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?
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. ?
That's the thing as an RN your purview includes virtually all issues with the patient from their safety, health, emotional, psychological and even spiritual well being. You are the central nexus of their care the one person who has the most intimate power, responsibility, and manifest duty to guide and guard virtually every aspect of their care to the best of your ability. That is why RN's should be empowered to constantly question, advocate and pursue these duties.
Sometimes there is a drug interaction issue between the psych meds and pain meds. What was the overall health of the person at the time, meaning would a stronger pain med overwhelm any of the patients body systems, to the point that it would not be advisable to prescribe the med?
There is a patient advocate number that is supposed to be posted on the unit. Not sure how you can give the patient the info without you being in trouble for disobeying the primary. But if acute pain is present it needs to be assessed by the physician.
So if I'm reading this correctly, Ibuprofen and Tylenol weren't given based on the assumption they wouldn't do anything?
Typical SOC, is that you give the medication available, the tylenol/ibuprofen (which if wasnt available as a PRN was the first ordered medication. Then you re-assess the patient after a period of time and see where their pain is at, then and only then would you seek an order for breakthrough pain. The other thing is how often was the APAP/Ibu being given? These meds should be given round the clock for optimum effectiveness particularly the nsaid as the antiinflamatory effect can take from 5-10 days for the full benefit to kick in. I think your advocating for the patient while well intended was misinformed. The hospitalist should have been advised the med s/he ordered was not given. Lastly, the psych doc yelling profanities over the phone is completely unprofessional and behavior I would take issue with. jmho.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
I'm confused why you didn't give the med after getting the order from the hospitalist. I think you should have given it. Also, I think you should have asked the hospitalist first. Next time go straight to the
hospitalist.
But yeah, if your patient is having pain that is not relieved by Tylenol and ibuprofen, then you need to get an order for something appropriate. It really doesn't matter if Tylenol and ibuprofen are often effective because in this case they weren't.
I'm all for pissing off a doc in order to help my patient, but only if it's necessary. You feel me?
Avoid this problem next time by calling the appropriate person the first time.
Specializes in ICU/community health/school nursing.
On 10/20/2020 at 7:30 PM, LovingLife123 said:
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.
Thank you for this. That's the main issue - the pain when your reproductive organs go rogue cannot really be understood by anyone who's not had that happen.
OP - not playing doctor but Ketorolac might have been a mid-way med between the narc and the ibuprofen. It's one of the few things that worked on my endo-related pain. For next time.
An intervention was required here, whatever it may have been. If the psych. MD proposed to do nothing at all I'd have gone to another doc. given whatever was ordered and be done with it. I also wouldn't go out of my way to inform the psych. MD unless it were required. Especially for a one time dose.
You have to trust your judgement, even if you ended up medicating them and later discovered you were being "played" - it's a learning experience and as you said, pain IS subjective.
Its never wrong to advocate for your patient, thats our job.
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’m very concerned about the fact that you’re blowing off ibuprofen and Tylenol. Please do some research. Ibuprofen and Tylenol, taken together, has been proven to offer as much pain relief as narcotics and since we have a bond fid opioid crisis, we need to find other pain relief; I work in periop and no one gets opioids as a standard discharge script anymore. What is key is keeping up on giving the medication to provide a level of pain relief. If you were giving these and your patient was “writhing” in pain as you’re describing, the hospitalist should have been call to evaluate your patient’s concerning symptoms.
Severe endometriosis is poorly understood by most healthcare providers. Commonly it is misunderstood.
Yea, it is inflammatory. Yes, NSAIDs are great for inflammatory conditions. But Endo pain can well beyond the capability of 1g of APAP and 800mg of ibuprofen. That is probably why this person has surgery recommended: Endo pain can be debilitating.
While psychiatrists are well versed in dealing with seekers, it is very unfortunate that Endo sufferers are all too frequently treated like seekers and fakers. How does that make them feel? Mental illness associated with chronic pain where the patient is mistreated by the healthcare system? Oh yea.
Let's look at treatment options. I don't have to tell this forum about high dose NSAIDs and lithium levels. However, the number one treatment for Endo is hormone suppression. This comes with psych effects so if you have a patient with comorbid mental health issues and add on hormone therapy, well not all of them are going to tolerate that therapy. Mirena IUDs are more targeted and less systemic.
However, if lesions are widespread/chronic, there is often a lot of associated complications such as massive abdominal adhesions that contribute to the pain and may cause bowel obstructions or strangulation. Many have to have lysis of adhesion and even bowel resection! This can be coupled with lesion cautery (may only be temporary without hormone suppression) or more advanced endometrial lesions removal like wide area excision (painful with long recovery, but effective).
So some patients do need hysterectomy in addition to other treatments or because other treatments were unsuccessful. Often hysterectomy is the rec after repeat failure of other surgeries.
You patient sounds like they were in bad enough pain that APAP/NSAIDs were not going to cut it all the time. Perhaps their pain threshold was affected by their current mental state. Good on you for your advocacy. Frankly, asking OB service to consult would have been appropriate but your hospitalist understood well enough.
.thumb.jpg.e7b5bd336d518053002d5b4dbeef882b.jpg){kind=small}
myoglobin, ASN, BSN, MSN
1,453 Posts
That's the thing as an RN your purview includes virtually all issues with the patient from their safety, health, emotional, psychological and even spiritual well being. You are the central nexus of their care the one person who has the most intimate power, responsibility, and manifest duty to guide and guard virtually every aspect of their care to the best of your ability. That is why RN's should be empowered to constantly question, advocate and pursue these duties.