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?
I found this great article from the Journal of PeriAnesthesia Nursing that I think is relevant to the discussion. The attached image has nothing to do with this article... I don't know how to delete it, sorry.
Assessment, Physiological Monitoring, and Consequences of Inadequately Treated Acute Pain
"Postoperative pain is a major health care issue. Several factors have contributed to inadequate postoperative pain control, including a lack of understanding of preemptive pain management strategies, mistaken beliefs and expectations of patients, inconsistencies in pain assessment practices, use of as-needed analgesics that patients must request, and lack of analgesic regimens that account for inter-individual differences and requirements. Untreated acute pain has the potential to produce acute neurohumoral changes, neuronal remodeling, and long-lasting psychological and emotional distress, and may lead to prolonged chronic pain states. To effectively manage postoperative pain, nurses must be able to adequately assess pain severity in diverse patient populations, understand how to monitor physiological changes associated with pain and its treatment, be prepared to address the psychosocial experiences accompanying pain, and know the consequences of inadequate analgesia. It is important for nurses to be aware of relevant research and evidence-based guidelines that are available to guide pain assessments and patient-monitoring practices."
There is also pseudo-addiction, where someone acts like a drug addict/seeker due to under treated pain. I'm not sure how common it is, but from the study I read It can be difficult to tell the difference.
There is also pseudo-addiction, where someone acts like a drug addict/seeker due to under treated pain. I'm not sure how common it is, but from the study I read It can be difficult to tell the difference.
I have been wanting to say this same thing throughout this thread as I have followed it. Glycerine82 said it better than I could have. :)
So many providers are so worried that they might be "fooled," that countless legitimate pain patients suffer needlessly.
There is also pseudo-addiction, where someone acts like a drug addict/seeker due to under treated pain. I'm not sure how common it is, but from the study I read It can be difficult to tell the difference.
A key difference is that in pseudoaddicts, when patient's pain is properly managed/relieved, the drug-seeking behaviors will go away. If they're a true addict, the behaviors will persist.
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?
I educate my patients on the risks/side effects of IV narcotics (respiratory depression, hypotension, ect...) I will explain why I am concerned about a specific observation (like hypotension) and why I am holding the requested or scheduled medication because of it. Then, if necessary, I will call the physician for further orders.
Obvious things I will call about are hypotension, decreased respirations, decreased oxygen saturation, not able to arouse, change in LOC, ect. They have to be objective reasons though. I might expect a fluid bolus ordered, med dose/frequency decreased, ect. I will explain that all to the patient. I remind them that their safety is my highest priority, but that I am concerned about their pain as well. I acknowledge that they are in pain and that I believe them. That makes a HUGE difference to them. It lets them know that yes, I am on their side, but also looking out for their safety first. I will offer and try alternative methods of pain control like heat/ice, encourage ambulation, repositioning, ect...
I have never once had a physician want me to still administer a narcotic after I report my concerns to them. I will go back to the patient and explain why the physician agrees to hold the med and what new interventions were ordered or what changes were made.
Ultimately, you report only your objective findings and then it is up to the physician. Educate your patients on their medications and side effects, explain everything you are doing/not doing and why. It's how you do this, in a way that doesn't make the patient feel attacked or neglected, that makes a difference.
A relative of mine has chronic exertional compartment syndrome. CECS His pain is never less than 4, often it is 7 or more, even on Morphine ER and IR.
Who has ever even heard of chronic CS? Until he was diagnosed, I'd only been aware that CS is a surgical emergency.
The only known treatment seems to be fasciotomy. This is successful in only about 65% of patients. The other 35% need long-term heavy duty pain Rx.
You would never know from his face that he is in pain. He does not allow himself to show pain. He does his very best to keep his life as normal as possible. He just uses his meds and has to limit standing and walking. Just to make life more fun, he has itching from the opiates. Benadryl helps only a little.
My point, of course, is to say that I think I'd rather give an addict a "fix" than deny pain med to anyone suffering, whether I particularly believe them or not.
