Was I wrong?

[Munch]

Bear with me for this is going to be a little long. I was covering part of a shift for a co-worker on my scheduled day off. The shift was 7am-730pm and I was working 9 to 3:30 for her on the regular med-surg floor(I work Neuro med-surg normally).

I came in and my co-worker gave me report on her patients and then she left. She told me she did everyone's vitals and morning meds so everyone was set that the only thing she asked me to do was to give her sickle cell patient her PRN morphine. So I went in and accessed the patient and the poor girl was clenching the side of the rails squeezing her eyes shut she was obviously hurting. She was admitted for pain control and dehydration. She had orders for morphine 6mgs IV q2hr. Oxycontin 40mgs q8hrs, ativan 2mgs IV q6hr she also had prns for benadryl and zofran forgot the dosages though..probably 25mgs and 4mgs respectively. So I went in and gave her the morphine and she said it hasnt been working and the other nurse was supposed to get an order for something else. The other nurse made no mention of this to me so I called her doctor.

I spoke to the resident and he was open to my suggestions so I suggested this patient would be a good candidate for a PCA since she was requiring PRNs Q2 and wasn't getting much relief from that I thought a PCA would be good for this patient. Not to mention most sicklers I get on my floor are on a PCA and do well. So I got an order for a fentanyl PCA and the doctor also ordered toradol 30 IV q6 and a one time dose of IVP fentanyl 50mcgs to break the pain she was in since the morphine didnt help and to hold her while I was setting up the PCA. So I gave her the fentanyl and toradol and just after that she said she was feeling a bit better. I gave her the PCA and about an hour and 15 minutes after I set it up for her she was up and sitting in a chair watching TV and drinking cranberry juice where before she was clenching the rails looking(and feeling I am sure) like death warmed over. She was smiling and thanked me and reported her pain down to 3 when it was a 9 before.

Now this is where the trouble started. My co-worker came back shortly after 3:00 to finish the rest of her shift. I gave her report and of course told her about her sickle cell patient how the morphine wasn't working and how I got her a PCA. My co-worker went ballistic on me. She told me this patient was a known drug seeker and scammer how she comes in the hospital all the time for narcotics and 3 hots and a cot and she was going to do everything in her power to get the PCA d/c because she wasn't going to cater to this addict when she had other patients with real problems to deal with. She was also mad that I didn't call her and consult with her about getting HER patients meds changed. I was just covering I should have just followed the med orders and she would be the one calling for order changes not me.

Am I losing it or am I really in the wrong here? This patient was obviously in genuine pain and with a sickle cell diagnosis I would rather treat faked pain then not treat potentially real pain. Also she didn't say one word about this patient being a seeker. She actually asked me to give her patient the morphine. I dont think anything is wrong with calling and getting a patients order changed that was visibly in distress. Its not like I was covering a lunch break. According to this nurse I should have made this poor patient wait 5 plus hours in excruciating pain for her to get back. I also didnt see any drug seeking red flags. She wasn't asking for any of the double D medications(demerol or dilaudid) she wasn't reporting 10 out of 10 pain while laughing on her phone and scarfing down trays of food and her HR was 110..she was in pain.

What would you have done? Would you have waited for your co-worker to get back or would you have called for a different order?

[3ringnursing, BSN]

No.

You were in the right, and by the laws of Occam's Razor, she was not {i.e., You (right) = She (wrong}.

Any questions?

[RNMomma91]

From the moment you received report she became your patient. You did exactly what any prudent nurse would do. It's not her place to make the decision on whether she believes a patient is experiencing true pain or not. I would report her behavior to a supervisor and I would never cover for her again. I understand that dealing with drug seekers can wear on a nurse but once you become that jaded you should probably take a break from that area from a while.

[mmc51264, BSN, MSN, RN]

All of our SS pts get a PCA. It is a horrible disease and many of them have high pain/high narcotic tolerance because of the disease. PCA meds can be better regulated than having prn meds to give. You would spend your whole day medicating one pt.

[Munch]

You did nothing wrong. Regardless of whether or not you are covering part ofsomeone's shift, once you take report and the patient is handed off to you, you are supposed to provide whatever care you think is best (provided of course you are engaging in evidence based practice and not doing anything against policy).

If this were me, I would report the incident. Even if you did do something wrong, her response was very inappropriate and surely against your organizations code of conduct. Also, just because you suspect a patient is a drug seeker and even if you know they are an addict, you still assess and treat their pain the same way. Considering he fact that addiction is now a diagnoseable disease, she is doubly wrong.

