Hi all! So this is going to be a rant slash plea for advice. I've been working as an RN for about 6 months now, and my patient population has really been terrible as of late. I work on a fairly busy med surge floor, and recently, it feels like every single patient I take care of, is just there for the pain medications. I'll have patients that come in for intractable pain, n/v, from surgeries that they had 6-12 months ago. And when they're assessed objectively, scans show no abnormalities, and vitals are also within normal ranges. Yet, they'll complain of 10/10 pain, that doesn't get relieved with heavy doses of morphine, oxycodone, dilaudid, etc. These are patients that have histories of multiple admits at multiple hospitals for the same issues. At what point do the doctor's decide to stop admitting patients like these? When do they stop giving in to their tantrums?
Just last week, when I let one of my patients know that she would be getting discharged and I had to stop her IV dilaudid, I walked into her room 10 minutes later to see her on the floor, claiming that she had fallen and hit her head. No bruising, no lump, no cuts, not even a hint of redness to her head. In the same week, I took care of another patient complaining of abd pain, n/v, and after being told she would no longer have IV pain meds ordered, she mysteriously started vomiting up all her oral medications. Always when her door was closed (requested by her), and almost on the hour episodes of emesis. No vomiting when she ate food, but any oral pain meds would be upchucked within minutes. And of course IV zofran did nothing for her nausea, only the promthezine ever worked, and only for a very short time.
It's gotten to the point where I feel that if I continue like this, I'll slowly come to hate and resent my patients, and nursing as a whole. I'm just barely starting out as a nurse, and this is not the outlook or mindset that I want to have. Please, please share any tips or advice on how you deal with patients like these.
Specializes in ICU/community health/school nursing.
17 hours ago, Quinnbee said:
Thanks for the advice, you guys, I sometimes find it hard to disengage, but I think it's definitely something I need to start working on. It's especially difficult when I get one or two demanding patients that take up most of my day, and by the time I'm done with them, I have very little left to spare. @ruby_jane Our standard ratio is 5:1, but most of the time we're at 6:1 or 7:1, with several admits and discharges throughout the day.
So....this is one of the problems, and it's completely out of your control. I don't know I'd be doing anything but the stuff ordered if I had six or seven patients in a shift. Is it possible that you're exhausted and that your tired (and I'm tired for you just thinking about six patients) is making it more difficult for you to disengage? Hang in there.
I found this frustrating also when working med-surg. The only thing that was ever effective with this type of patient was when the MD would lay her/his foot down and, with you in the room, tell the patient NO MORE. DO NOT ASK. THEY HAVE ORDERS TO NOT PAGE ME FOR THIS.
Usually what will happen is what is happening now. Give them their drugs and move on. I would ask MD when rounding if, when they would change to PO from IV to let the patient know this was happening. That way I would not be bombarded with ridiculousness/unnecessary drama.
Apparently we get along better with our Docs than most of you. We're a relatively small critical access hospital with an acute care/med surg floor that admits from our ER and clinics and we deal with a lot of the same patients over and over, some with incredibly painful conditions; some who are "drug seekers", and some who, I swear, would rather lose a foot than do what's necessary self care wise to avoid such mutilation because of the small amount (relatively) of drugs that they might get out of the deal.
I'm the nurse. I advocate for my patients by going to the Docs and "suggesting" that so and so might benefit from losing their Morphine in favor of Ketorolac or Tramadol ( a mu agonist) or having their Hydro halved and stretched to Q6 or maybe having something added for nerve pain, etc. We don't have Dilaudid in our formulary for a reason. Sometimes I go the other way. Not everybody experiences pain the same. Patients that have been here before usually get it. If you're strictly NPO for three days for pancreatitis, the pain meds end when you want something to drink or eat and you can hold it down, and we've been checking your Lipase and backing off on your Morphine and Fentanyl along the way. It really isn't that much fun. Maybe one of these days we'll lose the numeric pain scale and train RNs to objectively assess pain the way we assess other dysfunctions. The key word is "objectively". Whether somebody is a drug seeker is not really my business. Whether they're actually in pain, and what they're in pain from and what that might indicate is my business, and if they're obviously ******** me, their narcotics go away and they go home, all other things being equal.
Some days I may have AMA papers made out in advance to assist my patients who don't really want to be there after all. And then I have the heart breakers who really need to stay when they'd rather be out there dying. It keeps things interesting.
Specializes in ICU/community health/school nursing.