I once heard a nurse verbalize worry that a terminal Ca pt was going to develop addiction and was drug-seeking. I'd be seeking, too, if I were in the condition this pt was in. She was severely cachectic, darned near comatose, she died 2 days later. I'd much rather keep her comfortable than worry about addiction at that point in someone's life. Yes, I know the OP's pt wasn't like this, but I'm just sayin'.
Oh, actually, there is a radiologist in Wyoming who uses Botox for CECS and there are some docs, I forget where, who use a type of laser.
A relative of mine has chronic exertional compartment syndrome. CECS His pain is never less than 4, often it is 7 or more, even on Morphine ER and IR.
Who has ever even heard of chronic CS? Until he was diagnosed, I'd only been aware that CS is a surgical emergency.
I hadn't heard of it until now, either! That sounds horrendous.
My point, of course, is to say that I think I'd rather give an addict a "fix" than deny pain med to anyone suffering, whether I particularly believe them or not.
YES. I couldn't agree more.
I once heard a nurse verbalize worry that a terminal Ca pt was going to develop addiction and was drug-seeking. I'd be seeking, too, if I were in the condition this pt was in. She was severely cachectic, darned near comatose, she died 2 days later. I'd much rather keep her comfortable than worry about addiction at that point in someone's life. Yes, I know the OP's pt wasn't like this, but I'm just sayin'.
That is ignorance to the nth degree...actually, negligence. It's ignorant to the point of being negligent. Please say that she got a good schooling??
Less is more when it comes to pain since it is subjective. Take them at their word. Yes we all get burned but I feel not as often as the powers that be want us to believe. Pt say 7 because of fear of inadequate pain control. Lesson learned by me as a patient before and now get it.
I had a situation like this recently. Patient in for pain/nausea and on the clock requesting high doses of narcotics. As long as his vitals were good, and he was breathing sufficiently, I gave him the medication when he asked for it. I neither judged him, nor 100% believed every word he said.
The problem that I faced was when my report from the off-going night nurse was that the patient was close to sedated, BP dropping, respirations nearing 8, and she declined him the larger dose of the medication range. The patient was rating his pain a "5" yet still expected 3mg of Dilaudid. (Which as we all know is more concentrated than Morphine). The night nurse told me everything, the times, the doses she gave, how the patient rated his pain, his neuro/vital status each time...and then when the physician rounded in the morning and I was in the room, the patient tried to pull one over on me. He said he was awake and retching all night long--which was simply not true.
When this happened, I interrupted him. I stated exactly what the night nurse had reported to me, in the presence of the patient, the physician, and the patient's family member who was trying to get us to give the pt even more medication. The physician listened objectively, we talked it all out, and the patient seemed to realize that we want to keep him safe--not deny him pain medication. The pt's family member even said, "We think it's best that he stays sedated while he's having so much pain." To which the physician straight up stated, "that is not going to happen." Once outside the room, the physician told me that it's entirely within my scope of practice to be certain that the medication that I'm giving the patient will not do him any harm. He said, "if you think the BP is too low, don't give the Dilaudid." He also said, "there is a range order for a reason, do not automatically give the highest dose, it's PRN for a reason...use your judgement."
So, the moral of the story...we are responsible for the patient and to keep them safe. I'm not saying deny your patient pain medication, but I'm also saying do not believe every word they say. Use your judgement and be straightforward with you patients, the physician and the other nurses.
A rule of thumb I follow is to evaluate my motivation for considering to withhold a pain med.
Depressed respirations or a change in LOC or potential interactions with other meds are all valid reasons to consider withholding an ordered PRN narcotic. Thinking "They're not really in pain" or "She's a drug seeker" is NEVER a valid reason to consider withholding ordered PRN narcotics.
That is ignorance to the nth degree...actually, negligence. It's ignorant to the point of being negligent. Please say that she got a good schooling??
lovinglife2015
292 Posts
Please. The man was being medicated for pain in a clinical setting. Not your place to question his honesty. Very inappropriate,