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.
