
    2. I will be realistic. Why am I surprised when a person with a substance abuse disorder displays behaviors… consistent with those of a substance abuse disorder? Folks with DKA have high blood sugars. Folks with an active addiction lie, cheat, steal and manipulate to get their drugs. When Jake lies, flatters, or wheedles, I won’t take any of it personally.

    3. I will understand my job. I can’t cure Jake’s addiction. I’m not that powerful. Even if I could, which I can’t, and even if he wanted me to, which he doesn’t, that’s not why he’s here. Jake’s here because he had surgery. My job is to provide the best post-op nursing care I can.

    4. I will take control. Of myself. My anger is my problem, not Jake’s. I own it. I can only be manipulated if I allow it.

    5. I will not engage in a power struggle with Jake. We both lose. I’ve worked with nurses who use passive aggressive behaviors, “forget” to medicate their patient, wait until change of shift, etc. Failure to treat pain is profoundly wrong, unethical, and unprofessional. Nurses who position themselves as “She (or He) Who is the Gatekeeper of Pain Medication” need to re think how they’re using their authority.

    6. I will be professional. I won’t use stigmatizing terms such as “drug-seeking” and “clock-watcher.” In handoff report, I will simply inform the next RN when Jake’s pain med is due. Jake deserves the same access to pain medication as Edna, my 78 year old female post-op hip surgery patient, and the same dignity and vigilance. (Actually, I have a hunch Edna was a little tipsy when she fell and broke her hip). I will respect Jake as a fellow human being who, for all I know, is doing the best that he can with what he has. As are we all.

    Rewind and try Again

    New tactic.

    Time: 1945. I go into Jake’s room, smile, make eye contact, and ask him if needs his pain med. He is completely taken by surprise, and his face and eyes show it. Someone is treating him like a human being?

    As for me? My anger is gone! I’m in control and I feel much kinder towards Jake. I can do this. It just takes improve my nursing practice!

    These patients are tough.What’s your experience? What helps you get through your shift?

  • Mar 17

    Quote from 2mint
    Who is predicting that Rose_Queen is not going to apologize to 2mint?
    I was mistaken about who you were referring to, yes. I still stand by my comment that your other thread is irrelevant and quite frankly your posts are condescending and you do not come across well.

  • Mar 17

    You know 2 mint, for someone who prides themselves on being a master communicator you are stunningly oblivious to how you are coming across here.

  • Mar 17

    Quote from 2mint
    -It is "mildly related" bc that particular poster is an instructor.
    OP is not an instructor. OP is a preceptor. There is a difference. An instructor is an employee of the school. A preceptor is a nurse who has volunteered to go above and beyond the requirements of the job to take on the role of precepting a student during the final semester. And your other thread is 100% irrelevant to this thread.

  • Mar 17

    Quote from 2mint
    -It is "mildly related" bc that particular poster is an instructor.
    It is not at all related, because she is a clinical preceptor for a capstone project, not a tutor for NCLEX. Suggesting that her students "might benefit to know" that you wrote about your personal experience with the NCLEX on a message board is about as relevant to the specific topic as the fact that I too assist students in the outside world. Utterly irrelevant to the OP and her situation.

    -OP won't dismiss me because 1) I asked her questions that she like to answer and 2) OP has an MSN, and going to be a CNM...a working professional.
    I too am a working professional, but since I found your post thoroughly soaked in condescension I praised her for engaging at all. I would have likely disregarded your over-reaching criticism of the situation had I been the OP.

    When two educated professionals speak, they respect each other and converse in a civil manner.
    I asked OP in a factual, quotation-based way, and she responded thoroughly and professionally. I did likewise, all quotation-based, no emotions clouded my response, I spoke in context, and my assumptions were clarified with relevant qoutes and never far-fetched.
    See my comment above. Your post practically drips condescension, and if you were an educator you would probably be shocked to find your students detested being on the receiving end of such an attitude. Why did you think the OP would be any less offended by what is NOT simply a professional discussion but rather a condescending reprimand as though you were in some kind of position of authority over her and her teaching style?

    Perhaps it might benefit you to look over what I've posted here and see if there might be some room for improvement in your own communication skills, since you must not realize the effect your posts have. You believe you are engaging in professional discourse, and I am submitting that you should review the basics of communication techniques to better serve your purposes in the future. Good luck to you.

