Abusive patient

[Guest296136]

Just a question to anyone out there, there is a patient that is a frequent flyer in our hospital that comes in with sickle cell crisis, usually these patients are out of crisis within 72 hours, they get hydrated and pain meds and are discharged. But we get one that comes in and gets a very high dose of IV pain medication for weeks at a time, it is obvious that this person is addicted to the medication. The patient refuses to let the nurses do an assessment, verbally abusive and has fiddle with the IV pump to get more pain meds quicker, even with a lock on the maching.

Many of the nurses are afraid that this person is going to cause someone to lose their license, we document everything that this person does and the abuse and noncompliance. A pain managment specialist keeps the dosage at 8mg iv push Q1 hr and also a drip equal to 10mg and hour and is only on a med/surg floor not a monitored bed, many times we have questioned the need and voice our fear of over medication, but nothing is done.

How do we protect ourselves, can we refuse this patient?

[Hoozdo, ADN]

You are protected because there is an order from a pain management specialist.

The doctor is the specialist, not the nurse.

Protect yourself by having Narcan on hand. Is the patient trying to change a locked

PCA?

If the patient is verbally abusive, I would ask management how to respond. CYA and

keep documenting.

[indigonurse]

This person may have addiction issues. Might want to call in social services to see if there is someone in the hospital who is an addiction counselor that can help this patient. All you can do is teach the person about the benefits and risks with self admin. the meds. and document it. Does the hospital do a toxicology screen on the patient to make sure they are not giving meds on top of street meds that could harm this patient?

[Guest296136]

my concern is that the person will over dose and regardless of a doctors' order, it is on the nurse that gives the medication because it is a nursing judgement, the doc writes a Q1hr prn order and the patient asks for it every hour on top of the drip. I have refused to give the prn med a few times because respiration 14 or too lethargic, then a complaint goes to administration and we are told to give it as long as resp rate is greater than 12.

[southernbeegirl, BSN, RN]

Do you have ANY idea how painful a sickle cell crisis truly is?

[mskate]

my concern is that the person will over dose and regardless of a doctors' order, it is on the nurse that gives the medication because it is a nursing judgement, the doc writes a Q1hr prn order and the patient asks for it every hour on top of the drip. I have refused to give the prn med a few times because respiration 14 or too lethargic, then a complaint goes to administration and we are told to give it as long as resp rate is greater than 12.

When patients are long standing drug addicts, they have insane tolerance for pain medications. I have given 20+mg at a time of IV morphine to patients with chronic pain and/or narcotic addictions. Don't hesitate to treat pain, but hesitate if the assessment shows that it may not be safe. That being said, a resp rate of 14 might be OK to medicate if you know the patient and you know they already react to the drugs. Trying to fiddle with the pump though would buy that patient a sitter who can document!!!!

You have every right to decline to push drugs if you deem the patient is too lethargic or has a lowered resp. rate. Document the rationale thoroughly. "Pt woke briefly to ask for PRN pain medication. Pt too lethargic to keep eyes open, unable to complete full sentences without dozing. RN assessment determines pt is too high risk to administer pain medication. Offered tylenol, pt declined. Pt educated on risk of over sedation with pain medication. Dimmed lights, repositioned, offered cold/hot pack..." - If administration comes back to you, you can go to your notes - this is how he looked, I offered a non-narcotic medication that the pt refused and worked with the patient on non-medical pain relief options...

As far as administration is concerned - they want their patient satisfaction scores to be up. You want to keep your license. In the court of law - your rationale and charting will win over them wanting better perceived "customer is always right" service. In this feild, the customer isn't always right and if you let them be "right" all the time, their care may suffer and your license could be on the line. If admin. wants him to be medicated whenever he wants when you don't think it is safe, feel free to call the DON in to push the drug herself!!!

[Melody007_FNP-C, APRN]

We have a frequent flyer, who wants his pain meds pushed in the low port and then flush it fast even while he is on IVF! Now when he comes in the order is PCA and he immediately signs out AMA! No buzz from PCA! Even weirder is he loves to be stuck over and over again (his veins are shot) he refuses PICCS or ports, etc...must be a IV drug pusher maybe? So he gets a thrill of being stuck over and over!

[Tinknurse2B]

there is a patient that is a frequent flyer in our hospital that comes in with sickle cell crisis, usually these patients are out of crisis within 72 hours, they get hydrated and pain meds and are discharged. But we get one that comes in and gets a very high dose of IV pain medication for weeks at a time, it is obvious that this person is addicted to the medication.

