ANA code question... please help

ginger58, ASN, RN · Apr 20, 2007

Having worked palliative care I'd say A&D. Give the max ordered and call the doc. Morphine has no max dose in reality. One doesn't know if the patient is truly a drug abuser and maybe she was due to her pain not being relieved. As long as one isn't giving the drug to hasten death it's OK to give what the pt needs for comfort.

Home Health Columnist / Guide · Apr 20, 2007

d is most correct answer answer; if multiple answers then a+d

ana. (2003b). position statement: pain management and control of distressing symptoms in dying patients. retrieved april 20th, 2007 from http://www.ana.org/readroom/position/ethics/etpain.htm

tolerance may develop especially in those with prior narcotic drug use, so need to contact pcp for increased dose to meet patient goal of pain relief important in this situation. agreed morphine has no ceiling. seen 20mg/day to 250mg/hour in those with cancer pain.

loricatus · Apr 20, 2007

I would say D.

The key in this question is in the intent. The intent is to alleviate pain, the by-product of pain relief MAY hasten death; but, the intent is not to hasten death. I say D because there is no mention of hastening death, since it should not be a consideration in the decision to appropriately medicate the patient. The pain is supposed to be whatever the pt. states it is, without judgement on our part. If the pt was a drug abuser, then the only consideration we are supposed to make is that his tolerance/need will be for a greater amount to obtain relieve.

Proverbs 16:3 · Apr 20, 2007

Thank you soo much. I really really appreciate your input.

Daytonite, BSN, RN · Apr 20, 2007

I would do "A". Having been a cancer patient myself, taking care of my mother who died of mets to the lung, and taking care of hundreds of cancer patients over the years I have to say that the fact that the patient has a history of drug abuse doesn't bother me in the least. If anything, I would be advocating for more medication if I felt the patient needed it. You can tell from the physical signs that the patient exhibits. The history of drug abuse shouldn't be held over the patient's head as a punishment for giving them relief of pain when they really need it. But, you know, I've seen nurses do just that and I would have liked to have horse whipped them. It's like the story of the boy who cried wolf. I refuse to be put in the position of making that kind of decision. I'm not the judge and/or jury for his past actions. If there is a doctor's order for the pain medication, the patient is asking for it, then he gets it from me, no questions asked. The fact is that the doctor knows the patient and his needs better than I, as his nurse, do. If I want to get reamed a new one I could call the doctor, but not in this case. I'd feel comfortable giving this guy the maximum dose. And, I would hope that if I ever end up with cancer again and am in the position of needing pain medication that I would have a nurse that would be just as compassionate.

ginger58, ASN, RN · Apr 21, 2007

" The fact is that the doctor knows the patient and his needs better than I, as his nurse..." Sorry, but I don't agree with this at all. One never knows what a patient needs until the patient is going through the pain and the nurse is usually the one to determine if the patient's pain has been relieved. Docs aren't at the bedside like the nurse. Most docs ask the bedside nurse about the pain level and there is mutual input or in most cases the docs listen to what the RN wants for the patient.

Daytonite, BSN, RN · Apr 22, 2007

" the fact is that the doctor knows the patient and his needs better than i, as his nurse..." sorry, but i don't agree with this at all. one never knows what a patient needs until the patient is going through the pain and the nurse is usually the one to determine if the patient's pain has been relieved. docs aren't at the bedside like the nurse. most docs ask the bedside nurse about the pain level and there is mutual input or in most cases the docs listen to what the rn wants for the patient.

i sincerely hope that if you ever find yourself sick and hospitalized that you have better respect for the talent and capabilities of your own physician. i trust my doctor and feel that he knows me and my needs far better than any of the nurses. the doctor is the one who is in charge of the patient's case, not the nurse. i'm a nurse and i never forget my place in the healthcare hierarchy. doctors, like nurses, are taught to collect and analyze data before making a medical decision. their data collection involves querying the bedside nurses for data, but it's not the only factor that goes into their thinking. listening to a nurses' suggestions of a patient's needs is purely polite courtesy on the doctor's part. doctors have no obligation to take the suggestions of any of us. it's pretty conceited to believe that the data provided by the bedside nurse might be the deciding factor that results in the doctor changing a patient's dose of pain medication.

crystalcoastlvr, BSN · Apr 22, 2007

i sincerely hope that if you ever find yourself sick and hospitalized that you have better respect for the talent and capabilities of your own physician. i trust my doctor and feel that he knows me and my needs far better than any of the nurses. the doctor is the one who is in charge of the patient's case, not the nurse. i'm a nurse and i never forget my place in the healthcare hierarchy. doctors, like nurses, are taught to collect and analyze data before making a medical decision. their data collection involves querying the bedside nurses for data, but it's not the only factor that goes into their thinking. listening to a nurses' suggestions of a patient's needs is purely polite courtesy on the doctor's part. doctors have no obligation to take the suggestions of any of us. it's pretty conceited to believe that the data provided by the bedside nurse might be the deciding factor that results in the doctor changing a patient's dose of pain medication.