  • Mar 14

    I think it's weird how many people think that taking 30 minutes for a personal phone call on the clock (especially during orientation) is totally okay. What if she had just left 30 minutes early? Or taken a second lunch? Especially without telling anyone.

  • Mar 14

    Quote from Strugaaa4eva
    I explained what had occurred and I didn't realize that 5 days later I was going to be reprimanded for that. I received a call from the unit manager I was supposed to work at stating that I was technically supposed to come this weekend for my first day of clinical orientation (I was hired as a per diem nurse) she told me that I don't need to come.
    If I am following this correctly, it wasn't until 5 days later you were told not to come in? What, out of curiosity, makes you think it was the phone call that 5 days later resulted in your discharge?

    I'd think something came up on a CORI check or reference call or such that was more immediate to your being discharged....

  • Mar 14

    Quote from iluvivt
    The reality is we all take personal phone calls at work because we are human,have lives and things happen.You must ,however, be very discreet about it because many hospitals do not like it or allow it.It does seem extreme to fire you though!
    A lot of people do, but most people manage to get through the first week not talking to their lawyer on the clock during class.

  • Mar 14

    Quote from Emergent
    It may seem unconceivable to the younger generation , but it is possible to survive without a cell phone on one's person at all times.
    Can I hear an Amen?



  • Mar 14

    For all of you suggesting she wasn't interested in L&D, you are incorrect. She chose L&D and wanted to be hired on our floor after this rotation.
    I am a new grad CNM and am finishing my time as a bedside L&D RN, she is not being asked to do anything advanced or beyond the basics. Mostly vitals, head to toe assessments, electronic fetal monitoring, IV starts, foleys, and repositioning as well as some patient eduction and medication education with my direct supervision. She has observed all of this for the first half of her clinical with some guided participation and voiced confidence in each portion before she was asked to do it independently. I am always in the room with her for her to ask questions. For an IV, she gets one poke. If she doesn't get it I take over, same rules I use with all my students.
    I have been in communication with her faculty about my concerns and we did have a meeting in which Alice tried to blame me for not making her feel welcome and for "pushing her too hard." Her faculty member literally told her that what I was asking of her was the basics and that she could have been asked to do more.
    Alice was told last night that she failed her practicuum and would have to repeat it with another preceptor and in another area. I have never seen such a tantrum thrown by an adult before. I know for sure now that all my suspicions were true about Alice. She skated by in group clinical as never drawing attention to herself. I pity her future patients and hope no one I love ever comes into her care if she ever becomes a full fledged RN. At least I know that I did not take part in passing her along.

  • Mar 14

    Quote from srercg6
    IF she is a nursing "student" who has not graduated yet - she has been told, and ALL the hospital staff were told up front that she can not legally do anything outside the scope of what her school allows her. PERIOD. In this case - if this IS the case - you are not her "preceptor" - A preceptor is a nurse who is shadowing a new nurse who has been HIRED. If she is a STUDENT, there with other STUDENTS with a school group - you are nothing to her - she is only there to shadow you (legally) and nothing more.

    My school allowed us to get vital signs, do head to toe assessments - and that was it. Otherwise we had to have our SCHOOL instructor present to perform any procedures - drawing blood, removing an IV/starting an IV, catheters, flushes, dressing changes, etc. Our school instructor was usually ON THE FLOOR somewhere, and the student is responsible to her schools' instructor - no one else.

    However, if this is someone your company has HIRED and asked you to be her preceptor - that's another story.

    Also, I would not assume this person is just being lazy etc. Its an awful lot of work to get through nursing school to the point of being in a hospital for any reason just to go off and throw it away. I don't think she would have passed enough of her classes to get this far if that was the case - SOMETHING ELSE IS GOING ON. We do NOT have all the facts here.

    Too many are just "fire her" -without even hearing the other side, or even questioning it.
    The OP was told that Alice would be doing full patient care with the OP just there as backup. Alice was in that meeting as well. She is aware of the expectations of her. She "laughed it off" when she was told that disappearing is not an option. She's aware of the expectations, she chose to laugh it off. The OP has discussed this with her instructor. Given all of this, is it irresponsible NOT to fail her. Alice is presumably an adult. If there are extenuating circumstances, she should have brought them to her instructor early on. However, I cannot think of any circumstances which would make it OK to disappear on the OP (and then lie about where she was) and then be disrespectful when called on it.