I am writing this post because I'm feeling guilty on how i dealt with a patient. I apologize this is lengthy
I had a patient who came in for for pain management. Throughout time i had him i was careful not to over drug him. He had signs of being a drug seeker. Talking about schedules. Setting alarms for his next dose. Pain never less than 7. No expression. Yet he was getting up to the bathroom, even showering. if i found him asleep i knew his pain was controlled and refused to give him meds when his alarm went off. I waited usually until he was alert. He told me he passes out from the pain When he was falling asleep during conversations i told the doctor this. I never said he wasnt in pain because he did have a medical reason for having pain. I do think he had pain. Simply that he wasnt reporting it to me adequately. I only said the truwhich is he was sedated. The doctor cut his drugs and he was ****** with me because of it. No explanation was good for him.
I felt as though i was objective about his pain and the meds and i sought other nurses advice and the doctors with my decisions. They backed me up. Where i think i failed however was with communiating to the patient. What ways have you found to explain the risks of these meds or your decisions or that theyre sedated without essentially calling them a drug seeker or alienating them?
To the other posters: What if the patient is a frequent flier? with a documented history of drug seeking behavior, would you still treat objectively? We are human you know, I think the OP was right in giving the doctor her opinion of the situation and what happened afterwards.
Talking about schedules. Setting alarms for his next dose. When he was falling asleep during conversations. The doctor cut his drugs and he was ****** with me because of it. No explanation was good for him.
As someone stated before that this patient could have chronic pain and would behave this way but if you are an addict or know of one, this is also CLASSIC addict behavior!!! So, before you go criticizing the OP, read the whole post where she stated that she consulted other nurses and the doctor, she did what she was supposed to do.
To the other posters: What if the patient is a frequent flier? with a documented history of drug seeking behavior, would you still treat objectively? We are human you know, I think the OP was right in giving the doctor her opinion of the situation and what happened afterwards.
If the patient is prescribed a medication and if their vital signs permit, I will administer it.
Since I have no way of being certain of what another person feels or experiences it's the only thing I can do. I can live with myself if I give an addict a free "high" that's not strictly medically motivated, I can't live with myself if I let a person suffer when it's in my power to alleviate their suffering/pain. It's not only within my power, I consider it my darn duty as a nurse. So with incomplete information (which is all we ever have when it comes to pain and how another person experiences it), the choice for me is easy.
Of course it helps that I don't have a need/desire to change/reform/punish/help/foster (whichever applies) an addict who isn't motivated to combat their addiction because I consider that a ginormous waste of my time and energy and destined to fail.
As someone stated before that this patient could have chronic pain and would behave this way but if you are an addict or know of one, this is also CLASSIC addict behavior!!! So, before you go criticizing the OP, read the whole post where she stated that she consulted other nurses and the doctor, she did what she was supposed to do.
Generally speaking (since I wasn't present to hear the exchange in this specific situation), I find that the advice I receive is heavily influenced by how and what information I present about the problem/situation and also by the knowledge and value base of those I consult.
I read the whole post and from the information available to me, I'm not convinced that the patient's pain was optimally treated/medicated.
Specializes in NICU, PICU, Transport, L&D, Hospice.
To the other posters: What if the patient is a frequent flier? with a documented history of drug seeking behavior, would you still treat objectively? We are human you know, I think the OP was right in giving the doctor her opinion of the situation and what happened afterwards.
The OP described no frequent flier or undisputed drug seeking behavior.
The OP described what very easily could be the standard behavior of one who is trying to live with real chronic pain issues in today's world where doctors and nurses are reluctant to treat them. They are consistent with a person who has trained themselves to LIVE with untreated or poorly treated pain.
Congratulations. It seems that you succeeded in making some assumptions about the patient, painted a picture for the prescribing MD to support your notions, and achieved a reduction in pain control for the patient. I hope that you were intending to adversely affect the health status of the gentleman because that is very likely the outcome that you generated.
I would recommend that you educate yourself on proper pain management and worry less about drug seekers than you do about the pain management of the folks who are looking to you for help.
To the other posters: What if the patient is a frequent flier? with a documented history of drug seeking behavior, would you still treat objectively? We are human you know, I think the OP was right in giving the doctor her opinion of the situation and what happened afterwards.
Then give the prescriber all that information and let them make the call about what medications the patient should/shouldn't have ordered for them.
For PRN pain meds, I always write the time for the next dose on the white board and let the patient know that I'd be there about that time or a few minutes after it's due but I will be there with their medications. I also let them know that if I'm not there and it's 15 past that time to go ahead and buzz me. I take care of 6 patients on a given shift and sometimes pain meds times clash so in order to keep people off the light I explain the situation to them before hand. This usually works out pretty well. I think for the most part, patients just want to know that they will not be left in pain and most co-operate when they are kept in the loop.
Having said all that above, I will not give pain medications to a patient that appears too sedated (we usually give IV Dilaudid or Morphine). If you're slurring your speech and are unable to keep your eyes open, I'll check on you in a few to make sure you're A-ok before giving you meds. I usually will show them that I have their meds pulled but I'm uncomfortable giving it to them at that time based on my assessment, works most of the time.
Dealing with appropriate narcotic prescribing is a terrible burden. It's not yours to bare though. In my opinion, if they report pain and have an order and are not a safety risk, give the med.
