I had a Resident that threatened to sue/ call the state on the facility because she did not get her PRN dose of Oxy IR/ Vicodin RIGHT on schedule.
1. Resident says she is in 8/10 pain, and has been 'falling asleep but had to stay awake to get the next dose of pain meds' I re-educated about the pain scale and how w/ 8/10 pain you cant possibly be asleep and if you are asleep that's a good thingetc...
2. Resident pulls call bell right on schedule for PRN meds (all of them) and says she needs then NOW. When i am even 3 minutes late, she starts cursing and rolling around the bed.
3. Resident writes down all the doses and sets an alarm clock to wake her up during the night to get her PRN meds and then complains that she has had no sleep.
- How do you handle such a pt. One who has admitted to popping oxy before going to work. i'm documenting EVERYTHING that i do.
i understand that i am biased about this... its really frustrating and i need some advice on how to deal with this.
Look, my daughter had a traumatic brain injury from a car wreck. She had 10/10 pain, yet we did meditation to help it and she always appeared to be sleeping when she was meditating. Brought in a neuro guy that did accupuncture as well . Nurses refused to give scheduled pain meds because she was "sleeping". She WASN'T sleeping, but meditating. her pain from 4 brain bleeds was 10/10. This remained a constant battle. My 100 lb. kid with 17 bone fractures was a a fentanyl patch of 75, morphine, , 2mg of dilaudid every 2 hours, fiorocet with codeine and her pain could NOT be controlled.
Due to the brain injury, she would just lay there, but she suffered terribly due to nurses that didn't assess her pain, didn't even ask her, or didn't even comprehend the severity of her trauma. She simply laid there and suffered until I demanded treatment.
So she is an obvious suspected addict. It's NOT our place to detox and cut ANYONE off pain meds. detoxing someone that is a suspected addict has it's place and time. It is NOT in acute or recovery care or even in a nursing home.
Withdrawal from long term narcotics causes life threatening complications and should never, ever be played with, unless you are in an ICU setting. Cutting a patient off, can lead to their death from withdrawal and any "suspected addict " as you claim, needs to go through a safe detox, not what at all of what you are suggesting we do. Patients DIE of acute renal failure due to rhabdomylosis from the shakes from nurses that withhold meds... food for thought. You CAN CAN CAN kill patients by making them go through withdrawal without treatment. That is very poor nursing to say the least.
Just skimmed all the responses and don't know if I am repeating someone but I didn't see it - pain interferes with healing. Keeping a pt well medicated and managing their pain ON schedule promotes healing and results in less med use over time. Letting meds lapse and the pain to build up makes it longer/harder for them to get the relief they need. EBP is for a reason...
I had a Resident that threatened to sue/ call the state on the facility because she did not get her PRN dose of Oxy IR/ Vicodin RIGHT on schedule.
1. Resident says she is in 8/10 pain, and has been 'falling asleep but had to stay awake to get the next dose of pain meds' I re-educated about the pain scale and how w/ 8/10 pain you cant possibly be asleep and if you are asleep that's a good thingetc...
2. Resident pulls call bell right on schedule for PRN meds (all of them) and says she needs then NOW. When i am even 3 minutes late, she starts cursing and rolling around the bed.
3. Resident writes down all the doses and sets an alarm clock to wake her up during the night to get her PRN meds and then complains that she has had no sleep.
- How do you handle such a pt. One who has admitted to popping oxy before going to work. i'm documenting EVERYTHING that i do.
i understand that i am biased about this... its really frustrating and i need some advice on how to deal with this.
I work in acute care. I prioritize and have to. so the ones who time their cell phones for their oxy ir etc I don't care except that if i have something more important to do or am in the middle of getting a patient off the bed pan the, " pain meds right on the dot" will ahve to wait. too bad... I might have doubts about their so called 10/10 pain but will give them their prn meds as long as it is not contraindicated. Now what i hate more is the times the md refuses to write for more and the patient yells and screams at me and the md never brings the issue up withthe patient............
