IVDU pt kept asking for pain meds. Managment kept saying to just give it to her.

Nurses General Nursing

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I have a question, I'm a newbie nurse with only 2 years of experience. So, I work at a med/surg tele floor. I was assigned a pt who was very well known to be an IVDU and frequent flier. Pt was POD 7 from a spine surgery (totally forgot what the actual surgery was) and was getting pain med basically q1hr. She had orders for:

1. dilaudid PO 4mg q3hrs scheduled

2. dilaudid 2mg PO q4hrs PRN

3. diladid 2mg IV q2hrs for BTP PRN

4. oxycontin 10mg PO q12hrs scheduled

5. toradol 30mg IV q6hrs PRN

(**YES THERE ARE PAIN LEVEL PARAMETERS, but this pt is very manipulative and will do anything and I mean ANYTHING to get her beloved pain meds***)

So the nurse from previous shift was basically giving her pain meds every hour!! I did not feel that it was safe for her (and for my license) to be giving her all those pain med. It was a weekend and that particular surgeon who did her op was off. So I called their office and asked to for the on call dr. to be paged.

Dr. K came in to round on that pt, I told him my concern that Ms. so and so had been getting these kinds of pain meds basically every hour. The dr. was shocked when I told them all the kinds of pain meds and diff doses she was taking. He asked me who that pt was again and who was her primary ortho surgeon. I told him it's Dr. ***. Dr. K reacted very nonchalantly and said "Oh yeah she's known to our practice. She has high tolerance for pain meds since she's an IVDU. If she's still breathing just give it to her." I told him that her BP was low and his reply really caught me off guard, "I don't want to mess with whatever Dr. *** prescribe to her. Just wait for him to come back on Monday."

I was literally speechless!!! Pt's bp was already in the mid to low 90s, pt was not hooked up to tele.

Bottom line, I did not cater to her, I did not give her pain meds EVERY HOUR I made sure that atleast 2 hours has passed before I give her another pain meds. I explained her the legal side of nursing. Needless to say, she threw a **** show and threw the biggest tantrum a grown woman could every throw.

That pt filed a complaint against me to my director. My director talked to me and told me to just give her whatever MD ordered for her to have. I told her, NO it is my license on the line and not yours, if something were to happen to my pt it is not YOU AND YOUR LICENSE that would have to sit in front of the BON trying to explain why you did what you did. She said that it is very important that we earn pt's satisfaction.

I felt defeated and seemed like her priority was pt's satisfaction and not pt's and nurse's safety.

I told her and the charge nureses (whoever will be doing assigments) that I NEVER WANTED HER BACK as a pt.

DID I DO THE RIGHT THING? I MEAN I KNEW HER TOLERANCE FOR PAIN MEDS ARE HIGH GIVEN HER HX. BUT YOU REALLY NEVER KNOW WHAT WILL HAPPEN. 1 DAY SHE COULD BE FINE THE NEXT 2 FOR ALL I KNOW SHE'S OD from pain meds.

Specializes in ICU.

I do think you were wrong in this situation, but I also do understand your concerns and point of view. In this case you spoke with the provider, he explained that he was not concerned by the dosing and that you should follow the orders. So, I would have followed the orders, end of story. I would have documented your concerns, given her the meds, and closely monitored vitals. I also would have taken another approach with the provider when you spoke with them. Rather than trying to argue your point with them after they said to follow the orders (with your statements re: her BP, etc), I would have simply requested additional monitoring for her and also an order for narcan just in case. Specifically I would have asked for her to be on continuous end tidal CO2 monitoring- a simple solution to assessing whether her airway was impacted by the meds. Tele wouldn't hurt either.

I do completely understand where you were coming from with your reluctance, but the doctor said to carry out an order and you refused. You mention the legal side of nursing, and from that perspective you were wrong here.

I would have simply requested additional monitoring for her and also an order for narcan just in case. Specifically I would have asked for her to be on continuous end tidal CO2 monitoring- a simple solution to assessing whether her airway was impacted by the meds. Tele wouldn't hurt either.
Smart. Good suggestions.
Specializes in Critical Care.
...

