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

PRNketamine · Mar 28, 2013

I agree with the PP. 1mg of morphine is nothing. What the big deal? I have given babies more narcotics than that.

tnmarie · Mar 28, 2013

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).

JasonValentine · Mar 28, 2013

@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.

07302003, ASN, RN · Mar 28, 2013

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!

tots24 · Mar 28, 2013

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!

joanna73, BSN, RN · Mar 28, 2013

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.

FlorenceNtheMachine · Mar 28, 2013

I think this has been an interesting and enlightening discussion. I know I can't control how people "milk/abuse" the system. It would burn me out to a crisp trying to right all the wrongs of the healthcare machine. At least as a nurse in acute care, you know exactly who is receiving the pain medicine, and that it's not being sold to some little middle schooler at a party.

What I've learned, even more, is how wildly different someone can exhibit pain. When I'm in a lot of pain, I get turn very inward, and cry quietly in private. At least that's how I was in labor. I didn't scream or wildly sob, I would get embarrassed when the nurse would come in and try to hold it in as much as I could. But thank goodness, the nurse didn't have any preconceived notions about pain, and I got an epidural and was just peachy afterwards. I had a nursing student in the room when I was getting the epidural placed, and she asked "Are you even in any pain?" because my lack of visual cues. Haha! No I'm just paying for the epidural for *kicks* and giggles.

umcRN, BSN, RN · Mar 28, 2013

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'm great! Been back at work for over a year now. Really, all I needed that night in the ER was 10 mg of decadron...worked like a charm. I had my tumor removed a week later and haven't had a headache since! One of the biggest problems I faced at the time when I was seeking treatment for my "migraines" was that I had just moved to a new state and had a new primary care doc who didn't know me and didn't know that I had no past medical history and that for me to be in her office 3 times in 3 months complaining of headaches was NOT normal for me. I was 24 years old, healthy and had no other issues. I believed her for months that I just had "migraines" and dealt with them, even though she wouldn't even give me a prescription for anything (I went through A LOT of excedrin), it wasn't until the other symptoms started popping up that I researched and found a neurologist on my own and even he confessed that he didn't think anything else was wrong with me until I told him of my other symptoms (which were flashing lights in my vision, tunnel vision and blackouts in my vision). I am thankful every day that I found that neurologist. Had I not found him and continued on my own thinking I had "migraines" I likely would have wound up in the ER with seizures or wouldn't have made it to the ER at all (my tumor was 5x6cm and my surgeon said it definitely would have killed me if left to grow).

I work in a pedi cardiac icu so except for the rare adult we get there are not many drug seekers, however we have our fair share of kiddos who have had more narcs in their short lives than the average drug seeker in an adult hospital, and keeping them comfortable is a huge challenge some days, especially when the docs don't want to keep prescribing for them.

hodgieRN · Mar 28, 2013

For pts that have cancer, they get whatever is ordered. I don't know why nurses think that limiting pain medication in cancer pts is a good thing. The only time it should be backed off is when you are trying to get them mobilized after surgery. Oncology and anesthesia order specific pain management regimens and that should be followed. There are entire courses that are dedicated to pain management of cancer pts. Nurses that try to stay under that regimen usually have never had cancer. I understand the frustration with drug seekers, but cancer is an automatic pass.

tyvin, BSN, RN · Mar 28, 2013

I've only read the OP but I want to say that some nurses won't give morphine due to their own prejudices. I've had to have prn morphine doses for people about to pass routine because the other nurse wouldn't give the shots ever, even with r/r of over 45. :no: It's disgusting to have to find patients trying to gasp for breath when the report nurse told me nothing's wrong. :banghead: At this one place I worked, when I would come on I wouldn't go to report right away, but check the patients who I knew would be needing the morphine relief. If you can't give morphine and be sensible about it don't be a nurse. The OP is talking about cancer patients for Christ's sake not drug seekers; people who need the relief. It's not just cancer either, there are multiple diseases that cause pain and then there's even a natural death that can require morphine assistance...we like to call it comfort measures.

You know who you are...and I'll call you on it every single time.

Can you tell this is a pet peeve of mine... :yes:

Guest343211 · Mar 28, 2013

I'm great! Been back at work for over a year now. Really, all I needed that night in the ER was 10 mg of decadron...worked like a charm. I had my tumor removed a week later and haven't had a headache since! One of the biggest problems I faced at the time when I was seeking treatment for my "migraines" was that I had just moved to a new state and had a new primary care doc who didn't know me and didn't know that I had no past medical history and that for me to be in her office 3 times in 3 months complaining of headaches was NOT normal for me. I was 24 years old, healthy and had no other issues. I believed her for months that I just had "migraines" and dealt with them, even though she wouldn't even give me a prescription for anything (I went through A LOT of excedrin), it wasn't until the other symptoms started popping up that I researched and found a neurologist on my own and even he confessed that he didn't think anything else was wrong with me until I told him of my other symptoms (which were flashing lights in my vision, tunnel vision and blackouts in my vision). I am thankful every day that I found that neurologist. Had I not found him and continued on my own thinking I had "migraines" I likely would have wound up in the ER with seizures or wouldn't have made it to the ER at all (my tumor was 5x6cm and my surgeon said it definitely would have killed me if left to grow).
I work in a pedi cardiac icu so except for the rare adult we get there are not many drug seekers, however we have our fair share of kiddos who have had more narcs in their short lives than the average drug seeker in an adult hospital, and keeping them comfortable is a huge challenge some days, especially when the docs don't want to keep prescribing for them.