Although I don't approve of the patient tampering with the pump.....I'm must say that sc is a very painful disease!!! When sicklers go into to a pain crisis the pain is unbearable. My daughter has sickle cell disease and I've seen her in so much pain that morphine and other pain meds just didn't begin to take the edge off her pain. Let me also add that every crisis is different. She's bben in the hospital for pain crisis for a month at a time.....her minimum stay is atleast 2 wks with majority of the stay still having pain at the rate of a 9. This is a horrible disease that takes a toll on each patient very different at times. Although I'm not sure about the background of the sickel cell patient that you posted about I do know that there is a possiblility that this patient is not addicted and is just truly going into crisis that often. For a long while my daughter was going into the hospital every month. My daughter had an exchange transfusion in October ....most of the time that last for 6-9 months before she need a regular transfusion...but at the begin of this month I had to take her to the ER for a bad pain crisis and this hospital stay was a few days over 2 wks ...and in that time she had 3 transfusions...which was something new....but the crisis she was in kept sickling the blood it seems as soon as it went in...the blood didn't last long at all....and she stayed on the morphine pump until the day she was discharged...her pain only became tolerable...never really totally going away like it usually does. Sorry for the long post...just wanted to say the patient may really be in that much pain that the meds are truly needed.

[resumecpr]

SC patients who are in crisis can require a lot of pain meds just to take the edge off. And since this particular patient is frequently in crisis, his/her tolerance to meds is probably extremely high. A reticulocyte can indicate if the patient is truly in crisis or not most of the time.

One of my mentors did an entire study (which can be found in AACN) about the practice of healing touch for sickle cell patients. The study showed that their pain was significantly reduced with the incorporation if healing touch, IVF, and narcotic pain medicine.

[canoehead, BSN, RN]

Jeepers, the OP didn't say sickle cell was not painful. They said the patient is abusive and playing with the pump, and they have concerns about the respiratory rate when giving drugs. Is there anyone that says hypoventilation and brain damage is preferable to pain? Or they could give the drug, and then Narcan when RR reaches 4-6. That would help the pain...

The OP has some good legitimate questions. Back off PC police.

[heron, ASN, RN]

Folks, please read up on pseudoaddiction and the difference between addiction and tolerance. It may well be that this person with sickle cell is indeed a vulnerable personality that has developed an addiction on top of his physical illness and pain ... but I have seen little critical thinking on differentiating the two on this thread. At least decide whether you're treating pain or an addiction.

I'll spare you all my war story about the 35 year old sickler who first sparked my interest in pain management back in the seventies ... let me just say that these power struggles over pain meds make me see red!

[leslie :-D]

Although I don't approve of the patient tampering with the pump.....I'm must say that sc is a very painful disease!!! When sicklers go into to a pain crisis the pain is unbearable. My daughter has sickle cell disease and I've seen her in so much pain that morphine and other pain meds just didn't begin to take the edge off her pain. Let me also add that every crisis is different. She's bben in the hospital for pain crisis for a month at a time.....her minimum stay is atleast 2 wks with majority of the stay still having pain at the rate of a 9. This is a horrible disease that takes a toll on each patient very different at times. Although I'm not sure about the background of the sickel cell patient that you posted about I do know that there is a possiblility that this patient is not addicted and is just truly going into crisis that often. For a long while my daughter was going into the hospital every month. My daughter had an exchange transfusion in October ....most of the time that last for 6-9 months before she need a regular transfusion...but at the begin of this month I had to take her to the ER for a bad pain crisis and this hospital stay was a few days over 2 wks ...and in that time she had 3 transfusions...which was something new....but the crisis she was in kept sickling the blood it seems as soon as it went in...the blood didn't last long at all....and she stayed on the morphine pump until the day she was discharged...her pain only became tolerable...never really totally going away like it usually does. Sorry for the long post...just wanted to say the patient may really be in that much pain that the meds are truly needed.

i appreciate you sharing your story, tink.

until one has experienced scc, i'd seriously encourage all to withhold judgment.

as with any excruciating pain, many people will want all the pain meds they can get, in anticipation and FEAR of pain returning or worsening.

it's a human response versus an addictive one.

still, pts can't mess with our pumps.

continue to document, educate, reinforce...whatever it takes.

but please don't judge.

leslie