After that I was afraid to give her pain meds every hour.

This seems to be the gist, by itself the frequency that a patient is receiving a med isn't really a useful predictor of overmedicating a patient. Giving a patient x dose of opiate A every hour is no different than giving them 4 times that dose every 4 hours. What you're evaluating is the patient's response to the medications regardless of the dose or how often they are being administered; are they lethargic, somnolent, obtunded? Are they not protecting their airway? CO2 level? Is their RR 6? etc. Is there a pain contract in place?

(**YES THERE ARE PAIN LEVEL PARAMETERS, but this pt is very manipulative and will do anything and I mean ANYTHING to get her beloved pain meds***)

...she threw a **** show and threw the biggest tantrum a grown woman could every throw.

That pt filed a complaint against me to my director ... have to sit in front of the BON trying to explain why you did what you did.

First, when I hear nurses say things like this about patients my blood boils. Do you think any person wants to be an addict? Do you think they enjoy their lives falling apart, their closest relationships collapsing and all their hopes and dreams evaporating? Many of these people had an awful life from the start and it's no wonder they turned to this. So before you judge someone for ANY reason, stop for a second and think again why you decided to enter a profession where your job is to care for people even when society deems them the lowest of the low.

Second, denying patients a prescribed treatment with no clearly discernible, objective, observable facts or reasons is just as risky for your license. Don't do it again.

Third, if she was screaming and throwing a tantrum for meds then she was probably fine to have the meds. Most EMRs have a double check to see if the patient's condition will tolerate another dose of narcotic. (you should be able to do this in your head without prompting) It will ask LOC, respirations, O2 sat, etc. If she meets the criteria, she gets the med - see my second point. You're not a prescriber and you do not get to modify treatment plans in that way.

I have had patients getting doses of 36mg dilaudid PO - at one time - and more. It's all relative and not every patient fits into your singular views of treatment modalities.

1- Those are dumb orders. The doc MUST consider that every PRN will be used, and write limits if appropriate. Seriously poorly written. Q3 scheduled meds represent a particularly high level of idiocy. She gets woken up for pills?

2- Follow appropriate nursing procedures, and document. If you hold a requested PRN, document the slurred speech, or slow breathing, altered gait, or whatever it is, other than the number of mg, that is causing you concern. A SBP of 95 is not a good reason to hold narcotics. A SBP of 135 that drops to 95 after med administration might be.

I might have missed it, but was there a reason, other than the number of MG not to give meds?

3- You may have a common affliction: Lossoflicenencephobia. Check your BON and see how many nurses are now saying "Want fries with that?" because they gave medications as ordered.

Yes her RR would average only 8-10 and I saw her past trend she went as low as 6 but was easily arousable. As for LOC, yes she was lethargic but can still be aroused with touch . O2 was in the low 90s and would occasionally drop down to the high 80s when asleep. As a newbie nurse if I was not 100% sure whether to do something or not I ALWAYS asked a more seasoned nurse what their opinion is. Our unit is very young and the most seasoned nurse we have has 4 years of experience, even SHE'S icky to give that much pain meds. I always do assessments before giving her pain meds and yes she's mostly lethargic but oriented when aroused. Again, her bp was in the low 90s. That seasoned nurse told me to hold the pain meds because her BP is low. Yes maybe a more seasoned nurse like the majority here would not be fazed with a low 90s as BP but then again I am a new nurse.

To those who are saying that I should leave my personal beliefs outside the hospital, that I should NOT be treating pts that are POST OP and that I am being judgmental by calling the pt "manipulative".

First of all, I never intertwine my personal belief with work. I do as I what I am expected to do at work, but in this situation I really did not feel comfortable giving her all those pain meds. You guys will probably tell me "Then you shouldn't be taking care of that patient!" Yes, I told the charge nurse never to assign me to her because I think I will never be able to give her the care that she needs. When I was a nursing student we were always told that if we do NOT feel comfortable doing a certain thing then we have the right to say no. Of course just because I said no I'm not comfortable doing that so I won't do it -- I would always explain the situation to the charge nurse and ask if I can delegate that task to her so that the pt will not be neglected.

