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Discussion

Any advice, PLEASE

I received my license iat the end of July. I work on a very busy med-surg unit, high acuity patients. For the last three days I have had the most frustrating days as a nurse. Had a patient with pancreatitis, plus hx of pain issues and drug seeking. On scheduled ms-contin. However, md wrote orders for prn's- 50 mg benadryl iv q 4, 5 mg morphine q 4, 5-10 mg morphine iv q 4 for breakthrough pain, 1 mg ativan iv q 4, . The guy kept a log of when all his prn's were due. So q 4 , he would either ring the call light, or walk the halls to tell me that his breakthrough morphine iv was due, or that his iv benadryl was due. The last straw was yesterday. It was 1525, I was giving report to next shift, and guy wants his benadryl. Nursing assistant says guy and his aunt, whom guy lives with are livid and are going to file a report with the ceo because prn's have been late all day. Went into room to explain that benadryl will be given asap. Explained that prn's were not late, and that I have tried to keep him as comfortable as possible all day. He then proceeded to question me why I didn't wake him up to give him his prn's during mid-aftertoon, which totally through off his schedule. I said that I would not wake up a patient for a prn ativan if the patient was sleeping, since the ativan is for anxiety, and if the patient is sleeping, apparently anxiety is under control. Aunt belittled my nuring abilities, saying that if a prn is due at 1530, it should be given at exactly 1530. At that time it was 1540. pm nurse walked in with prn benadryl, and guy said, she is a much better nurse than you, I always get my prn's exactly on time. Well, besides prn guy, I had 2 total care patients, and a patient with escalating blood pressures who wouldn't take his meds, who only understood russian, and whose daughter accused the md of trying to hurt her father because we weren't doing more for him. Bad day yesterday. About prn guy- md aware of his whole situation. Sorry this is so long. Never been threatened to be reported before. My confidence is a little shaken. Any advice as how to handle these patients and families.

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First, I see that you did absolutely nothing wrong. Unfortunately, some people feel the need to intimidate others. It is virtually impossible for every patient to get their pain meds exactly at the same time. For example, a 10 pm med pass may have 5 patients that need meds, not all 5 are going to get their meds exactly at 10 pm. If you have a patient with unstable BP, they definitely come before a drug seeking prn-Ativan.

As you get more experienced, you'll find it easier to let it just run over.

CAJAM6, take a deep breath and relax. If his meds were ordered to be given PRN, that means AS NEEDED. If he was sleeping, he obviously didn't need a AS NEEDED dose of Ativan. I'd simply go ahead and write up a statement of what happend, in my own words, with as much documentation as I could, and give it to my manager. Just a quick conversation with her that this patient could cause you a bumpy ride. She'll appreciate knowing something about it before the patient comes to her and blind sides her with "his side" of the story. She may also have the initiative to go ahead and do a litte PI work herself and check out your documentation. (There's that nasty word again). She may also be able to give you some encouragement on what you did correctly, and maybe some pointers on what to do differently next time.

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This is what I have been doing for years when I have these kinds of patients. At the beginning of the shift, or whenever I realize I've got someone who is clock-watching, I go in to them with their med sheet in hand and a smile on my face and have a pow-wow. Together we make a plan as to when the shots and pills are going to get given to him. It's all based on the doctor's order. Then I write the times down to remind me. I don't even wait for the patient to ask for these things, I just pour them and take them in to this kind of patient. It solves the whole problem of trust, complaining and light-ringing. I don't have to like this and I don't feel like I'm selling out. There isn't really much of a choice and it makes my shift go so much smoother and without this person having a tantrum that I don't need. I also will poke my head in an hour or so later and inquire how the pain med is working. That will give this kind of patient the security of knowing I am concerned about his comfort. I will often pop in before the next dose is due and let them know I didn't forget about it and I'll be back with their pain med in a bit.

cajam6, You did your job perfect!! Don't worry, you just had a PIA patient and family. Unfortunately there are too many of those around. With more experience, you will learn how to deal with them. You can also ask your charge nurse to speak with him and his family. Sounds like you are going to be a great nurse.

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