1. Resident says she is in 8/10 pain, and has been 'falling asleep but had to stay awake to get the next dose of pain meds' I re-educated about the pain scale and how w/ 8/10 pain you cant possibly be asleep and if you are asleep that's a good thingetc...
While this is true of acute pain, people who experience chronic pain often live with very high pain levels, and yet their behavior and vital signs don't reflect their stated pain score. With acute pain, a score of 8/10 would be accompanied by abnormal vital signs and behaviors such as moaning and writhing. With chronic pain, however, the mind and body adapt over time. A person can be experiencing a high level of pain without the associated changes in vital signs and behavior that you might see with acute pain. Add acute on chronic pain into the mix, and things can get complicated!
Because of this, if I have a patient complaining of acute pain, with no history of chronic pain, and they're telling me their pain score is 8/10 while texting on their cell phone and snarfing down a burrito, I tend to think that perhaps their stated pain score is not as severe as an 8, and maybe they don't understand the pain scale. I might grab one of our visual aids and go over it with them, just to make sure we're on the same page. However, if the person has a history of chronic pain and they're complaining of 8/10 pain while texting and snarfing, I tend to believe them.
2. Resident pulls call bell right on schedule for PRN meds (all of them) and says she needs then NOW. When i am even 3 minutes late, she starts cursing and rolling around the bed.
3. Resident writes down all the doses and sets an alarm clock to wake her up during the night to get her PRN meds and then complains that she has had no sleep.
These behaviors sound a lot like pseudoaddiction, which means basically that, because the person's pain is not being adequately addressed, they adopt behaviors like the ones you describe in an effort to get their needs met.
I know it's really annoying and probably feels like you're being manipulated, and I don't think anybody likes feeling manipulated.
But, picture this: You can't get water for yourself. Someone has to bring you water. But every time you ask for some water, the person doesn't believe that you are thirsty; they question how thirsty you really are, and whether you even need any water. So you learn to ACT thirsty. What does it look like when someone is thirsty? You adopt those behaviors so that the person who can give you water will believe you and give you water. You might even go to the effort of finding out how much water you can have and at what intervals, write it down and set your alarm clock, because you know from past experience that nobody will bring you water at those intervals unless you make sure.
It's a survival mechanism adopted by the person who is simply trying to get their need for pain control met. It looks like addiction, but it is not, hence the term "pseudoaddiction".
I know the behaviors can be incredibly annoying; BEYOND annoying and downright maddening, especially when you are very busy. But most likely, the person is not trying to get your goat. They are simply trying to get their needs met the only way they know how.
- How do you handle such a pt. One who has admitted to popping oxy before going to work. i'm documenting EVERYTHING that i do.
Well, unless the person is an air traffic controller, oil tanker captain, brain surgeon, or operates heavy machinery (and walks or takes a bus or taxi to work), I'm not sure it matters to me much if they have to take oxycodone to get through their work day. Particularly if they have had chronic pain long term and have been on the medication long term, most likely their body has acclimated to any sedating effects. For me, it is merely a safety issue, not a moral one.
How I handle the behaviors mentioned above is this: I make the patient my partner in trying to get their pain under control. I tell them that making them more comfortable is important to me, and that I will do my best, but I also try to keep things realistic. Sometimes I say that it would take enough medication to kill an elephant to get them pain free, and I don't want to harm them by giving them too much medication. I might not be able to make their pain go away completely, but maybe we can get it down to a 4/10 (for example), and I ask them if they think this is a pain level they can live with (and if not, what is?). Most people with chronic pain know they will never be pain free, and have a pain score that they think is reasonable for them to live with. I tell them that I will check in on them as often as I can, and that if I don't answer their call bell right away, it's not because I'm ignoring them. If I am in the middle of something I can't leave, or if I am with someone sicker who needs my attention, then it will take me a few minutes to get to them. But, I *will* get to them, this I can promise. I also try to be proactive and beat them to the call bell. In other words, if I know they will be on the call bell at precisely 6:30, I do my best to get into the room at 6:20 and beat them to the punch.
i understand that i am biased about this... its really frustrating and i need some advice on how to deal with this.