Second, I have had many post op patients and I can 100% say that NONE of them has had any issues with their pain when I am their care givers. I always do subjective and objective assessments. I'm not going to say that I AM AN EXPERT WITH ASSESSMENT. I always advocated for the patients! I had another IVDU pt, like her, he was getting high doses of pain meds every 2 hours. The difference was that the patient was very restless, agitated but not hostile, his vitals were SKY HIGH!! I know he's not getting adequate amount of pain medicines. I advocated for him!! The dr just shrugged it and told me "eh he's a user and probably just seeking" -- that was the Dr's POV. I get it. But I am not letting that patient suffer just because the Dr thinks he's just a user. When the Dr didn't listen to me, I made sure I used all my resources -- charge nurse, unit director, nursing supervisor, and MD supervisor were all involved. In the end the patient was cared for and the pain was well managed. SO PLEASE TO ALL THE PEOPLE WHO POSTED THAT I AM BIASED AND ACTING ON PERSONAL BELIEF , YOU ARE WRONG --It's just this particular patient that I have had trouble with. Yes, I do not know how her body operates and how her body tolerates pain med, but again when I do my assessments subjective (when she's fully awake, she will say that yes she is in an 8 out of 10 pain while eating an ice cream and laughing while watching a movie, AGAIN NOT JUDGING, maybe that's her body's coping mechanism, I DON'T KNOW, but I still give her the benefit of the doubt) and objective (vitals are not WNL -- probably to some it's not concerning if her bp is in the low 90s resp 8 or 10 O2 low 90s% -- BUT THEN AGAIN you guys have to remember I am a new nurse I AM LEARNING)

Third, I did not see her manipulative at FIRST, because again, I gave her the benefit of the doubt. Other nurses would see her as a "manipulative B". But because of the on going issues about her pain management and more nurses were complaining about her (yes I was not the only one uncomfortable giving her those pain meds). The admin decided to intervene. They sent a psych nurse to our floor and all of the staff had a meeting regarding the situation. All of the nurses complaints and concerns were all laid out on the table. The psych nurse was told that the patient --

1. Would fake a seizure just to get what she wants (neuro examined her and wrote that it was not a real seizure)

2. Would say she has psych issues, she's depressed and bad anxiety "high dose of ativan" (psych MD was consulted and the pt was evaluated - I don't remember what the psych md had written in his notes but he prescribed her ativan 1mg PO)

3. Would throw tantrums if she didn't get her pain medicine ON THE DOT (I kid you not -- she will lash out if you're 5 mins late -- I promise you I am not exaggerating)

3. Would curse every nurses that would not give her meds every hour (I don't know about the other nurses but I told her at the beginning of my shift that I will be doing an assessment before I even give her any pain medicines. I also told her that I do not feel comfortable giving her pain meds every hour because -- I gave her a speech about the whole thing about CNS depression, giving narcan if that ever happened and what narcan is for, the pt probably knew what narcan was but I just went on educating her -- I also told her my strategy that day on how we're going to schedule her pain meds -- q2 not q1 -- I also asked her that if she has any concern or questions with what I had said. At that time she did NOT have any problems with what I have just told her)

After that meeting -- the psych nurse went in the pt's room -- made conversation -- assessed her. How she ended up with saying she's manipulating us, I don't know. So, with that said - when I say she's manipulative - it came from a psych nurse.

**I AM TRYING TO DESCRIBE EVERY SITUATION AS THOROUGH AS I COULD SO YOU GUYS CAN PAINT A BETTER PICTURE OF MY SITUATION***

I apologize if I you think I am bad mouthing the patient -- that is not my intention

Again, I joined this group to gain knowledge. I will accept constructive criticism wholeheartedly. But what I do not accept is when people who do not know me as a nurse are telling me that I should NOT be taking care of a certain type of patients.

Next time you post, mention the objective data and leave the denigratory/demeaning remarks about the patient out. I think that is what turned off most of the posters (including myself). I really can't stand it when I hear health care providers make remarks like that. Now, with the additional information you added, then I agree, perhaps she was getting too much medication. I also agree that those orders could be cleaned up a bit because they are sloppy orders.

