Between a rock and a hard place (or Sedated patient deemed me uncompassionate)

[Ioreth, ADN, RN]

TLDR (cause I can't edit): Patient loopy and sedated arrived to unit, requiring lots of work to keep safe. Came more awake shortly before shift change, safe, pain acceptable, respiratory status stable. Patient fired me as an RN for the next day saying I was incompassionate and didn't manage pain. Management says I should have given more pain meds.

Long version (story time!):
I work on a post-surgical floor that also gets a fair bit of non-surgical patients. Hospital was at capacity and we were being pressured to take more patients while the charge RN was trying hard to keep beds open for our surgicals. Meanwhile, PACU was being slammed and out of room. It was a mess waiting to happen.

I already had a full load and took report on a patient coming up to us from PACU. Report was unremarkable. They mentioned that they had trouble meeting pain needs and keeping the patient breathing, but the patient was having itchiness from the narcotics given in PACU. Again, not unusual. I live in a marijuana-legal state, and recreational MJ use really messes up narcotics effectiveness, and most of our patients won't admit to MJ use (and most of our surgeons don't screen for it). I mentally prepared to use non-pharm methods of pain control and set up my room.

Patient arrived writhing in pain, screaming, and clawing up her bed. She also was completely unresponsive to me and the PACU RNs. She was doing all this essentially in her sleep. If I could, I would rate her RASS a +2 and a -2 at the same time. Her husband was in the corner constantly asking "Is this normal?" No sir, it is NOT. 

The PACU nurses that brought her in had already fled, and I was trying my best to both get her to respond to me and improve her comfort. The CNA came in (probably because of the screaming) and asked if I needed help. I told her "Yes, go get the charge". Charge came in with one of the management RNs and we spent the next 30 minutes trying to settle this patient, who was still not responding to us and intermittently crying in her sleep. Remember that I had a full load before this patient showed up, so I was essentially neglecting my other patients until I got this one safe enough for me to leave her.

We finally got her a little more comfortable with ice packs on the surgical site and warm blankets on non-surgical sites. The consensus was that she came to the floor way too quickly from PACU and we just needed to wait out the anesthesia. I checked the charting while I was staying in her room to make sure she didn't claw off her oxygen (which she did frequently) or try to flop out of bed (slightly less frequently). PACU had her RASS at -2 when she left them. I had never seen that, at most (least?) a -1. I don't know what their criteria for transfer are, but this was odd from my end.

I was finally able to step away from this patient and check on my other patients, who all needed something, some anxious, some grumpy, some cheerfully waiting for something they should have asked for instead of silently waiting. I ran my tail off filling needs and darting back to this patient's room to ensure safety and check for improved rousal. Needless to say I did NOT get a lunch. Hell, I didn't even get to pee.

Sometime after 3 hours of checking this patient every 15 minutes or so, she started to mentally clear and was able to converse with me. Fortunately, she didn't remember much of anything of the last 4 hours. It was not a good time for teaching, but I expect to repeat teaching anyway, so I oriented her to the room, discussed medications, and filled in the gaps of my assessment now that she could talk to me. Pain wasn't bad, a 3/10 and I told her this is a good place to be as long as she can sleep and isn't afraid of movement. She got up and peed. She was wobbly, so we didn't go far. I talked about pain medication as part of my standard orientation to floor. She said she doesn't like morphine because it makes her feel weird. That wasn't the drug she had available IV, but I shrugged it off as a refusal. She was still dry heaving often, which cut out oral pain meds. Besides, her pain was manageable through non-pharm methods, so I didn't dwell on it.

At this point I mostly left her alone. CNA walked her to the toilet and into the hall, but again didn't get far. I raced time to finish the tasks my other patients needed done before the end of the shift. I continued to pop in occasionally, and she was much more stable. I was even able to titrate down the oxygen a bit. Patient was still pretty nauseated, for which I gave PRN antiemetics. I honestly don't remember discussing pain again. Before end of shift, I felt pretty proud about keeping my patient safe, getting her non-formulary home med checked by pharmacy so it was ready for next shift, checking in with the husband before he left, getting this patient ambulatory, and using all my tricks for combating nausea and pain. AND I got out on time, due to all the charting while sitting (standing) with this patient while she was still unsafe to leave. 