Wow, so, so glad you are doing well. I love peds cardiac ICU! Well, except the politics. . .ugh.

Thank you for weighing in on this topic. Your input is appreciated and is powerfully true!

I know exactly what you mean re: peds cardiac ICU. How many babies do we end up having on methadone? I don't even know. Of course, not the ones that are straight-forward and staged repairs w/o complications. But there are plenty of complicated kids and situations, and it does happen more than we would like. But you have to take care of first things first.

Again, really, thank you for sharing your story. That must have been quite scary for you.

Guest343211 · Mar 28, 2013

I've only read the OP but I want to say that some nurses won't give morphine due to their own prejudices. I've had to have prn morphine doses for people about to pass routine because the other nurse wouldn't give the shots ever, even with r/r of over 45. It's disgusting to have to find patients trying to gasp for breath when the report nurse told me nothing's wrong. At this one place I worked, when I would come on I wouldn't go to report right away, but check the patients who I knew would be needing the morphine relief. If you can't give morphine and be sensible about it don't be a nurse. The OP is talking about cancer patients for Christ's sake not drug seekers; people who need the relief. It's not just cancer either, there are multiple diseases that cause pain and then there's even a natural death that can require morphine assistance...we like to call it comfort measures.
You know who you are...and I'll call you on it every single time.
Can you tell this is a pet peeve of mine...

Thank God I haven't had to work with a lot of nurses that feel this way. That would so frustrate the life out of me. I'd end up opening my mouth and. . . lol

Do you think maybe some of these nurses that have resistance to administer pain medication might have had addiction issues or something; b/c otherwise, call me an idiot, but I don't understand why you wouldn't want to relieve someone's pain and suffering. And I say that, and I'm not big on people have epidurals and so forth; but I'm not going to get in their way or help facilitate it if they want it. I just think, in many cases when in labor, you are shortchanging yourself and at times even the baby. Personally I think it's only a very, very small percentage of people that couldn't get through labor w/o and epidural, if they were in good physical shape, exercise-wise, prior to labor. That was what helped me. Uping my exercise and being in shape for the delivery. And my labors weren't easy. I'm so glad I got to have a least one the old fashioned way. And the recovery was a zillion times better than having a C-section. Course that is a whole other topic, but since pain in light of labor was brought up. Just saying, this to me is the only real exception to not being all out for pain administration. But even then, it's up to the mom to make the decision, not me. It's her labor after all.

For cancer patients, burn patients, direct post-op patients, patients with acute onset of certain conditions--even people with real and severe migraines. . .patients like those. . . well, to give IV pain meds is a total no brainer. I say if you have ever had a real migraine or headache so bad that your BP is 180/110 or you just can't see and/or you are vomiting your guts up, or if you were ever a surgical patients--like abdominal surgery or the like--unless you have ever really had pain that truly was 8-10/10, you really can't appreciate what these people are going through. Who the heck am I to tell someone that their pain is BS?! I don't have the right to even think it, IMHO, unless the patient is a known drug-seeker--and even then, you worry about the one time it may be real with them.

Those people that have a history of addiction and who are managing to stay in recovery usually ask for a non-narcotic kind of pain relief for legitimate things in the ICU or ED. In fact, we have had some folks in the ICU that really needed narcotic, IV pain mgt, even though they have a hx of addiction. It sucks, b/c you don't know what kind of cascade will take over in their lives afterwards; but sometimes you have focus on the acute or critical, and then deal with the other sequalae later. For the person that wants to stay in recovery, well, it's a big deal; but what are you going to do. You hope to get t he right people on board to help them with this after the acute or critical phase of the other prominent illness is past. It does sadden me though, b/c I have seen what this will do to people that have the illness of addiction--and their famlies. It's kind of a no-win situation that they have to get support with and fight their way through. Usually, however, if their pain isn't compromising them, in the past, we have given them non-narcotics first and tried other things. You have a lot of kids out there that have been on oxy's for a long time. . .they finally get off, and then they end up in the hospital for something, and they then get percocets, etc. I have had to have talks with them about them thinking about their choices. I tell them that I can't tell them what their pain is; but they know what they went through to get clean, how hard it was, even with using methadone or suboxone. Is the pain bad enough that you would put yourself at risk to go through that again, and would you be as success next time, as you were last time? It's a tough situation to me in if you have an addiction problem. We've gotten so used to the scourge of drug abuse and addiction, we've forgotten how absolutely horrible it is to individuals, families, and society. I know a young girl right now that is pregnant and addicted to snorting heroine. I've cried at home and prayed for this kid all week long. I can only imagine about the ultimate health of the baby, and I worry that someone will find this girl dead on the street.

But if she came in with severe trauma, burns, whatever, we'd put her at risk in terms of survival, at least I believe so, in the critical phase of her physical recovery. So we would have to give her strong pain meds. I hate what drug addiction does to people. It makes me so angry.