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?
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.
The patient complained of pain; add into that that the pain apparently isn't new as the patient had been previously recommended surgical intervention (which we assume the pt declined).
Escalating from APAP to oxycodone warrants an assessment from the provider (at least for non-surgical non-oncologic pain) though a one-time order is a compassionate thing to do if immediate assessment isn't available. I am equeally critical of the pych who flatly refused without seeing patient. Are there other pains that can mimic endometriosis pain? Did the RN examine the patient with the proper expertise to make that differential dx?
Most providers work under the adage that even crocs get sick.
Assessing how the patient is able to move? Try to observe when unnoticed. A patient in any kind of abdominal pain will be unable to be relaxed or stand and move easily.
I would do as many of these observations as able before making a referral to a Medic. I believe the Pulse is probably the best indication of what might actually be going on.
I think at this point it is not important to question whether you did the “right” thing but rather focus on the outcome which was less than satisfactory for everyone involved and find out why something as simple as getting a patient’s pain properly evaluated and treated in a inpatient hospital setting got so convoluted. Clearly there was a deficiency here in some area, and most likely in more than one area. So the only question that needs to be asked is what needs to be done so this doesn’t happen again. Is there a clearly written policy outlining the procedure to request a medical consult? Have the nurses received the proper training regarding the process? Do the nurses and doctors do regular case meetings to facilitate communication and to coordinate care? I've been a nurse 35 years, sometimes things go wrong and the professional thing to do Is to determine why and implement a plan to correct it. Determining right or wrong is irrelevant bc provider focused and not patient focused. You can use this experience as a way to make positive changes in patient care.
In my opinion it is almost never wrong to advocate for the patient. Disagreeing with physicians I would argue can be a key component of effective nursing. RN's can be one of the "checks and balances" in the system and an adversarial (but hopefully respectful and polite) exchange of ideas may lead to better patient outcomes. When I used to sometimes get "written up" for calling MD's late at night over a patient issue I literally considered it a "badge of honor" an intrinsic part of my sacred responsibilities as a patient advocate sometimes of last resort.
Disagreeing with physicians I would argue can be a key component of effective nursing. RN's can be one of the "checks and balances" in the system and an adversarial (but hopefully respectful and polite) exchange of ideas may lead to better patient outcomes.
Argument for the sake of argument and calling it 'advocating for the patient' is not in my book of nursing. Look, we all want what's best for the patient including physicians. An adversarial interaction is by definition "involving or characterized by conflict or opposition". Maybe a discussion of your concerns may lead to a better outcome.
1 hour ago, myoglobin said:
When I used to sometimes get "written up" for calling MD's late at night over a patient issue I literally considered it a "badge of honor" an intrinsic part of my sacred responsibilities as a patient advocate sometimes of last resort.
When I was a new grad working on a surgical floor, patients came in the night before surgery. I worked evenings. Before going home at after midnight, I reviewed the data for the patients having surgery the next morning and started their 'pre-op checkoff list' -----a remnant of the ice age! One patient's CXR showed active TB. I got masks for outside the room - and all rooms were private. I told the noc nurse and called the OR to cancel the surgery. I didn't see any reason to call the surgeon before early morning. Wouldn't you know the noc nurse called him in the middle of the night for in her opinion an 'immediately needed' order.
I have noticed that there are some nurses who end up in conflict with physicians time after time.
I have avoided saying this but I do think it needs to be said. The OP called 'advocating for the patient' getting her own way, not what was really best for the patient. A one time order for an opiate is never going to catch up her pain and 'calling' it a med for breakthrough pain is a misnomer.
As a midwife, hysterectomies are rarely "recommended" for endometriosis anymore. In fact, it's a lazy providers way of dismissing the patient. A hysterectomy doesn't necessarily solve the problem as endometriosis is an inflammatory condition that can impact other organs than just the uterus. The pain can be so bad I have seen patients vomit. The treatment is to shut the cycles down. Stop the cycling = stopping the pain.
The problem is there wasn't an appropriate discipline available to help this woman nor was an ovarian cyst (that can lead to ovarian torsion) ruled out.
Had this been a man with a swollen member or scrotum, a urologist would have been consulted, but this is another example of providers dismissing a gynecological complaint because it was a female.
More times than I can count I have had psych doctors tell me they would rather the medical doctor handle severe pai.The charge or supervisor should have assisted more with this situation.
Argument for the sake of argument and calling it 'advocating for the patient' is not in my book of nursing. Look, we all want what's best for the patient including physicians. An adversarial interaction is by definition "involving or characterized by conflict or opposition". Maybe a discussion of your concerns may lead to a better outcome.
When I was a new grad working on a surgical floor, patients came in the night before surgery. I worked evenings. Before going home at after midnight, I reviewed the data for the patients having surgery the next morning and started their 'pre-op checkoff list' -----a remnant of the ice age! One patient's CXR showed active TB. I got masks for outside the room - and all rooms were private. I told the noc nurse and called the OR to cancel the surgery. I didn't see any reason to call the surgeon before early morning. Wouldn't you know the noc nurse called him in the middle of the night for in her opinion an 'immediately needed' order.
I have noticed that there are some nurses who end up in conflict with physicians time after time.
I have avoided saying this but I do think it needs to be said. The OP called 'advocating for the patient' getting her own way, not what was really best for the patient. A one time order for an opiate is never going to catch up her pain and 'calling' it a med for breakthrough pain is a misnomer.
While I don't believe that "arguing" is ever ideal. I do want to emphasize that I believe a key roll and function of nurses is to act as advocates and I would indeed submit guardians of patients welfare. Nurses are at the nexus of patient care and are perhaps even better suited to guard the interests of patients than doctors or any other health professional. It is not only our right, but indeed our duty to act in this manner. I wish to contrast this with the attitude that I sometimes see in physicians that RN's are there to "implement MD orders". Indeed such advocacy can and should include sometimes include questioning the medical decisions of MD's (although that doesn't mean we have the right or ability to implement our own medical orders without getting an appropriate order from a licensed clinician). I want to make it clear that my approach on this can be either seen as very necessary or quite radical.
Specializes in Mental Health, Gerontology, Palliative.
On 10/21/2020 at 2:46 AM, Davey Do said:
At Wrongway Regional Medical Center, the psychiatrists dealt with the psych issues and the hospitalists dealt with the medical issues.
Kept everything simple.
Our psych doctors deal with the mental health stuff, if the patient has physical health issues we send them out to the main hospital
Once was case managing a palliative patient who also had a major mental illness. Was told that my purview did not include dealing with physical health issues. ?
BostonFNP, APRN
2 Articles; 5,584 Posts
The patient complained of pain; add into that that the pain apparently isn't new as the patient had been previously recommended surgical intervention (which we assume the pt declined).
Escalating from APAP to oxycodone warrants an assessment from the provider (at least for non-surgical non-oncologic pain) though a one-time order is a compassionate thing to do if immediate assessment isn't available. I am equeally critical of the pych who flatly refused without seeing patient. Are there other pains that can mimic endometriosis pain? Did the RN examine the patient with the proper expertise to make that differential dx?
Most providers work under the adage that even crocs get sick.