I am a psychiatric nurse who has been working in the field for about a year now. Today, I had a patient who complained of severe abdominal pain and had a history of endometriosis which had gotten so bad to the point where they recommended she have a hysterectomy. She was currently being medicated on Ibuprofen and Tylenol which had no effect. I knew that these would not even touch her.
Come on Tylenol and Ibuprofen for endometriotic pain?
I then contacted the psychiatrist to see if I could get an order for breakthrough pain to which she declined. Narcotics are typically not prescribed in the psychiatric setting due to how common opioid addiction is within this population. The only patient I have even had who was on opioids was my patient who was post op ORIF after having jumped off a two story building.
There is a common misconception in the psychiatric field that many patients are "faking it." I believe that pain is subjective and try to give my patients the benefit of the doubt. That being said, as a psych nurse I am not oblivious to the fact that some patients are "medication seeking."
I typically am a good judge of character, but this was not one of those moments. She was wrenching in pain to the point of tears. If she was "faking it" she was doing a really good job at it.
At this point, I decided to advocate for my patient and escalate the situation. I asked again and she [psychiatrist] continued to refuse. I then relayed this to my charge nurse and she recommended getting an order from the hospitalist because all medical issues are under the jurisdiction of the medical doctor.
The hospitalist agreed to order a one time breakthrough pain med. I told the psychiatrist what I had done and then she proceeded to berate me over the phone spurting profanities, saying I was insubordinate and said "I was being played by [my] patient."
I then escalated the issue to my nurse manager who recommended I follow the psychiatrist orders and let it go. When I asked if I did the right thing, he praised my efforts in advocating for my patient, but believed at the end of the day, the doctor's orders should be respected and followed.
I followed his advise and after all was said and done, the patient had to bear through the pain and eventually it subsided. Nursing community, did I do the right thing? Should I have done more?
All I’m going to say as someone who suffered for many years from endo, ibuprofen and Tylenol are not effective. At all. I had 6 surgeries for it, and it caused my ovaries to twist and attach themselves to my bladder. It’s much more than inflammation.
I would get horrible migraines and vomit from the pain. Percocet was the only thing that came close to alleviating the pain. The pain was awful for 2 weeks a month. My first pregnancy was what finally made it go away. But my entire twenties were miserable.
We cannot dismiss women’s pain and say ibuprofen should take care of it. I’m not saying everyone needs high dose pain medicine, but some of these responses are why many women don’t seek help when they should. They fear being told here’s some Tylenol go home and put a heating pad on it.
I then escalated the issue to my nurse manager who recommended I follow the psychiatrist orders and let it go.
At that juncture the best thing to do would be to call the hospitalist back and come clean about the problem, which is that the patient's situation had been previously discussed with the psychiatrist who did not favor treatment with narcotics for this patient. Suggest that maybe they speak to each other about the reasonable way to handle this (LOL, riiiight) and/or does the hospitalist have any other ideas for how to provide some relief. If they have another suggestion then you can let them know you'll cancel the other order. By hherrn is correct, you don't just independently decide not to do what you discussed with the hospitalist, and your manager doesn't have the qualifications to make that decision either.
All I’m going to say as someone who suffered for many years from endo, ibuprofen and Tylenol are not effective. At all. I had 6 surgeries for it, and it caused my ovaries to twist and attach themselves to my bladder. It’s much more than inflammation.
I would get horrible migraines and vomit from the pain. Percocet was the only thing that came close to alleviating the pain. The pain was awful for 2 weeks a month. My first pregnancy was what finally made it go away. But my entire twenties were miserable.
We cannot dismiss women’s pain and say ibuprofen should take care of it. I’m not saying everyone needs high dose pain medicine, but some of these responses are why many women don’t seek help when they should. They fear being told here’s some Tylenol go home and put a heating pad on it.
All you can say is that they were not effective FOR YOU. And that possibility has already been acknowledged here.