Even documented "drug seekers" are prone to accidents that may cause acute pain. As professionals one must be objective in their treatment of patients. I know that as a chronic pain patient myself, if I am not on a long acting opioid and am solely relying on breakthrough pain meds, that I am more likely to need to set an alarm for my next PRN dose. This could be for one of two reasons, neither of which include the intention of "getting high". First, if I am having an acute exacerbation of my chronic pain, in order to get a "jump" on the pain to bring it down to a manageable level I might need several "scheduled/timed" PRN doses before I can start extending the length of time between doses. Second, for someone who is on a long acting med that is dc'd upon admission for faster working, shorter acting meds they might require doses at evenly spaced times to keep from having highs and lows in their pain control because of the differing half lives of the different medications, bioavailability and changes in equianalgesic dosing, etc.
I know that if I were to be admitted and a nurse thought I was "seeking" and got my attending to decrease my pain management regimen, I would be way less than happy since my pain is managed by a pain specialist and I am on a set amount of medication to adequately control my pain. Mistaking me being TIRED for over sedated and thus getting my meds decreased would get you a complaint to your charge and I would go up the chain of command as needed. My attending would be paged and I would likely request for him/her to have the pain team come see me instead so that someone competent to treat chronic pain could control that part of my care.
To the other posters: What if the patient is a frequent flier? with a documented history of drug seeking behavior, would you still treat objectively? We are human you know, I think the OP was right in giving the doctor her opinion of the situation and what happened afterwards.
Full disclosure: I've never worked in an ED, so don't get any non-sick frequent fliers who actually do put on a show for the Rx. The repeatedly hospitalized who have come into my care have done so because they had a medical dx that warranted hospital admission: hydrocephalus, sickle cell when the BMT floor was full, CF with chronic cepacia sinus infections. Whether they liked the side effects from their Dilaudid was not my business. They had very legitimate pain control needs, and I gave them their prn's as ordered.
I stand by my original statement that I would rather give 1000 addicts their fix than deny one person pain relief.
I was a supervisor in a chem dependency hospital, and like every other nurse have encountered drug seekers or pts who appeared to be, as well as people on a pain management service on scary loads of Dilaudid. It was quite an education and I have to agree with most of the posters here that in the end, WE don't diagnose the quality or quantity of a patient's pain, and we follow the doctor's orders using our experience and skill set.
You ask about how to keep a 'therapeutic' relationship with a possible drug seeker. What you DID was how NOT to and those lessons are everyone's. The people most vocal about just giving the meds per orders went through this too. It's not a big weird mistake or anything like that, it's complicated -- so make it simple in your own mind.
Working in oncology we had patients you could NOT kill with an opiate or benzo overdose. Couldn't even come close! And that's how it is with heroin addicts or pill addicts, their tolerance is plain out of this world. Beyond belief. 0.2mg of Dilaudid would make me projectile vomit on the wall, but it would be a shame to give to an opiate tolerant patient no matter what kind of pain and how long they've had it. And yes, 'sedation' is a slightly different thing with opiate tolerant persons. My yard stick for 'sedation' in an opiate tolerant person is not so much reliant on observation but how quickly they can go from RR of 8 to full alertness and pain when I hit the hand sanitizer. They are TOUGH. It's really sad, too, these are the folks who wake up during surgery and can't get adequate pain control without a LOT of drama. They are in a tough spot.
So you are always a 'learner' and this is one of those learning situations that is a little rough on the conscience and practice, but it's very doable.
It can be tricky giving report to a doctor and having them take what you said to mean they could decrease the prn narcotic. I always ask the doctor to tell the patient THEMSELVES, rather than leave me to be the bad guy. And I don't go behind a patient's back and have orders for narcotics changed with such a patient, not if I ever want to feel like an effective nurse with them ever again. Even the genuine patients get painted with the black paintbrush and I don't blame them for feeling betrayed.
Specializes in Acute Care - Adult, Med Surg, Neuro.
It doesn't matter whether they are drug seekers or not. You are going to drive yourself crazy. Like another poster said, it's not healthy for you to "go to war" with these patients. We are not going to fix them on an acute hospital admission. If you allow yourself to get sucked into their drama, it will take a toll on your own well-being. Their behaviors are draining and frustrating. Separate yourself and don't engage in the drama. Lay out the plan and treat them with respect, listen and sympathize, offer interventions that are available but establish boundaries and don't become sucked into their world. Some of these patients can be manipulative and can try to weasel their way into your psych. Some of them enjoy the sick role, Protect yourself and don't try to wage war with them. You won't win. I was on the way to burn out before learning these lessons. If you try and argue with these individuals, or engage them in their toxic behaviors, YOU are the one who will come out worse for wear.
Also always diluate meds when indicated and push over 2-3 minutes. I have many patients complain because I'm not :"pushing the med fast enough." When you take these safety precautions, the "high" people get is diminished (and that's why they're upset).
Same here. I was taught a patients pain is what they say it is and unless they are hypotension and risks outweigh benefits, you treat their pain.
I was taught that pain is what the patient states it to be.
The 1-10 score is a joke to me. People don't understand it. Worst pain ever? You get the full dose.
The scale comment was funny to me. I've always wanted to say "0-10, 0 being no pain and 10 is having both arms ripped off being fed live scorpions, how bad is your pain?"
and those lessons are everyone's. The people most vocal about just giving the meds per orders went through this too. It's not a big weird mistake or anything like that, it's complicated -- so make it simple in your own mind.
workinmomRN2012, BSN
212 Posts
To the other posters: What if the patient is a frequent flier? with a documented history of drug seeking behavior, would you still treat objectively? We are human you know, I think the OP was right in giving the doctor her opinion of the situation and what happened afterwards.