new nurse needs advise to deal with difficul pts

  1. I am a new graduate. I have being working for a community clinic for the last 3 months.
    We get a lot of patients that are in pain meds for example I had one today that needed refills on
    Ultram (tramadol)

    He broke his back 7ys ago and has being taking those meds since them. The MD (new MD for the patient) decided to refill only Ultram and flexeril and sent him to a pain management doctor.
    The pt was very upset because he also wanted his vicoprofen. The worse part is this MD always send me as messenger to tell this pts that certain pain killers Rx won't be refill by the MD, so I am the one that has to deal with their fit.

    Since I don't have experience dealing with long time user pain killers pt's. I am not sure if it was a good idea to get this pt out of vicoprofen. What I understand ultram and vicoprofen taken at the same time seems to be kind of a lot!

    I will appreciate your advise
  2. 13 Comments

  3. by   rn/writer
    It isn't your job to evaluate the doc's recommendation or to try to explain the doc's rationale to the irate patient. Neither is it your job to placate someone who is upset about not getting a refill on his pain meds. A patient who has been on a particular regimen for seven years is not going to be happy about having it changed against his will. That just goes with the territory.

    It IS your job to develop good boundaries that allow you to treat the patient with courtesty while still sticking to the doc's plan. "I'm sorry you didn't get what you hoped for. Here is the phone number for the pain management clinic."

    Do not engage any further than that.

    "I need my meds. No one else gives me a hard time about getting a prescription."

    "Sorry about that. You'll have to contact the pain management clinic."

    "You just don't care. Nobody cares because I'm (old, black, on Medicare, disabled, Martian, made out of macadamia nuts, etc.).

    "I'm sure it seems that way. I'm sorry I can't help you."

    "Just let me see the doc."

    "You'll have to contact the pain management clinic."

    And so on.

    If you have access to security, have them on speed dial. Otherwise, if threats are made or the patient won't leave, call the police.

    YOU need to have a good sense of where the lines are drawn. It would be nice if the doc came out and did his own dirty work, and you can ask him to do that with someone who won't leave, but ultimately, the patients will size you up and see if you're too worried about being nice. They will push you around if you let them.

    The only way to win is not to play. Repeat the mantra ("you'll have to call the pain management clinic.") fifty times if you have to, but the minute you try to convince an angry patient about anything else, you've already lost.

    Google, "assertive," and you should find all kinds of tricks and techniques for standing strong. I wish you the best.
  4. by   Karl Farmer
    It is not your place to have to tell a patient what will or will not be prescibed- you are being taken advantage of, and placed in a vulnerable position (as in taking the brunt of his rage) by a lazy physician.
  5. by   topacio
    thanks karl and rn/writer. Tomorrow it will be another day. I will start to handle this kind of situations in a better way.
  6. by   cclear2020
    Focus on what you can do for the patient:
    I can hand you a RX for these two medications.
    I can provide you with a referral that the MD recommends you go to for follow up and the Vicoprofen.

    Then after the reaction:
    you repeat the above again, and again. keep strong eye contact, no fear, the decision as you can say, is by the MD. This is the solution. and if the patient disagrees, then the new rx may not be able to be given at all. and ask, do you want the MD's recommendation? or leave today with a plan you feel is better suited for you situation. Again, strong voice.
  7. by   cclear2020
    Quote from Karl Farmer
    It is not your place to have to tell a patient what will or will not be prescibed- you are being taken advantage of, and placed in a vulnerable position (as in taking the brunt of his rage) by a lazy physician.
    If the RX was for all the patient's requested meds, then of course the RN would take this on. Though unfortunate to have to deliver bad news, the RN is there to do the discharge teaching, and with confidence explain the discharge plan. Otherwise you might make the argument that the RN's job is not to deliver the discharge RX or review the plan on cases where the patient might get mad.
  8. by   Karl Farmer
    I disagree totally. The scenario indicates that the physician was NOT forthright when he was in direct contact with the patient, which leaves the other staff to take the abuse.
  9. by   cclear2020
    You mean an MD would leave the RN to do the dirty work?? there are many situations that will require the RN to take the lead, when the MD has left behind holes. I guess I did not feel that the MD was not "forthright" and we do not know that the conversation was really "abuse". My goal is to overall empower the RN to push forward, with the teaching,
    Here is the RX. What did the MD tell you? Here is what I understand.
    If a new nurse simply punts the ball back to the MD everytime there is a perception of non-forthright MD behavior, then you may not ever improve on speaking with patients on difficult matters and the MD may fire you.
    In my solution, you may need to get the MD involved who probably will not come back to the room, so do your best as the RN to do your job, teach on the discharge medication and plan, probe more as to why the vicoprofen is so important or why the patient can not see a pain specialist? (ie insurance issue, dependency).
    Don't give up the ship just because the captain steers you in the wrong place.
  10. by   Karl Farmer
    If a patient wanted an RX, and did not get it- that is certainly not the job of the nurse to placate an irate patient. The phsyician is the prescriber. Fact.
  11. by   cclear2020
    Then who in the real world's job is to give the rx to the patient whethere they are happy or unhappy about it?
    At your clinic, it is the MD's job to placate/deal with irate patients?
  12. by   Karl Farmer
    If a patient is not happy with what is prescribed, the physician is at fault for not doing his job and being professional. Shameful to let him allow a patient to walk out and take out his anger on anybody else. I think it's a throwback to the days of 'Florence' to be treated with such disrespect.
  13. by   caregiver1977
    Some people are going to be upset no matter what you do or what explanation you give them if they are not getting what they want. However, people might respond better if they are given a decent, clear explanation why they are not receiving a prescription for the medication they have been taking for the last seven years, etc. I think the patient deserves that.

    If he/she can't accept that then maybe it is time for them to seek their health care from another provider (I had to do that myself recently, but not for pain meds).
  14. by   beckster_01
    Did you try asking the MD for a specific answer on why he stopped the medication? Something a little more detailed than "I am uncomfortable with that drug." Make the doctor tell you what makes him uncomfortable with it, if the patient has been using it for long term therapy and hasn't had adverse effects yet. Does s/he think that the pain service can find a more effective therapy? How long will it be before the patient has access to the pain service? Ask the doctor if there is a way he can prescribe enough of the drug to last the patient until they can get to their appointment so the patient isn't left out to dry...