No one on this thread has dismissed this patient's pain. It is not dismissing it to say that an antiinflammatory is a first line treatment for an condition well-known to cause inflammation (including the fact that it is not going to be sufficient for everyone as already stated) or to say that a complete nursing assessment of the pain setting/context should take place...or any of the rest of it that has been said.
One of the reasons it is difficult to encourage thorough pain assessments is because there is always someone right there to make the kind of inappropriate charge you are making.
Lastly, if the thorough assessment rendered the professional opinion that the patient's pain had not been adequately treated with NSAIDS and acetaminopen, that still doesn't dictate what needs to happen next, nor does it dictate that the best plan is one that one of the specialists disagrees with.
I would think any provider being asked to manage a patient's acute pain should maybe actually, oh I don't know, assess the patient. ?
The RN assessed the patient and determined the pain level. I don't think a reputable nurse needs to have an assessment of pain verified before any nursing/medical action is taken. When you contact a physician, who is not present, with your findings, it is usually because you want them to do something about it. That being said, leap-frogging over the psych doctor's conclusion to get what the nurse really wanted to do was objectionable.
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. Come on Tylenol and Ibuprofen for endometriotic pain? I then contacted the psychiatrist to see if I could get an order for breakthrough pain to which she declined. Narcotics are typically not prescribed in the psychiatric setting due to how common opioid addiction is within this population.
This situation reminds of the kind of decision we see when a new nurse 'drunk with the power' they now have, start deciding they know better. And you know that the next nurse will have to deal with the patient asking for 'what that other nurse gave me."
Positioning, heat, distraction as well as the Ibuprofen should have been tried first and you owe the psychiatrist an appology.
The RN assessed the patient and determined the pain level. I don't think a reputable nurse needs to have an assessment of pain verified before any nursing/medical action is taken.
I wasn't talking about assessing the pain. I was talking about assessing the patient. If a patient has an acute onset of pain for a condition that is normally treated with NSAIDS but now requires a narcotic for pain control then an assessment by a provider is prudent. There could be other things going on and assuming it's just the endometriosis is short-sighted.
I wasn't talking about assessing the pain. I was talking about assessing the patient. If a patient has an acute onset of pain for a condition that is normally treated with NSAIDS but now requires a narcotic for pain control then an assessment by a provider is prudent.
I'm confused. You asked the hospitalist who ordered the pain meds but you didn't give them to the patient because the psych doctor threw a tantrum? Or you did medicate the patient per hospitalist's orders and the psych doctor threw a tantrum because you did? Also, why not call the hospitalist in the first place? And your nurse manager agreed but didn't agree? Too much going on here.
I'm still lost. So if you didn't give the order what becomes of that? And why is your charge nursing riding the fence instead of being a productive resource? Granted, she doesn't override either but fence riding instead of constructive guidance is no help to you or the patients. Where's the update or answers to our questions?
Thank you to everyone who has responded so far. Posting about this incident has helped me see this situation in a whole new light. I forgot go mention that when I had discussed this with my nurse manager, he believed that mistakes were made on both sides. We agreed that there should have been better communication between providers: nurse, psychiatrist and hospitalist. One responder made a good point, assessment could have been better. It was wrong for me to assume the cause of her pain was endometriosis. It was wrong of the psychiatrist to assume the reason for her pain was psychosomatic. For all we know, the patient could have had peritonitis, gone septic and died. Yes this is extreme, but you cannot know unless you assess for yourself. The psychiatrist did not even lay her eyes on the patient. Confirmation bias is dangerous. All in all, I do not regret what I did. I regret the way I approached the situation but if I could turn back time, I would not hesitate to advocate for my patient again. Oftentimes, we forget why we went into this field in the first place. Nursing is the caring profession. There is nothing more I care about than my patient's wellbeing. Ignore the politics, disregard the hurt feelings and broken egos, at the end of the day if my patient leaves the unit safe, healthier and better than when they first came in, we have accomplished our job. If we do not advocate for our patients who will? As another poster mentioned, you live and you learn. Again, thank you everyone for your responses. I have learned a lot! Cheers and good luck and safe wished to all!