I'm glad that you are able to recognize your bias. As nurses, we all have biases, but we have an ethical responsibility to set those aside and provide the best care we can for those we are entrusted to care for. Unfortunately, sometimes our biases show, and this can influence patient behavior. I'm certain that you are not singlehandedly responsible for this resident's irritating behavior, it is multifactorial and complex. However, I have no doubts that the resident is aware of your bias, and that if you could set it aside for just a minute and see this person as someone who is hurting and looking to you for help, and doesn't know any non-irritating ways to get that help (they're just doing what they've learned)....maybe you could connect with her on some level and change the dynamic between the two of you for the better.
In a nutshell, her behavior displays a lack of trust. In order to adequately address her behavior, you have to gain her trust.
I'm also in agreement with the idea of getting the MD to reassess her pain control plan. Perhaps she has developed a higher tolerance to pain meds, and needs an increase in the dosage of her long acting scheduled medications so that she can be less reliant on her PRNs.
Thank you ~*stargazer*~ for your detailed, well thought out reply. I appreciate the time you took to read my post objectively and form a helpful reply!
I'm probably going to need a flameproof suit for this, but I can't help it. I just can't let this go without saying something in defense of addicts.
SO WHAT if they are addicted? Addiction is a physical dependence on a substance, right?
Doesn't that mean that they physically NEED whatever it is they are addicted to?
So, really, I think a lot of nurses are being unintentionally cruel when they withhold pain meds because they think the patient may be addicted. They are basically causing physical and psychological harm to a patient.
If she is breathing well, isn't snowed, and it helps her feel better, GIVE HER THE MEDICINE!!!
I get emotional over these discussions, I admit it. My father has severe pain from back, neck, and spinal cord injuries. He's a walkie-talkie, though, so no one believes him. He is often treated like a junkie. He rarely slept more than 4 or 5 hours at a time for the past couple of decades, because the pain gets so bad it wakes him up.
This year, he finally got to a pain specialist that believed him. He called me one morning at 0530, crying, because he slept through the night for the first time in almost 20 years and he woke up on his own, without having to reach for a pill bottle.
Please believe your patients when they say they hurt. If they aren't getting relief, try to work with them until they do. If they are using the pain medications to get high, then get them help, instead of judging them. It takes a lot of psychological pain to put up with all the rudeness, judging, and general crappy attitudes toward addicts.
I've been on both sides of the fence, nurse and patient. I have chronic pain, from several sources (proven by either surgery [direct visualization] or radiographic films). There isn't a day that goes by that I don't have pain, some days are worse than others (of course). Being treated like a "junkie" because of it is VERY real, as you wouldn't know by looking at me what I deal with. It's disheartening at best, soul-crushing at the worst. All you do, and want to do, is to both feel and function as normally as possible, and are frowned upon/snarked at/mocked because of it.
This is a touchy subject for me. I am not saying that addicts and seekers don't exist, we all know they do. I just honestly feel that there are less of them than most HCP's assume. That should be the last consideration, rather than the first.
Thank you ~*stargazer*~ for your detailed well thought out reply. I appreciate the time you took to read my post objectively and form a helpful reply![/quote']
I've been on both sides of the fence, nurse and patient. I have chronic pain, from several sources (proven by either surgery [direct visualization] or radiographic films). There isn't a day that goes by that I don't have pain, some days are worse than others (of course). Being treated like a "junkie" because of it is VERY real, as you wouldn't know by looking at me what I deal with. It's disheartening at best, soul-crushing at the worst. All you do, and want to do, is to both feel and function as normally as possible, and are frowned upon/snarked at/mocked because of it.
This is a touchy subject for me. I am not saying that addicts and seekers don't exist, we all know they do. I just honestly feel that there are less of them than most HCP's assume. That should be the last consideration, rather than the first.[/QUOTE]
Pain is pain...you treat what the patient says (within orders and common sense).