We did bedside shift report, which I hate doing "bedside", but I was being a good nurse example for the new hire. At one point I mentioned that she had not had any pain medications yet due to being sedated on arrival, I discussed the non-pharm methods used, and suggested that she could probably get something for pain if nausea came more under control. Said "bye, I'll see you tomorrow" and went home.

The next day the noc charge came to me and said "no matter what anyone says, you are a good nurse and you did what was right" and left without another word. Bewildered I asked the day charge (same as the previous day) what the heck that was about. She told me the patient fired me as her nurse because she thought I was not compassionate enough and didn't care about her pain. This charge disagreed and thought I did a pretty good job of maintaining safety in that situation.

Even if it was wise to give medications when she was unsafe, we were locked out of most medications simply due to that most were DCed when she left PACU (as they should be) and the ones remaining were too close in time to when they were given in PACU. After I could actually talk to the patient and get a response, I had assessed her for pain and at a 3/10 she was OK then. I probably should have reassessed pain before end of shift, but I remember her complaining more of nausea than pain at that point. 

I checked in with my manager and the manager said I should have given IV pain medication, and that I was being too cautious. I didn't really have anything else to say, but I am rather flabbergasted by this entire situation. 

[speedynurse, ADN, BSN, RN, EMT-P]

Why would you give pain medicine for a 3? IV pain medicine is generally for moderate to severe pain. There are some situations beyond your control and some people beyond common sense. Sounds like you did exactly what was right and move on that your patient is alive and well, not so sedated that a rapid response was called or some other unfortunate circumstance.

[Ioreth, ADN, RN]

1 minute ago, speedynurse said:

Why would you give pain medicine for a 3? IV pain medicine is generally for moderate to severe pain. There are some situations beyond your control and some people beyond common sense. Sounds like you did exactly what was right and move on that your patient is alive and well, not so sedated that a rapid response was called or some other unfortunate circumstance.

Exactly my thought! I don't break out the IV stuff unless that pain is at least 7/10. The manager is an RN and generally someone whose judgement I trust, but wasn't the management RN that came to the bedside to help settle this patient. She was kept in the loop and probably did talk to the patient that day, but wasn't physically there for the worst of it. She thought I should have broken out the IV stuff when the patient couldn't take orals. *shrug* Maybe the patient's pain did creep up before end of shift above a 3/10.

To be clear, we're not talking about a huge length of time. 
1400-1430 Patient to floor, Charge and management RN in room
1430-1500 Charge and Management RN leave, I stay in room
1500-1700 I tend to my other patients while checking this patient at least q15m. 
1700-1730 Patient STARTS to be more interactive and able to converse, finish assessment, get patient to toilet, 3/10 pain
1730-1900 Race around trying to finish shift like a crazy woman

[acmt27, BSN, RN]

At my hospital, they use pain parameters for IV pain meds (ex: fentanyl 50mcg q1h PRN for pain 7-10). If I rated the pt's pain as a 3 and gave that med, I'd be flagged by pharmacy. That's crazy that they expect you to give IV for a pain of 3.

[UrbanHealthRN, BSN, RN]

Pardon my lack of medical terms, but she sounds like she was still totally out of it from the anesthesia when she arrived to your unit. Clawing out of the bed, screaming, etc.....yes, that could be pain, but that could also be the other meds making her act that way- anesthesia meds, pain meds, who knows. I've seen patients do pretty weird things during procedures with moderate sedation, and it's not because they were in pain, it was the sedation meds. I think that was very prudent of you to hold off on adding more medication to the mix- you wanted to get a better sense of her baseline and see if any symptoms would worsen or improve. Don't pay attention to what that manager said- at the end of the day, it was your butt on the line to maintain patient safety, not the manager's. It's always easier to throw stones than it is to catch them. 

