Drug addicted patient at a nursing home and only 46 years old

Published

I need a professionals help on showing me the right way to protect myself and my license. I am an lvn and I work at a nursing home. We have a 46 year old female that's a patient there. Her history states she was a heavy drug user and seeker before she was admitted into our facility. The problem is, the physician gives her whatever she wants. For example, some of her routine meds are dilaudid, soma, duragesic patches, tegretol, etc. Next she complained that she has a cough that robitussin want help. So he puts her on prn phenergan elixir(which is also an antihistamine), then she c/o itching due to her patches, he then puts her on prn benadryl. Two days ago she called the doctor's office herself and stated she had oral pain because the dentist saw her. The doctor's nurse called our facility and gave a t.o. for hydrocodone. The only problem there was, the dentist didn't do any oral procedure on her. And she had never complained of pain to us. The patient frequently comes to the nurses station asking for different meds: phenergan elixir, benadryl, combivent, etc. She just about wants every prn drug she has.

My question is: what do I do to protect myself and my license? she has orders for these meds and she makes the complaints. She also has a drug book in her room. She's very smart. I try to make the best judgement, but it's hard when the patient and the doctor agree on everything. When she complains of a problem, do I give her prn or refuse her? How do I deal with a very drug smart, drug seeker and be in the right with my Texas state? Please help me someone.

Ro

Up Vote Up Vote ×

where i work, whenever patient brings prescription from doctor's office, we have to call the attending physician in our nursing home and those medications have to be approved by him. is dilaudid scheduled or prn? if she have prn pain medicine, i would call the doctor and ask him to write an order that this resident can receive prn medicine in between scheduled pain medicine. i had a patient who is pretty young, in 40's also and she always ask nurses to give her both the scheudled and prn together, which are dilaudid and oxycontin and i"m like, uh, uh, none from me.:nono::nono::nono: she was very manipulative, stating other nurses gave her both together. all day long she watched clock, waiting for next pain medicine. about an hour prior, she called the desk reminding nurses that she needs pain medicine, the half our before she called again for pain medicine. she did anything, including lying to our bosses to get more than she can have.

just give her whatever is prescribed from her physician and dont give in to patient trying to get medicine earlier or more than she can have. always write down in mar what time you gave them and always give them on time. if she wants this and that and if its not written in physician order or mar, tell patient "no". i also think its better to make meds scheduled instead of prn so patient knows she is going to get it and what time she can get it. i also think you should suggest to her doctor to send her to pain clinic for pain management. we sent my lady to clinic and they gave her methadone and she got little better.

Up Vote Up Vote ×

Thank you so much for replying. The patient's dilaudid is routine. Before the patient came to the north side, she was on south. They had orders for her to go to pain management, but she kept changing her mind and then refusing to go. And after 3 times, they wouldn't except her. It's just not pain meds she's interested in, it's all meds that can cause the drowsiness effect. Right now, her main thing is the Phenergan Elixir and Benadryl. She has faked her cough so long, and now she may be serious. Her Phenergan Elixir is 2 tsp every 4 hours prn and her Benadryl is 25 mg 2 tabs every 6 hours. After she recieves that, she comes back to the nurses station again, c/o shortness of breath, in which she has prn combivent and prn albuterol/atrovent inh.

Up Vote Up Vote ×

it appears that she simply doesnt want to be "with us", i would think a psych eval would be in order.

Up Vote Up Vote ×
Specializes in Med/Surg, Ortho, ASC.

Why is the 46 year old in the nursing home?

Up Vote Up Vote ×
Specializes in LTC, Disease Management, smoking Cessati.

Document, Document, Document!!!! Document her complaint, behavior, and attitude every time she is asking for the PRN medications. speak with the physician about all the overlapping meds, and how they can best be handled. She sounds like a master manipulator, so be on your toes! We had a saying in nursing school many years ago: "On the 7th day God charted".... good advice.

Good luck!

Up Vote Up Vote ×
Specializes in Public Health, Teaching, Geriatric, M/S.