This is the type of situation that should be discussed as a case study in nursing school or in an in service. I‘ll bet I am not the only person who thinks they would have made an even bigger kerfluffle of this. Talking about examples of good clinical judgement can go far to prepare a novice or inexperienced person so that they might start out down the right path.
Thank you to everyone who has responded so far. Posting about this incident has helped me see this situation in a whole new light. I forgot go mention that when I had discussed this with my nurse manager, he believed that mistakes were made on both sides. We agreed that there should have been better communication between providers: nurse, psychiatrist and hospitalist. One responder made a good point, assessment could have been better. It was wrong for me to assume the cause of her pain was endometriosis. It was wrong of the psychiatrist to assume the reason for her pain was psychosomatic. For all we know, the patient could have had peritonitis, gone septic and died. Yes this is extreme, but you cannot know unless you assess for yourself. The psychiatrist did not even lay her eyes on the patient. Confirmation bias is dangerous. All in all, I do not regret what I did. I regret the way I approached the situation but if I could turn back time, I would not hesitate to advocate for my patient again. Oftentimes, we forget why we went into this field in the first place. Nursing is the caring profession. There is nothing more I care about than my patient's wellbeing. Ignore the politics, disregard the hurt feelings and broken egos, at the end of the day if my patient leaves the unit safe, healthier and better than when they first came in, we have accomplished our job. If we do not advocate for our patients who will? As another poster mentioned, you live and you learn. Again, thank you everyone for your responses. I have learned a lot! Cheers and good luck and safe wished to all!
Thanks for the update and glad you had time to reflect and learn from the situation. Also, thanks for viewing our responses as constructive feedback and not as an attack on you, as some have in these types of threads.
Just take it as a learning experience and now you know how to proceed in the future. Good luck & you stay safe too!
maximum dose of ibuprofen in conjunction with acetaminophen ES will cover the same pain receptors and provide the same efficacy of relief as Tramadol w/o the narcotic side effects
even so...if the pt was experiencing that level of pain/discomfort she should have been referred back to her primary for further eval and tx
All I’m going to say as someone who suffered for many years from endo, ibuprofen and Tylenol are not effective. At all. I had 6 surgeries for it, and it caused my ovaries to twist and attach themselves to my bladder. It’s much more than inflammation.
You had a traumatic experience. It sounds awful. You still have to be objective when treating patients. When you make a blanket statement that these meds are “not effective at all” for endometriosis pain, you are generalizing and assuming that every woman’s experience is the same as yours. Endometriosis is on a spectrum (as you obviously know) and each case is individual. Percocet worked for you. That does not mean that every woman who has endometriosis should always be given Percocet. They have to be assessed (by a provider to start with) and a variety of treatments have to be considered.
It is totally inappropriate for an MD to say “Oh she’s just being dramatic, give her Tylenol” when a woman has endometriosis and is in severe pain. It is equally inappropriate to say “Her diagnosis is endometriosis so she obviously needs an opiate.”
LovingLife123
1,592 Posts
All I’m going to say as someone who suffered for many years from endo, ibuprofen and Tylenol are not effective. At all. I had 6 surgeries for it, and it caused my ovaries to twist and attach themselves to my bladder. It’s much more than inflammation.
I would get horrible migraines and vomit from the pain. Percocet was the only thing that came close to alleviating the pain. The pain was awful for 2 weeks a month. My first pregnancy was what finally made it go away. But my entire twenties were miserable.
We cannot dismiss women’s pain and say ibuprofen should take care of it. I’m not saying everyone needs high dose pain medicine, but some of these responses are why many women don’t seek help when they should. They fear being told here’s some Tylenol go home and put a heating pad on it.