IMO from what you said, your coworker is not a good nurse and may actually be harming patients by improperly addressing real pain. Even if you are one of those people who think addiciton is not a disease and addicts should not get narcotics, you should realize that you arent going to cure their addiction during this admission and giving them the meds isnt going to make things worse, it might actually make things better because what if (and this happens relatively often) they sign out AMA because they arent getting enough drugs and instead go and do something illegal or dangerous? Regardless of you views on addiction, you have to admit that getting pharmaceutical quality medication while being monitored in a hospital setting is safe better/safe for the patient and everyone else than having them do something dangerous/illegal (i.e. mug someone for drug money) and use street drugs that are not only sterile, but could contain any number of harmful even deadly additives. Even from a financial perspective it costs a lot less to give and admitted patient pain meds than treat them for hep C or other drug use related disease later on.

Sorry to rant, In short, your coworker was wrong and you did everything right. Even if we ignore the whole addiction is a disease thing she still behaved inappropriately in front of a co-worker and you treated you patient according to how the ANA, state BON, and most medical professionals would consider correct.

I totally agree with what you are saying. I am a big believer in harm reduction and while I DO NOT think we should be giving every addict that walks through their doors a fix but we aren't going to cure addiction in an acute care setting. Also my hospital serves a lot of underserved people with addictions so I see the outcome the war on drugs has created(a different discussion all together). Not to mention with this patient..addiction or not she has a painful condition that requires narcotics regardless. Withholding pain meds from her is not productive. Even if she admitted she was an addict and got her into detox its counterproductive she is going to need narcotics sooner or later.

[Munch]

Thanks for being a patient advocate, your actions were appropiate to acheve adequate pain control. I've cared for hundreds of patients with Sickle Cell Disease.... they are admitted often for pain management and hydrationmany with vaso-occlusive disease causing cell and bone death, which many nurses don't understand. Following article informative of this disease.

Sickle patients best managed by Hematologist. Having a pain management + care plan for handling acute crisis as part pf patients medical record is best practice these days.

American Academy Family Physicians.

Approach to the vaso-occlusive crisis in adults with sickle cell disease

Thank you for that information! We see such a huge population of sickle cell patients in my hospital as well. Actually when I came on that day I was covering I found it odd the patient wasn't on a PCA. When we get med-surg overflow on my floor(which actually we mostly have more med-surg patients than Neuro patients on my floor at any given time) we get a lot of sicklers and they always come up from the ED with a PCA order. If not and they require q1hr or q2hr narcotic doses then we get a PCA ordered right away. So I was just doing what was standard on my floor by getting her a PCA.

[crashcartqueen, BSN, RN]

I hope your coworker is never my nurse...

[mudd68]

You did the right thing but her behavior makes me think that maybe your co-worker is the addict and has been stealing the patient's morphine for herself (I've witnessed this in previous hospital jobs I've held). She might be furious that the PCA won't require her to get narcs every 1-2 hrs. Just a thought.

This was exactly my thinking! This type of reaction raises red flags in my opinion.

[PudgeMC, ADN]

How can she call the PT "HER PT" if y'all both worked half of the shift? Isn't she the one that told her that she was gonna try to get the orders changed in the first place?

I would've done the same thing.

[Munch]

I hope your coworker is never my nurse...

Me too I would never want her as my nurse either. Thankfully the patient I was talking about will be going home tomorrow. A good friend of mine that floats on that unit often told me the patient is going home tomorrow on her oral regimen that they tweaked a little bit. It was oxycontin 40mgs q8hrs with OxyIR 15mgs q6hrs for BTP they bumped up her oxycontin up to 60mgs q8hrs and her oxycodone 15mgs q4hrs prn. So that should help her and hopefully prevent her from having to come to the hospital for crisis pain. As for this nurse my friend said a lot of the patients have been complaining about how she is being stingy with pain meds, not getting them in a timely manner if at all. The charge nurse is going to have a talk with her so hopefully the situation should resolve.

[NuGuyNurse2b]

I think your friend nurse is being stingy on purpose. She wants those sickle patients to request anyone but her. It's old hat. We have one on our floor who's notorious for that. The sickle cells require PRN Dilaudid or whatever drug of choice Q2-3 hrs and that becomes a heavy assignment cause they also request their Benadryl and heaven forbid that IV line clots, you're looking at a very hard stick. One of our regular sicklers - their IV line literally goes bad within seconds when you're changing IV bags. We finally got them to agree to a PICC line and it's been so much better. So your nurse friend is making it obvious she's not a good fit for this patient, hence don't assign her this patience, since the sickle cell patients are often recurring patients and I don't know about your facility but at mine, they typically hang in the unit for 3+ weeks.

[Have Nurse, ADN, RN]

You owe her no courtesy to get her opinion first. You owe no apology. The other nurse does not have the right to diagnose as to whether or not your pt was a "known drug seeker." Pain control is a priority regardless. You did just fine, Sweetheart!

[Have Nurse, ADN, RN]

Good point. ...hadn't considered that. Perhaps it is time for a drug test.....