You have to protect your license and not get caught up in a potential malpractice suit. You as the nurse are the last line of defense for the patient/resident when it comes to giving ANY medications. Have you gone to the unit manager? DON? Believe me, if this woman dies of an overdose at your facility, I doubt the MD will back you up. If this woman constantly wants pain meds, document exactly what she says, rate the pain, and what she was doing prior to the complaint. Then, start with a psych consult. Does she have a guardian? If none of this helps, I would talk to the MD. Call him constantly about your concerns and document his responses. Good luck to you!

Up Vote Up Vote ×
Specializes in psych, addictions, hospice, education.

Please think about this in a somewhat different way. I understand you are frustrated by and worried about the patient and her "drug-seeking." What I'd like you to remember is that if she is drug-seeking, it's because she NEEDS the drugs. Sure, her needs are inappropriate and over-the-top, but the fact remains that if she doesn't get the drugs, she will be experiencing the symptoms they treat in a huge way. I imagine she does have intense pain and anxiety and without meds they're worse. (phenergan and benadryl taken for the calming effect) I'm not saying you should give her what she asks for if it's above-and-beyond, but something is going on! Sure she's addicted, and manipulative, and threatens your peace and your license, but what's best for her?

Is there a chemical dependency doctor that could see her? What's under her need for meds, emotionally? She's 46 and institutionalized! That has to be very emotionally difficult! Does she need a psychiatric therapist? Does she have a support system? Does she need more efficient pain management? Might different meds or changes in dosage help? This is a huge situation for you, and one that comes up alot with people who over-use lots of painkillers and anxiolytics. She might not ever even be cooperative about changes, but this needs to be addressed for her health. She needs to be assessed to see what's at the root of her situation, so change can happen.

Please remember that if a patient is non-compliant, or drug-seeking, there's always at least one reason behind the behavior besides being a druggie or a pain-in-the-neck, and we need to advocate for what's best (even though sometimes it's like hitting your head against a wall).

That being said, I empathize with you--it's a very difficult situation to have such a patient in your care!

Up Vote Up Vote ×
Specializes in Utilization Management.

I'd also get some just in case....

Up Vote Up Vote ×
Specializes in LTC.

I have an older pt on my unit who will literally gag herself (I've watched her do it) to produce a very small amount of emesis, then ring for her phenergan. She insists on the IM, but I always start with the p.o., as we wrote the order to "use po med first". (She is a direct admit from home, and is a "frequent flyer". She will stay home until she can get Medicare to kick in again, then here she comes. This is the 4th or 5th admit). She will then complain of pain and diff sleeping, and want her norco as well as valium at the same time. I will give the pain med simply because "pain is what the pt says it is, where it is, and how bad it is" even if I'm certain she's seeking. And, maybe it'll help her sleep. I chart the emesis as reason for the phenergan, and chart my pain assess. as reason for norco. I tell her that we'll wait and see if the pain med works, but I can't/won't give a narc with a sedative because "according to state, it looks like I'm trying to knock you out, and I can only try one intervention at a time. In about an hour, if you still feel like you need the valium, ring for me and I'll bring you a valium". Naturally, she'll ring and I'll reassess her, chart it, then give her the valium. That way, I've done my proper assessments, proper charting, and have given each intervention time to work before medicating with another prn. My license stays safe, she's finally happy, and I can move on with the rest of my life. Until tonight, that is!:icon_roll

Up Vote Up Vote ×

Having just recently attended a pain seminar. We were told pain is whatever the patient says it is. Try again to get her to a pain management clinic. Oxycodone IR and morphineIR are the two long acting pain meds available and usually can be given every 12 hours. She may still require something for breakthrough pain. Also Neurontin is something that might help. She may also require and adjunct such as something for depression. Instead of prn why not just make it routine. Patients of this nature tend to get anxious if they think someone is going to forget to offer them something for pain. This will also save time documenting prn's given.

Up Vote Up Vote ×
Specializes in education,LTC, orthopedics, LTACH.

All good posts. Don't forget the basics and monitor her respirations and other for other side effects, such as itching, pinned pupils etc. These indicate opiate toxicity and we actually had a patient OD at my Ltc facility and need narcan, on her own prn drugs. This is very difficult, but remember addiction is a disease. It just sucks to treat. Been there

Up Vote Up Vote ×
+ Join the Discussion