You make the decisions on YOUR shift and I'll make the decisions on MINE - page 3

by CrazierThanYou 7,476 Views | 49 Comments

Here lately, I've had a couple of situations where the oncoming nurse didn't agree with choices I made on my shift regarding patient care. Usually, it is regarding pain medication. In nursing school, I was taught that it... Read More


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    Just a little background I work on Med/Surg-Tele unit which at my hospital is designated to get all of patients receiving inpatient chemo. We by far use the most pain meds of any floor in the entire hospital, and nearly as much as rest of the hospital combined. If you exclude OR, PACU & ED we use more than the other 5 floors combined. We're a 30 bed unit and the hospital has 186 beds, just to put it in perscpective.

    I have had the Cervical CA patient's who are getting 3mg of Dilaudid every 6 minutes with a 55mg 2 hours lockout on a PCA, because we can't set the settings any higher. But I have also had the patient that has a uretal stent that rates their pain 10/10 and I proceed to give them their ordered 1mg Dilaudid IVP. As I'm pushing said medication into the most proximal site with fluids running at 100ml/hr the patient looks at me and states "Would you like me to rate my pain now?" I of course reply "Yes." She answers with "It's a 0 now. Thanks!" and proceeds to smile and wink at me.

    Don't get me wrong I will never deny a patient pain meddication. But it certainly can be frustrating. There are times that I feel like a legal drug dealer. But I won't hold pain medicine, I've even asked for patients to get more pain medication when I personally don't believe they are experiencing any pain.

    We as nurses have to set aside our biases and remember who comes first. I'm glad to see this isn't something that only nurses I know have diffulty with.
    MLB4 likes this.
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    Quote from umcRN
    A year and a half ago I walked into an ER with a known brain tumor (diagnosed by MRI and the initial doc I saw thought it was too complex for his system to treat so he sent me to the closest large neuro center). I'd been having 10/10 headaches for MONTHS, nothing touched them. Part of this is my fault, I thought I was over reacting, that it "couldn't hurt that much" so I did not do a good job expressing the severity of the pain when I saw my primary, my dentist, my ophthalmologist - I was trying to see anyone to help me with the pain, but I didn't scream loudly enough apparently for anyone to take me seriously. Every time I would get a headache I would vomit from the increased ICP and pain. In the ER I waited 10 hours to get anything for pain. Every time someone asked I said it was 8 or 10/10, I vomited multiple times, and no one came to me with anything. Yes, when I wasn't puking my brains out, I was trying to distract myself with a game on my phone or talking to my friend who came with me. I guess I didn't look to be in enough pain to warrant any meds. Pain is subjective and people shouldn't have to get to the point od screaming and crying before their pain is managed.

    OMG, really, this is so true. I know there are drug seekers, but that is not what was described by the OP, and I think we have to be really careful with making judgments about other people's pain. I had some tough labor, but I was not crazied out, and I was stubborn enough to not want to scream and yell and scare other moms that were laboring. The contractions were measured as off the wall, but they were something I could deal with and still stay focused. OTOH, I have had vascular headaches/migraines that brought my BP to increadibly dangerous levels, and nurses and doctors still ignored it, b/c I was NOT screaming in their faces.

    umcrn, I hope you are doing well, and I so sorry that you had to endure any of that. It's a peeve of mine. Not everyone is drug-seeking--especially if they don't have a history, and if there is a real potential for some serious health issue/s. Both my parents were seriously under-treated for pain when in the hospital with serious issues. You don't want to get all crazy like Shirley MacLaine in Terms of Endearment; but the idea of your loved one, a friend, or really any patient suffering needlessly is hard to take.

    I don't believe any nurse or physician should allow other patients to "ruin it for others." Patient A's pain and their ability to deal with it may be worlds apart from Patient B. It shouldn't even come into consideration IMO. You assess and re-assess and evaluate based on all the data and the whole picture. But there;s another person above that is right also when he or she suggests that the pt's pain was not being properly managed in the first place--ithat is, n terms of a pain -mgt regime.

    All you need is to be wrong one time in terms of under-treating serious pain. It's not worth it to me to take on the role of judge and jury. And usually those that are trying to get over end up showing their cards in time.
    Last edit by samadams8 on Mar 27, '13
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    Quote from Jenni811
    i just don't like when patients take advantage of the system. 90% of them rate their back pain a 10/10. Majority of the tim ei want to be like "well if you would listen to me and get off you're arse and move a bt maybe you wouldn't be so cramped up and constipated" When someone tells me their pain is a 10/10 im thinking burn patients, or a woman in labor. Not someone who is comfortably enjoying a glass of choolate milk and a cheeseburger snuck in by family. i once had a patient who rated his pain an 8/10, was in for back pain. The guy would SCREAM out in pain when it would come on. He was so considerate, he asked me to shut the door so the others couldn't hear him scream. I gave that guy everything under the sun that i could. i fought for certain pain medications.

    Its the patients who do not act like that and rate their pain a 10/10 and tell me "im doing nothing to control their pain" I know pain is what the patient says it is...but come on, lets get real here people. So whatever, I guess im "one of those nurses." I'll control your pain if it is there, but if you are laughing, eating cheeseburgers, visiting on the phone, texting, sitting on facebook then no i'm not going to control you for a 10/10 pain.
    So what do you tell these patients? "Sorry, you don't look like you're in pain, so you aren't getting anything for it?"

