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

[ella2990]

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.

[Ben_Dover]

All points are valid.

One thing that concerns me the most is the pt's significant other, who perhaps, "might" be sneaking in some other type of medications or illicit drugs for her. That's when it becomes truly problematic, i.e., if the pt. does OD and without you not even knowing what the patient may have had taken.

Is it possible?!

Yes, very much so!

Lesson learned, if there's any, is that: just be always on the guard and continue to follow-up with your PRN effectiveness with v/s per your company's protocol. DO check that respiratory rate and level of "arousability"

[Daisy4RN]

Sorry you are having a tough time. While it is important to protect your license, it is just as important to care for any patient to the best of your ability without personal bias. I am not saying you did or didn't show bias, but it is true that we all have them. That being said, I have taken care of patients who have shown these type of behaviors and know how frustrating they can be at times. But, in order to withhold pain (or other medications) nurses need to have reasons why other than the fact that you are worried. If you can document decreased VS, LOC (specific to that pt) etc than there should not be a problem withholding and you should also speak to the MD and doc that too. If the patient is yelling etc that is not a reason. Just give the pain meds (if no adverse s/s from previous meds), observe/assess the pt appropriately, document appropriately either way, and move on with your day. In the med/surg unit you are not going to be able to address the issues causing the overuse of meds but you can address the pain and other post-op issues, just focus on that and make the situation the best you can for your patient and yourself.

[CCRN2BE]

Yes we do reporting and I did explain why she rapid in my previous replies.

When I say I am a new nurse, I am not looking for an excuse, IMO 2 yrs of experience is nothing compare to 5 or 10. So yes I have a lot to learn and a long way to go. Like I said our unit is very young 70% of the nurses in our unit are new grads and our most seasoned nurse has 4 years of experience. So I didn't really get the kind of advice that I got here when I asked around our unit for opinion.

I really do appreciate all the post here as it did shed new light on how to handle pain management. And I never really knew how high their pain tolerance is because most of my pts who were post op only required a low dose of pain meds. So when I saw the dosage and frequency I freaked.

AGAIN THANK YOU ALL FOR TELLING ME YOUR EXPERIENCES.

At the end of the day, you learned something from this experience and from the explanations provided by those here (that you unfortunately don't have readily available while at work).

I see it as a sign of maturity that you acknowledge your shortcomings, learn from them and do it in a respectful and non-defensive manner. I bet you are a good nurse who will only get better with time and experience. Good luck to you in the future.

[amzyRN]

Assess her LOC and VS paying close attention to respiratory rate and SpO2, then treat her pain with those in mind. She probably has a very high tolerance and just because she is a drug addict doesn't mean she shouldn't get treated for her pain. I'm wondering though why she's not on an epidural infusion though. I've used those when on a surgical floor or PCA so I didn't have to go back in to give meds every hour.

A BP in the low 90s with a MAP greater than 60 isn't that dangerous, but I think narcotic meds should be held until you have an SBP greater than 100. (I'd ask the doctor if the BP was okay to give it and document) Narcotics can cause low BP, bradycardia and decreased respiratory rate. Those need to be monitored closely in any patient, high tolerance or not, so I agree she should have been monitored more carefully. Maybe continuous pulse ox. I think you did the right thing in that you wanted the patient to be safe while also guarding your license.

If her vitals were stable and she was awake with adequate respiration I think you should have given the meds.

One of the biggest reasons I left floor nursing is the stupid patient satisfaction garbage. I thought the ER would have less of it, and it does to a certain degree, but it is slowly creeping in.

[mushyrn, BSN, RN]

You got a Bachelors degree with English writing like that? Let's talk about that for a minute.

But heck no. IV drug user doesn't need all of that crap. Poor MD work, they should consult pain management.

[Purple_roses]

OP, with respirations and SpO2 like that, I would have held the meds as well and documented exactly why I wasn't giving the med. Doesn't even have to do with drug use.

[Kooky Korky, BSN, RN]

That's what I was thinking also.

depends on the patient/whole situation

[Kooky Korky, BSN, RN]

OP, first, your boss has her head so filled with "patient satisfaction" that she didn't even really address, apparently, your concerns about

overdosing the patient.