On 9/4/2019 at 11:25 PM, Tomascz said:
Apparently we get along better with our Docs than most of you. We're a relatively small critical access hospital with an acute care/med surg floor that admits from our ER and clinics and we deal with a lot of the same patients over and over, some with incredibly painful conditions; some who are "drug seekers", and some who, I swear, would rather lose a foot than do what's necessary self care wise to avoid such mutilation because of the small amount (relatively) of drugs that they might get out of the deal.
I'm the nurse. I advocate for my patients by going to the Docs and "suggesting" that so and so might benefit from losing their Morphine in favor of Ketorolac or Tramadol ( a mu agonist) or having their Hydro halved and stretched to Q6 or maybe having something added for nerve pain, etc. We don't have Dilaudid in our formulary for a reason. Sometimes I go the other way. Not everybody experiences pain the same. Patients that have been here before usually get it. If you're strictly NPO for three days for pancreatitis, the pain meds end when you want something to drink or eat and you can hold it down, and we've been checking your Lipase and backing off on your Morphine and Fentanyl along the way. It really isn't that much fun. Maybe one of these days we'll lose the numeric pain scale and train RNs to objectively assess pain the way we assess other dysfunctions. The key word is "objectively". Whether somebody is a drug seeker is not really my business. Whether they're actually in pain, and what they're in pain from and what that might indicate is my business, and if they're obviously ********** me, their narcotics go away and they go home, all other things being equal.
Some days I may have AMA papers made out in advance to assist my patients who don't really want to be there after all. And then I have the heart breakers who really need to stay when they'd rather be out there dying. It keeps things interesting.
You are an excellent nurse. Beautifully stated especially the part about self care. I love the use of adjuncts (like something to quiet nerve pain). Not all pain is the same pain.
Specializes in Critical Care; Cardiac; Professional Development.
On 9/3/2019 at 3:09 PM, Davey Do said:
We all need to feel good. We all need to avoid pain, be it of the mind or body.
I feel pity on those who have to go through great lengths to get that need met.
There for the grace of God go I.
I try really hard to live this. I admit its difficult when I feel like I am being pressured or manipulated.
The solution I learned for stopping manipulation was to let the patient know I would give them ALL the meds, scheduled and prn, that were ordered as close to on the dot as I could. That they could count on me to do that and to monitor them to be sure they were safe. I would say 80% of the time that eliminated the demanding or manipulative behaviors.
Obviously I do not do this for patients who are not being manipulative or demanding about pain meds. Just the ones who are. Honestly, once I had experience under my belt I considered these to be pretty easy patients. It was obvious what they wanted and when they got it they left me alone to take care of other patients. The only time I really resented it was when they had Dilaudid ordered q2h. That was a lot of running around.
Yes it is very disheartening, and I understand I won't cure them; nor would I want to put my energy into doing so, simply because I'm not an addiction nurse. Any time I have a patient who generally has normal baseline vitals and I suspect they may be drug seeking, I always check their vitals after they request something for pain. I do this because many times, their bp and pulse ox will fall out of normal; especially on IV pain meds. I take this as an opportunity to discuss the dangers of the adverse effects of these meds and inform them the physician will be notified of the abnormal vitals. If they claim to be allergic to acetaminophen or nsaids, then we will work together to seek alternative methods of relief, at least until their vitals reach normal values. I also set boundaries making it clear I'm not going to stand there continuing to take their vitals until they're wnl.
On the other hand, if their vitals are stable and they can handle the meds, then I just give it to them, on one condition: that the pain is not a headache. If it's a headache, then most likely it's a rebound pain from the opioids and obviously giving more of those will only make their headache linger, so they get a non-narcotic for that or an ice pack or no meds until the headache subsides.
There's a lot of individual factors that must be investigated before giving pain meds just because the patient asks for them. Thats our job as a nurse: investigate within the constraints of your time, and within the subjective and objective data.
After a combined 7 years of ED and floor nursing, I've decided to venture into homecare. I love it because there's rarely any of that drug seeking behavior you have to deal with, and if there is, you educate, inform the doc, their family member, and other staff; and of course, make sure you chart your *** off.
Those people drive me insane. I asked a guy his pain level one time and described it to him as “Zero is no pain, and ten is you’re on fire and your skin is falling off”. He replied, as he calmly sat in his bed, “Oh, about a nine”. Ooooh-kaybee!