Disregard your judgements...
This is one of the hardest things for me to do as a nurse.
If I had pain on an 8/10 scale, I would be on the floor rolling and screaming. I have never had severe pain in my life, and can't imagine it, but because I have had pain, I find it to to believe some people when they tell me what their level is.
Specializes in Oncology; medical specialty website.
This is one of the hardest things for me to do as a nurse.
If I had pain on an 8/10 scale, I would be on the floor rolling and screaming. I have never had severe pain in my life, and can't imagine it, but because I have had pain, I find it to to believe some people when they tell me what their level is.
When the pain is severe and unrelenting, you learn how to put on a brave face and suck it up.
We should not be judging our patient's pain level based on how we think we would respond in the same situation.
This is one of the hardest things for me to do as a nurse.
If I had pain on an 8/10 scale, I would be on the floor rolling and screaming. I have never had severe pain in my life, and can't imagine it, but because I have had pain, I find it to to believe some people when they tell me what their level is.
Yeah- and you're very common in that :) I understand that people want to be able to SEE the symptoms and complaints match up, but they are too varied between individual people.
Like a LOT of people, I live with chronic pain, and literally do not remember being pain free since 1996...15 years ago. I don't even aim for pain free- it isn't realistic. I aim for tolerable. My body is so sensitized to pain that I don't know how to answer the 1-10 scale. It's meaningless to me. It's confusing; chronic pain doesn't "work" with the 1-10 scale.
If you have chronic pain, your "normal" is reset. You have normal vital signs (and if the pain gets really, really bad, even drops to pre-syncopal or syncopal levels because of vasovagal reactions).....have you ever had menstrual cramps so bad you felt like you'd pass out? It's the same principle. The autonomic system - while already readjusted to the chronic pain- goes haywire with either acute pain of a different type, or worsening of the 'normal' pain.
That's one of the hardest things for chronic pain patients...nobody can see pain. They see behaviors and what they 'think' should be appropriate, but in reality many with chronic pain have learned to shut up so they don't get judged, ridiculed, shamed, or otherwise dismissed for having pain. The vast majority of pain patients (something like >98%) never have addiction issues. They may have tolerance and dependence issues, which are very different than seeking a psychological high.
When I need pain relief, I don't care about a high. I want something to make just being in my skin not so bad I can't get to the store, or do my laundry, or even get in the shower because washing my hair hurts my shoulders and upper back so much. The more pain medication I have at my disposal, the less I take, because I'm not worried about "what if" it gets worse. The stress of not having enough medication causes muscle tension that just makes everything worse. Fear of pain is not the same as drug seeking. :)
The last 8 years I worked, I would go to my car after the shift, and get in- knowing that my muscles would seize up by the time I got home, and be horrific to just get out of the car. But I was afraid to tell my doc how much it hurt. I didn't want labels. THAT was worse than the pain- which was completely unnecessary to put up with at that level.
This is probably pretty common: I tried chiropractors, TENS units, creams, NSAIDs (when I wasn't on Coumadin), epidural injections, facet injections, PT evaluations/exercises, Fentanyl patches (which I asked my doc to wean me off of, because they scared me-- I worked alcohol/drug rehab at a great facility- I know what opiates & benzos can do), propoxyphene (which worked if I stayed ahead of the pain until it was decided after a million years of the stuff being prescribed that it was bad for heart function - lol) and methadone (which is a very valid pain med- but I asked to go off of that as well, even though it worked.
I didn't want to ever go through the nasty withdrawal of methadone- THE absolute worst detox of any of the patients I saw in the years I worked detox). SO, now I'm on a few anticonvulsants for epilepsy that happen to be adjunct pain meds, Flexeril, tramadol, and for severe headaches, Norco (the milder ones, I try to catch with Excedrin)...and I guard the snot out of those meds. I ration (and never call for a refill before my monthly pharmacy run- though with the directions, I could get them 2 weeks earlier). Methadone remains on my last ditch list...and I don't go back to that pain doc, because the injections only lasted as long as the local to put them in...not worth the invasion into the epidural space for nothing lasting.