    There are people who milk the system. Doing what you do won't fix the system, though. Besides, there will *always* be a faker. It isn't worth your time to figure out who that faker is. Give the meds if ordered, and move along with taking care of sick people.
    sharpeimom, MLB4, redhead_NURSE98!, and 9 others like this.
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    Someone freaking out over you giving 1 mg iv morphine? Think I've been working in burn for too long...
    /routinely gives 300 mcg of fent, 4 of versed for minor dressing
    changes
    //we make a lot of narc addicts on my unit
    ///not my place to judge
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    I agree with the PP. 1mg of morphine is nothing. What the big deal? I have given babies more narcotics than that.
    sharpeimom, joanna73, sapphire18, and 2 others like this.
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    That's when I would have had to have beaten back my sarcasm ("I obviously thought it was a *terrible* idea"). Don't worry, I would have only thought it as sarcasm while fun, isn't very constructive.

    It is true that perhaps your relief needs some reeducation regarding pain management. Heck, reeducate the whole floor, it couldn't hurt (muahaha pun!). Ahem, not everyone has been reeducated about pain management and still believe much of the false info there is floating around about narcs (some of that false info was actually taught in nursing school before we knew better).

    I'd rather not take the risk that the person is just drug seeking than not treat someone in pain (hint: cancer patient is probably not drug seeking).
    nursel56, samadams8, tewdles, and 1 other like this.
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    @Jenni811
    My diagnosis was "downgraded" from MS to Transverse Myelitis. My symptoms are a feeling like some one is inflating the disks between my L 2-3 and 4 vertebrae, a huge maddening balloon of pressure. I wake up with tingling in my legs from the knees down and by the end of the day it goes to the feeling you get when your face is starting to wake up from morphine. Pins and needles. My feet, after an hour of being on them, feel like I'm standing in two buckets of 120 degree water. I know the specific temp, because until I get my license, I'm washing dishes in that hot of a water. After 7 hours its more like 130 degrees and feeling like a bone or two is fractured.
    How do I measure my pain on a scale of 1-10. On a good day it is 5-6, at the end of a work shift,7-8. On a bad day...its a 9/10 and I can barely bring myself to set my feet down, but I don't have a choice. For me 10/10 means...I can't put my feet down. Lately I've been nudging that end of the scale.

    And no..I'm not going to be moaning and limping and crying. I'll be sitting there cracking jokes, talking on Facebook and if I can ,be up and walking. Why? Because it fooking HURTS ya numbwit..and that's how I deal with my pain. Doesn't it mean I don't need pain relief. If my pain has driven me in desperation to a hospital..you can bet your sweet bustle I'm hurting.

    And I'm one of those patients that has a terrifically HIGH pain resistance. It's called pain agnosia. People who are in chronic pain for a long time learn to put it out of their minds. Often associated with child abuse, and child abuse survivors learn not to express their pain...ever.. So no I'm not going to scream and moan...I don't cry. I worked 8 hours at a nursing home with an unset broken wrist because they couldn't get a replacement for my shift. I broke it riding my bicycle into work. When I wasn't pacing the breakroom, I was helping on rounds because in that home LPN's turned patients and ran lights.

    When I'm in pain, I'm not a nice..sympathetic patient worthy of your tenderness...I'm the guy who won't ride the call light, won't make a sound..eat his sneaky cheeseburgers and laugh on facebook cause it's all I got... because I got you for a nurse...and I won't get anything for pain relief until the decent one from the next shift who bothered to get a pain assessment history gives me the medication I needed on YOUR shift, but you were too busy being judgmental to get a decent history and give me something for pain.
    Last edit by JasonValentine on Mar 28, '13 : Reason: refer to specific poster
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    As I've gotten older and wiser I've found that it is NOT worth a power struggle, or judgement.
    I sit down with the patient with pain issues at the start of my shift, talk to them, assess their pain, history, etc, and make a plan. Do you want to be given the meds if you are asleep and they are due? Sometimes I would write their dosing times on the whiteboard. Explain, I will do everything I can to be on time, except if there's an issue with another patient, and deliver their meds as on time as possible.

    And if I think they're really legitimately under-medicated we make a plan to try the current regimen and then I call the doctor and advocate for more relief.
    And then the patient is happy, not on the call light as much, you are happy, and the shift goes well. And hopefully you made a difference by listening and respect for them.
    And I do the same thing for patients I judge as "seekers" - if the doctor wrote for it Q2 then you'll get it, no skin off my back. I worked the floor for many years and am now in ICU.
    But I'm always running late and behind because I spend time doing this type of nursing!
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    I feel bad for not only the patient, but whoever follows the cranky, I'm-not-going-to-give-pain-meds-unless-you're-screaming nurse. They're going to be playing catch up all shift to get the pain under control!
    sharpeimom, MLB4, WunMsJayLPNtoRN, and 8 others like this.
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    Pain is whatever your patient says it is. As long as their vitals are within normal limits for their particular baseline, I will administer the medication.

    I will also incorporate a regular dosing schedule into their plan of care and advise Drs and oncoming staff. We have no right to judge, and someone who rates 10/10 may be a 3/10 for someone else.

    That's why pain is subjective. Who are we to decide to withhold pain medication? What purpose would this serve? I'd much rather try to ensure the pt enjoys a better quality of life.
    sharpeimom, nursel56, MLB4, and 3 others like this.


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