I give them their medications, but no early PRNs, and I am firm with them. They can throw a pitty party all they want. Thankfully, as nurses, we go by what the docs order. We can’t just deal out drugs like candy, so you can always use that excuse to fall back on (even though they’ll still whine and complain). Good luck. It’s a pain, but those kind will always be around, so it’s just something we deal with.
If they are an addict, there isn't anything you are going to do during their stay that is going to curb that. It took me a long time to wrap my head around, "the hospital can't solve every problem".
Just give the meds as ordered and wait for the discharge. Trust me, the physicians know what is going on and I'll tell you why they keep admitting them.
Addicts come in with tons of other issues as a result of their drug use that is typically layered as most of them engage in alcohol abuse and smoke. Nutrition tends to be poor. Add all of that together and symptoms of addiction can mask legit disorders.
Example: Female comes in, abdominal pain, she's emaciated, long history of alcoholism, ulcers, Hepatitis C, elevated liver enzymes, some cirrhosis, etc. She has been losing weight for a long time because she's a hard core addict, meth user, alcoholic, comes in, stays for a couple of days, she's right back at it the second you discharge her. Nothing to see here, right?
We had a patient that fit this description years ago...ovarian cancer was completely missed until it was advanced and she died. She had been an alcoholic/drug addict for so long nobody even looked at anything else.
This wasn't my patient, but this is what physicians fear in terms of liability and whey they keep admitting them.
You will learn to let it go after awhile. Sad, but you need to for your own sanity.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
The term "drug seeking" is a trap, because everyone who needs a drug is drug seeking. I recommend that you just don't use the term. It will decrease your resentment and frustration if you just get rid of it.
I agree with PP that you are not in an environment where you can treat active addiction. You should consider active addiction as part of the clinical picture, but you aren't able to treat it. If a patient tells you he is a drug addict and wants treatment, you need to refer to another facility.
Dependence, however, is very important in your environment and dependence is not the same as addiction. Dependence can happen very quickly with some of the meds you give in the hospital. Make sure your patients have an appropriate taper and exit plan so they don't wind up in the emergency room with withdrawal symptoms.
I work outpatient and we also have a lot of drug seekers (I work in community health). We have a pain management APRN who writes bucketfuls of narcotic prescriptions. Then the patients call angry when they run out of refills and/or say that they left their pills on the bus and need a replacement. My mental strategy is, I just make myself assume that they are all legitimately suffering from terrible pain and aren’t addicted at all. Now, the logical part of my brain is aware that that’s probably not the case for some percentage of them. But since it’s not my problem, and I can’t control it, I choose not to think about it. If I am ever an APRN I can handle my own practice differently. But right now, well, here’s the script for oxy from the provider, sir, I hope you feel better soon.
I take a completely different approach and go home with my conscience in tact. If they want a drug dealer, they can return to the street where they were buying their meth/heroin/crack. While they're here, any contraindication will be utilized to avoid administering unnecessary narcotics. Not just for them, but for me. Figuring out how to avoid being sucked into becoming someone's drug dealer took me about a year. I go into these situations well aware they'll throw an adult temper tantrum when I explain their contraindications then security may be called. I'll have avoided doing anything unsafe while also avoiding manipulation. Win win.
You can stick to your guns without any intention of "curing" their lifestyles. It's certainly made me feel a lot better.
I take a completely different approach and go home with my conscience in tact. If they want a drug dealer, they can return to the street where they were buying their meth/heroin/crack. While they're here, any contraindication will be utilized to avoid administering unnecessary narcotics. Not just for them, but for me. Figuring out how to avoid being sucked into becoming someone's drug dealer took me about a year. I go into these situations well aware they'll throw an adult temper tantrum when I explain their contraindications then security may be called. I'll have avoided doing anything unsafe while also avoiding manipulation. Win win.
You can stick to your guns without any intention of "curing" their lifestyles. It's certainly made me feel a lot better.
Sounds like a lot of work. I don't have time to look for ways not to medicate someone. If they have a legit order, and the med isn't contraindicated, I give it as ordered. I learned long to take to heart "pain is what the patient says it is" and just treat and move on. Trying to find ways to "beat" a manipulative patient is a waste of time and energy.
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ruby_jane, BSN, RN
3,142 Posts
So....this is one of the problems, and it's completely out of your control. I don't know I'd be doing anything but the stuff ordered if I had six or seven patients in a shift. Is it possible that you're exhausted and that your tired (and I'm tired for you just thinking about six patients) is making it more difficult for you to disengage? Hang in there.