seriously! are you kidding me. i have to agree with the previous poster who said that nurses at the bedside tend to understand their patients needs more. nurses do not have the knowledge of the physicians, however it is not just a "polite courtesy," to listen to our suggestions! a patient needs a team of healthcare professionals, which includes the physician, nurse, respiratory assistant, physical therapy, etc. data such as s/s of bleeding the nurse assessed in a pt on an anticoagulant would be just one example of many, when a physician would utilize a nurse's skills and knowledge in order to determine what he/she needs to do next. like order more labs, change med levels, whatever! seriously! i may just be a nursing student in my last quarter, but come on!

jules

Daytonite, BSN, RN · Apr 22, 2007

Seriously! Are you kidding me. I have to agree with the previous poster who said that nurses at the bedside tend to understand their patients needs more. Nurses do not have the knowledge of the physicians, however it is not just a "polite courtesy," to listen to our suggestions! A patient needs a team of healthcare professionals, which includes the physician, nurse, respiratory assistant, physical therapy, etc. Data such as s/s of bleeding the nurse assessed in a pt on an anticoagulant would be just one example of many, when a physician would utilize a nurse's skills and knowledge in order to determine what he/she needs to do next. Like order more labs, change med levels, whatever! Seriously! I may just be a nursing student in my last quarter, but come on!
jules

I have two relatives who are physicians. One a family physician, the other an internist. Both are married to nurses. They will both disagree with you and probably say something like "and where did you get your medical degree?"

CRNI-ICU20 · Apr 22, 2007

Daytonite,

I work with at least 600 doctors at my hospital. I have never been listened to as a 'courtesy'. I have been collaborated with, encouraged to give my input, and thanked hundreds of times for 'catching' something they had forgotten or not thought of. Here's an example: we had a pt. who was admitted to the ICU and had been given Narcan AND Romazicon for what was thought to be an OD of narcs. But he would still doze off, lose his sat....and then wake up just flailing and wild, and crazed....his eyes were glassy, and he had to be restrained to keep him from clocking one of us in the head! His doctor was completely baffled by his bizarro behaviour....

I suggested, "did they do a tox screen in the ER?" He said, "I don't think so..." He asked me why....and I said, he acts to me like he's been doin' some coke....just his other symptoms, and the fact that he had some nasal ulcerations....sure enough, he was high on cocaine....and put himself into an MI....so, you see, maybe your family members have a different view of what a nurse does, or is....(a person without a medical degree, ie, doesn't have as much education...ect.) but, they don't speak for the 600 drs. I work with, nor do they speak for the hundreds of others that I have had the fortunate pleasure of working with across 30 years....(I was a scrub nurse in surgery for 13 years before I became an RN). I have had docs call me and say, "Oh, I am so glad that it is you who is caring for Mrs. so and so....now I can go home and sleep tonight!"....I consider that a very high rated compliment, and they know that if anything looks untoward to me, they definitely will get a phone call....and no, they don't ever mind educating me, or teaching me, or answering me when I have a question....

I guess my experience has been different than yours.

I would agree that their views often encompasse a huge variable of factors....some of which many nurses may not have thought of....but I have yet to meet a doctor who is not interested in "how is mrs. so and so doing?".....they welcome my opinions, views, and suggestions...and I think it is because I am at the bedside....

I recognized long ago that I am their eyes, their touch, their ears, their voice....and I don't think I am 'less than' because I didn't get a medical degree....I think that I am really 'more than'.....because I am both a nurse AND the one who stands at the bedside and carries forth the doctor's orders....without me, his medical degree would collect dust, because he couldn't do all that I do for his patients daily and still have time for all his other stuff....

If I was ever asked that question by a doctor in a condescending manner, I might just be tempted to ask them where they got their nursing degree.....

and when they say, "I don't have a nursing degree!"

I would then say, "EXACTLY!, NOW GO ANSWER YOUR PATIENT'S LIGHT, WILL YOU?"

:smiley_ab

ginger58, ASN, RN · Apr 22, 2007

I have two relatives who are physicians. One a family physician, the other an internist. Both are married to nurses. They will both disagree with you and probably say something like "and where did you get your medical degree?"

I don't really think you've worked in a setting where nurses are specialized in making decisions, based on orders, to keep a patient comfortable. I have to determine at the bedside that my patient is getting enough, or the correct medicine, to help them achieve comfort.

Don't really care about what your relatives have to say. I know our physicians value our input and often pain issues are dealt with over the phone so he/she has to listen to our input and usually a mutual decision is made. Often they ask what we'd like to do. It hasn't been until recently that docs have HAD to take courses on pain management because it's sorely missing and misunderstood.

I am practicing nursingwithin my scope of practice. If that bothers you than I feel for your patients, because I am a patient advocate.