[Been there,done that, ASN, RN]

You sound like an excellent nurse. Patient fired you, oh well. Your manager is just trying to deflect the complaint back to you.

 I hope you had time to chart most of what you did. Pain scale 3/10 when you signed off should do it.

 

[JKL33]

I wasn't there so take my comments for what they're worth. ?

- From the sounds of this I'm not sure I would've assessed it as a straightforward situation of uncontrolled pain

- Patient shouldn't have left PACU in this condition

- I probably would've called anesthesia; I don't think it's appropriate nursing functioning to have things fairly out of control without at least notifying the responsible provider(s).

 

17 hours ago, Ioreth said:

The next day the noc charge came to me and said "no matter what anyone says, you are a good nurse and you did what was right" and left without another word. Bewildered I asked the day charge (same as the previous day) what the heck that was about. She told me the patient fired me as her nurse because she thought I was not compassionate enough and didn't care about her pain. This charge disagreed and thought I did a pretty good job of maintaining safety in that situation.

I am not sure I would've even passed this on to my coworker (you) if I were in these nurses' positions.  There are some things that just aren't even worth it, IMO. I'm sorry they bothered you with this.

 

17 hours ago, Ioreth said:

I checked in with my manager and the manager said I should have given IV pain medication, and that I was being too cautious.

Well, she wasn't there and that doesn't sound very insightful.  Now you know not to ask her opinion again.

Learn whatever there is to learn from this and let the rest of it go. ??

[LibraNurse27, BSN, RN]

I started working in PACU 5 months ago and even I can tell from the story it was too soon to transfer to the floor. Pt was still coming out of anesthesia, and that can require 1:1 observation or even more than one nurse if pt is thrashing/very sedated/airway support. That wasn't cool of them to dump that on you. Some PACU pts get TONS of meds and that needs constant monitoring to make sure pain is controlled but that vitals are still stable. I had a pt today who got 10mg oxycodone, 150mcg fentanyl, 2mg dilaudid, plus a Norco when all that STILL wasn't enough. Her vitals stayed good otherwise I wouldn't have given so many meds, but there is no way I could have done all that on the floor with other pts. 

[Nunya, BSN]

In my experience, I take what a charge nurse says about clinical skills/decisions/management more to heart than what a manager says.  You did fine, don't worry about it.  Sometimes being "fired" is a blessing in disguise.

[JadedCPN, BSN, RN]

Once again, the previous posters have offered some excellent insight which I completely agree with. And the fact that it was only 2 hours between when the patient rated their pain a 3/10 and when you gave report, I wouldn’t have went back to reassess pain unless the patient called out. It sounds like you did an amazing job in a situation you shouldn’t have been placed in. Honestly you probably could have filled out an incident report about the patient being transferred too early from PACU. 
Assuming all your charting accurately reflects everything as it went down, don’t let this weigh too heavy on you. You did great.

[DesiDani]

Nursing world is the Twilight Zone. People think that since you are safely managing their conditions you are cruel. While the admin who comes around with a checklist and promises them a cheesecake without knowing the patient is diabetic with a blood sugar at last accu-check  of 500 is seen as compassionate.

I always say I care because I am still here taking care of you despite your insults.

[Mavnurse17, BSN, RN]

Some shifts you do all the right things to keep the patient comfortable while still being safe, and it's still not enough for them.

I reflect on a night that I was a "super nurse" for my bed-bound, total care elderly patient.  I don't remember what she was there for but she was mostly non-verbal, only able to gesture what she was needing.  But I medicated her for pain as needed and performed peri-care and turns q2h like clockwork, since she was high-risk for skin breakdown.  She still had some chronic pain when she moved that was unrelieved by her PRNs, but I made sure to educate that it was important we turned her and cleaned her appropriately.  All this to say, I finished the shift feeling like I'd performed stellar nursing care.  I went to say goodbye to her and told her "I hope I was able to make you comfortable last night" and she mumbled back, "No, not really."