So I have a work friend that had this similar experience with a pain clinic patient. Here's my advice. Don't let your beliefs and opinions get in the way of patient care. If this person is a drug addict, you are not going to cure them by withholding a dose or 2. If the patient's BP was in the 90s after getting pain meds q1h sounds like he or she was tolerating well. How were O2 sats? RR rate? LOC? Looks like the provider was okay with what he or she ordered. It was good to question the orders if you had concerns, but when you did, they said it was fine. I know you were trying to do what you thought was best but don't let your personal opinions or beliefs about addiction get in the way of a patient getting pain control. That patient undoubtedly had a huge pain tolerance. I think you were in the wrong in this situation. That being said, I've been wrong before too. Take it as a learning experience!

Specializes in Pediatric Critical Care.

DID I DO THE RIGHT THING? I MEAN I KNEW HER TOLERANCE FOR PAIN MEDS ARE HIGH GIVEN HER HX. BUT YOU REALLY NEVER KNOW WHAT WILL HAPPEN.

(you guys have to remember I am a new nurse I AM LEARNING)

Again, I joined this group to gain knowledge. I will accept constructive criticism wholeheartedly. But what I do not accept is when people who do not know me as a nurse are telling me that I should NOT be taking care of a certain type of patients.

You appear to have gotten a lot of constructive criticism and good advise here in this thread. Hopefully it has contributed to your learning and will be able to grow as a nurse from this experience.

Your job is to follow prescribed medication orders and GET THE PATIENT COMFORTABLE.

Instead, you chose to judge the patient and worry about yourself.

I truly hope you are written up for this travesty of nursing judgement.

Blondekristi and Been there,done that

Please read my previous post. I explained everything regarding personal beliefs, and why I thought it was unsafe based on my assessments. It wasn't solely based on MY judgment. I ASKED OTHER NURSES FOR THEIR OPINION. They too were not comfortable.

Your job is to follow prescribed medication orders and GET THE PATIENT COMFORTABLE.

Instead, you chose to judge the patient and worry about yourself.

I truly hope you are written up for this travesty of nursing judgement.

Honestly, I find that a bit harsh. Not the part about getting the patient comfortable, I obviously agree with you on that. But nursing judgement comes with experience and OP is still a newish nurse. To make things worse, it sounds as if the nurse with the most nursing experience on her floor has a grand total of four years. Not an ideal situation in my opinion. For new nurses who live in fear that their licenses will be revoked for any reason under the sun, the security that one or two 20-year veterans provide, is priceless.

Personally, I think the solution here is information/education, not a write-up.

Then 10 mins before shift change they had to call a rapid on her. I was not involved in the rapid because I was asked to man the nurse's station because our DA left early while the charge nurse was running the code. So I did not get the whole story on what led her to a rapid response.

After that I was afraid to give her pain meds every hour.

OP, you should have found out why the rapid response occurred before you assumed responsibility for the patient. There should be an established routine for this, whether it's giving verbal report at shift change or if it's reading up on the patient's chart. (A rapid response and the reason for it should of course be included in a patient's chart). You're now saying that this rapid response that you didn't really know all the details about, contributed to your worry/reluctance to give the prn meds as prescribed. You have to be in a situation where you base your decisions on all the pertinent and available information. The whole thing seems a bit disorganized.

(It would have been helpful if you've included the rapid response information in your original post).

Judging from your first post, it really seems like of all the vital signs it was the patient's blood pressure that was your main concern. You only added information about oxygen saturation and respiratory rate in a later post (those two vital signs along with level of consciousness would have been of more interest to me). Why did a blood pressure in the low to mid 90's ( and I'm guessing a ~60-ish, 70-ish diastolic pressure??) have you so worried? As another poster mentioned, the patient had received most/all? her ordered meds, including prn's during the previous shift. With a MAP of approximately 70 mmHg you have adequate organ/tissue perfusion. Oh, and I'm sure that you know this already but if you have a post-surgical hypotensive patient, always keep hypovolemia in mind as a possibility.

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