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?

[leslie :-D]

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.

easy enough to get parameters from the dr.

i would also advise a psych consult.

leslie

[canesdukegirl, BSN, RN]

OP, I had a very similar situation. I cannot even begin to understand the pain of SCD, but my patient was extremely abusive to the staff, throwing things at the nurses if her demands were not met, throwing things at the doors or into the hall to get someone's attention. I realized that much of this behavior stemmed from fear, so I asked her doc if he thought a visit from the hospital staff's spiritual counselor would help. The counselor came and spent a while with this pt. She did benefit from his teaching about guided imagery and alternative ways to deal with her fear.

Every SCD pt is different. It is hard to deal with sometimes.

[cherrybreeze, ADN, 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!

Thank you for posting this; as I was reading, I was formulating the same type of answer in my head. While I can't and won't make a judgment on whether or not this patient is addicted (and I also don't approve of the pump-tampering, no matter what), there is no "ceiling" dose on narcotics like there is on something like Tylenol, so people on long-term and/or high-dose opioids can handle a LOT without depressive side effects. It absolutely does NOT indicate addiction or misuse by itself, tolerance will develop no matter what, and a patient will go through opioid withdrawal when meds are stopped, even when taken by the letter as prescribed.

All you can do is document, really. And defer to the pain specialist; they know what they are doing.

[cherrybreeze, ADN, RN]

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.

14 is a normal respiratory rate, I wouldn't call that depressed. I know in patients with epidurals and PCAs, our protocol calls for calling the doc/giving Narcan for a RR of 9 or less (I realize every facility will handle things differently). For me, though, 14 doesn't raise an alarm.

[heron, ASN, RN]

Back off PC police.

It's not about PC ... it's about critical thinking and a reasonable knowledge base. Is the OP treating sickle cell pain or an assumed addiction? Are the patient's behaviors a result of addiction or pseudoaddiction or some other comorbid mood disorder? Or is he responding to staff behaviors? If the patient is indeed addicted as well as in severe pain, what is the best way to address the pain without enabling the addiction?

No way do I support abusive behavior by anyone toward anyone, but if I were in the position of being in severe pain and dependent on staff for relief, I might get a little testy myself if the staff was more concerned about whether I was getting high than with relieving my pain.

I've often said that nurses need our own version of Al-Anon to cope with the stress of dealing with drug-seeking behaviors, starting with clarity on the reasons people learn these behaviors in the first place.

So ... back off morality police.