Next, the doctor should be flogged for not dealing with the problem by revising the orders or referring her to Pain Management.

Stop saying "cater". It has a negative connotation and makes it sound like you don't like the patient and find her unpleasant to deal with.

Even if you do, don't say it. Say something like "meeting" her needs.

How often do narcotic orders have to be renewed at your facility? I'm betting some or all of those were expired orders. Just saying.

Keep looking out for yourself as well as your patients. Yes, her tolerance of the meds is probably real and she would likely need higher

doses than a non IVDU. Seems, though, like by POD 7, she'd be having a decrease in post-op pain, but I don't know.

This type of patient is sad but you can do only so much. You might want to think about getting away from drug addicts. They need

care but you have to look out for yourself, not just for your patients.

Stand by your refusal to be her nurse again - at least until all of the other nurses have taken their turn.

[CCRN2BE]

depends on the patient/whole situation

Well, obviously. My comment was an agreement to another poster and in reference to the patient in this situation.

[MPKH, BSN, RN]

I work in a hospital that serves the downtown and inner city area of the city I live in. IVDU patients aren't a foreign specimen to me. If there is no clinical reason to hold an opiate (or any drug, really), I give it, providing that the patient's mentation and overall status is adequate.

Because of the high population of IVDU patients we get, there is a group of clinicians specializing in treating pain in people with addiction in my hospital, as well as helping people rehabilitate. That program is a godsend to us nurses.

[Fiona59]

I work in a hospital that serves the downtown and inner city area of the city I live in. IVDU patients aren't a foreign specimen to me. If there is no clinical reason to hold an opiate (or any drug, really), I give it, providing that the patient's mentation and overall status is adequate.

Because of the high population of IVDU patients we get, there is a group of clinicians specializing in treating pain in people with addiction in my hospital, as well as helping people rehabilitate. That program is a godsend to us nurses.

Let's celebrate our inner city pride! ARCH!

[3ringnursing, BSN]

I completely understand your reluctance to administer what in your opinion amounts to excessive or unsafe dosages of narcotics, but please bear in mind that the human body has an amazing ability to become tolerant to many things in a relatively short time. Her history alone indicates this patient falls into this category.

Because of her history this patient's narcotic tolerance level is extremely high, therefore it's my belief that she could probably handle even higher doses than what she was currently taking. That being said, the ability to obtain acute post-op pain relief from even frequent doses of strong narcotics is likely to be negligible in some patients whom are narcotic tolerant (meaning even with all that on board she was probably still suffering from pain even before you began withholding doses).

The tantrum you described was probably not due to drug seeking merely "to get her beloved pain meds" per se, but more likely due to the fact that your refusal to give her what the surgeon legitimately Rx'd for her has now put her even further behind the pain 8 ball of trying to remain semi comfortable (because let's face it - she will never be pain free post-op due to her very high narcotic tolerance level). Please consider that after your shift ended, assuming every incoming nurse caring for her administers her Rx pain meds exactly as ordered, it will likely take days for this patient to catch up on her pain management needs again.

I've never had spinal surgery, but in my opinion it is not unreasonable that some post operative patients could still have significant pain levels on POD 7 (Why the heck wasn't she on a PCA pump?).

The fact she was wake, alert, oriented and throwing a fit also tells me she was breathing and moving air well - therefore able to tolerate those doses just fine without imminent concern of overdose in the near future.

Discussing the patient with the inpatient pharmacist may have provided some information to make you feel more comfortable over all - and taping a vial of narcan to her IV pump or wall couldn't hurt either. Withholding pain med doses due to your personal discomfort or distaste isn't appropriate.

Next time (if possible) perhaps you could trade assignments with another nurse who has more experience with this type of patient rather than withholding the Rx meds that were ordered and the patient appeared to be tolerating? It seems cruel to allow a patient to suffer post operative pain when she didn't have to.

No offense intended, but it appears you have a bias towards patients with histories of IVDU. Regardless of your personal feelings, these are still patients who deserve adequate post-op pain management, as well respect as a person. Being a patient, or suffering from pain sucks.