Dealing with patients

[Babynurse1992]

Hi everyone!

So I am a brand new nurse about a week out of orientation in an ICU. Last night I had my first admit and he was in pain even with his PCA. We gave him the prescribed clinician bolus, and he continued to press his button, but the pain was still unrelieved. I called the doctor and she gave me the option to Discontinue the PCA and start him on Percocet orally along with iv morphine. When I told the patient, he refused discontinuing the PCA pump and claimed that Percocet would not do anything to help. I obtained his home medication list to find that he takes a substantial amount of pain medication on a daily basis. I called the doctor back and she gave me the option to D.C. The PCA again and start him on his PO medications. When I presented this option to the patient he still refused and asked if we could give him pain medication on top of his PCA, which was not allowed. So he refused removing the PCA and continued to press his button. He was very pleasant after this for the rest of the night. When the oncoming nurse came in he told her he was never given the option to take his home medications and that he had been miserable all night. I told him that we had discussed starting PO pain medication twice that night, but he was still unhappy. As a new nurse, I Am just wondering if this is something that will fall back on me. I did my best to control his pain and give him options, but nothing worked out. I feel like I did what I could, but naturally as a new nurse I get nervous that I could have done more or didn't do enough. I feel like there is a fine line between doing what I could do and him just being a disgruntled patient. I don't think the nurse coming on was upset with me, which makes me feel a little better, but I also don't like leaving the oncoming nurse with difficult situations. Any advice?

Being a a brand new nurse is proving to be very challenging, and I feel as though I am constantly worried about messing up when I don't always know what to do. I ask for help (a ton), but sometimes help isn't available or I feel like I am not handling situations in the most efficient way. I try to make sure I document every little thing, but sometimes I worry I forget details.

Thanks in advance!

[Babynurse1992]

Also, in now way did I want the patient to be in pain or feel like I wasn't doing my best to help him. I just felt so hopeless because no matter what I offered, he was not happy with it. I am just worried to get into trouble for not managing his pain adequately or for him to come back and complain about me (typical new nurse worries I guess). I am just constantly overwhelmed at work right now and even though I am trying my best, there are still so many things I don't know how to handle just yet. I absolutely hate the idea of making a patient upset, so I guess with this being my first upset patient I am overly concerned.

[JKL33]

It'll be okay.

Documentation will tell the story.

I dislike that we focus on box-checking to the extent that people aren't prepared to write adequate notes about important things. I'm not saying you didn't do that (I hope you did).

Each instance of talking with the patient, notifying the physician and the patient's decision to decline the options given should be concisely documented. And then, when you receive feedback about his inaccurate portrayal of what happened, do NOT entertain it. Meaning, stay calm and simply say his portrayal is not accurate and you spent significant time working with him on the issue and believed he was satisfied with his decision, and that everything is documented in the record. But don't cower and fret and act as if you did something wrong.

[Sour Lemon]

Hi everyone!

So I am a brand new nurse about a week out of orientation in an ICU. Last night I had my first admit and he was in pain even with his PCA. We gave him the prescribed clinician bolus, and he continued to press his button, but the pain was still unrelieved. I called the doctor and she gave me the option to Discontinue the PCA and start him on Percocet orally along with iv morphine. When I told the patient, he refused discontinuing the PCA pump and claimed that Percocet would not do anything to help. I obtained his home medication list to find that he takes a substantial amount of pain medication on a daily basis. I called the doctor back and she gave me the option to D.C. The PCA again and start him on his PO medications. When I presented this option to the patient he still refused and asked if we could give him pain medication on top of his PCA, which was not allowed. So he refused removing the PCA and continued to press his button. He was very pleasant after this for the rest of the night. When the oncoming nurse came in he told her he was never given the option to take his home medications and that he had been miserable all night. I told him that we had discussed starting PO pain medication twice that night, but he was still unhappy. As a new nurse, I Am just wondering if this is something that will fall back on me. I did my best to control his pain and give him options, but nothing worked out. I feel like I did what I could, but naturally as a new nurse I get nervous that I could have done more or didn't do enough. I feel like there is a fine line between doing what I could do and him just being a disgruntled patient. I don't think the nurse coming on was upset with me, which makes me feel a little better, but I also don't like leaving the oncoming nurse with difficult situations. Any advice?

Being a a brand new nurse is proving to be very challenging, and I feel as though I am constantly worried about messing up when I don't always know what to do. I ask for help (a ton), but sometimes help isn't available or I feel like I am not handling situations in the most efficient way. I try to make sure I document every little thing, but sometimes I worry I forget details.

Thanks in advance!

Yep, just document. That sounds like a typical patient ...nothing out of the ordinary.

[MunoRN, RN]

It's not unusual for patients to get the impression at some point that they will have absolutely no pain, although this isn't always realistic, so defining what the reasonable goals are is important.

There's not really any reason why a patient can't be on both a PO pain med for basal control, as well as a PCA for breakthrough pain, this may have helped, particularly at night when patients on a PCA tend to have periods of poorly controlled pain since if their pain does get controlled enough to get some sleep, they aren't hitting their button while asleep and often wake up in extreme pain, which can require far more medication to catch up on that what would have been required to just stay on top of it with an added PO med.

[Sour Lemon]

There's not really any reason why a patient can't be on both a PO pain med for basal control, as well as a PCA for breakthrough pain, this may have helped, particularly at night when patients on a PCA tend to have periods of poorly controlled pain since if their pain does get controlled enough to get some sleep, they aren't hitting their button while asleep and often wake up in extreme pain, which can require far more medication to catch up on that what would have been required to just stay on top of it with an added PO med.

One place I worked at actually had a policy that no other pain medication could be given while a patient was on a PCA.

[mmc51264, BSN, MSN, RN]

My guess is that if this pt takes a high quantity of narcotics at home and then gets hurt, you are always trying to catch up. We had a pt that had a traumatic ortho injury. Found out he was taking like 300 mg of street oxy per day. We can medicate that much! Those are the ones that end up on ketamine or lidocaine drips. You never know what people take. It can be rough.

[hppygr8ful, ASN, RN, EMT-I]

It sounds like you did everything possible in this situation. You showed appropriate and immediate concern for the patients unrelieved pain. Called the Doctor and received orders for appropriate intervention that took the patient's tolerance/ dependence into consideration and offered the patient reasonable solutions which were refused. Some days you just can't win! As long as your charting reflects what you have said here you will be fine.

Hppy