Also, what works for one person (say propoxyphene working for me) may be totally useless for someone else. And trying Tylenol first? Please. Don't insult my awareness of my own health issues :) Tylenol is good for fevers. Any pain that would respond to Tylenol became "normal" a long time ago My MRIs and CTs show the visible causes for some of my pain. I shouldn't have to carry them around with me
You can't see pain. And behaviors are modified to deal with HCPs- whether enhanced, or minimized- to avoid further hassles than just living in my own body (or the many, many others who deal with chronic pain who work really hard so you DON'T see how bad it is).
I've been in positions where I thought patients were milking the prn menu for all it was worth. But basically, if they had no indication of respiratory depression, and the orders were clear, I gave the meds. I don't want to do to someone else what I've experienced and what I've seen.
Acute care is just that- you get them better for the admitting diagnosis- and turf or discharge. You can't fix drug problems in acute settings- and even addicts have pain when their guts are cut open
Pain is about the only symptom that the patient has to "prove". Vital signs can be measured objectively & lab values are objective. Bruising/lacerations/incisions are visible. Vomiting and diarrhea are visible. Pus and drainage can be measured. Skin color is basically objective (minus a spray tan ). Edema is visible. Wasting is visible. Limb deformity is visible. O2 sats can be measured- though a chronic COPD patient will have different tolerances than someone with normally healthy lungs. Etc......
The patients have to jump through hoops to be believed with pain - and that's not their fault. We, nurses, along with other HCPs have made that necessary if someone decides to TRY to get some sort of relief. The rest just put up with it, and a compromised quality of life.
I understand drug seeking behavior (saw some really creative excuses in acute med-surg/ortho, and alcohol/drug rehab )...but it's not what a person with chronic pain is really doing. They just want some relief , to have a shot at some sort of existence.
None of this is new...and I'm sure it will never be "fixed". All any of us can do is try and do the best for the patient for the purpose they are admitted to the service/facility we are working in....:) If a known addict is trying to get mood-altering medications for the purpose of getting high (these folks took easily 60-70 Vicodin a DAY) at a drug rehab facility- that's not the same as someone with chronic pain and a coincidental acute illness trying to get physical relief. :)
It's confusing; chronic pain doesn't "work" with the 1-10 scale. 
My MRIs and CTs show the visible causes for some of my pain. I shouldn't have to carry them around with me 
)...but it's not what a person with chronic pain is really doing. They just want some relief , to have a shot at some sort of existence. 
Back to my hole
Zookeeper3
1,361 Posts
Look, my daughter had a traumatic brain injury from a car wreck. She had 10/10 pain, yet we did meditation to help it and she always appeared to be sleeping when she was meditating. Brought in a neuro guy that did accupuncture as well . Nurses refused to give scheduled pain meds because she was "sleeping". She WASN'T sleeping, but meditating. her pain from 4 brain bleeds was 10/10. This remained a constant battle. My 100 lb. kid with 17 bone fractures was a a fentanyl patch of 75, morphine, , 2mg of dilaudid every 2 hours, fiorocet with codeine and her pain could NOT be controlled.
Due to the brain injury, she would just lay there, but she suffered terribly due to nurses that didn't assess her pain, didn't even ask her, or didn't even comprehend the severity of her trauma. She simply laid there and suffered until I demanded treatment.
So she is an obvious suspected addict. It's NOT our place to detox and cut ANYONE off pain meds. detoxing someone that is a suspected addict has it's place and time. It is NOT in acute or recovery care or even in a nursing home.
Withdrawal from long term narcotics causes life threatening complications and should never, ever be played with, unless you are in an ICU setting. Cutting a patient off, can lead to their death from withdrawal and any "suspected addict " as you claim, needs to go through a safe detox, not what at all of what you are suggesting we do. Patients DIE of acute renal failure due to rhabdomylosis from the shakes from nurses that withhold meds... food for thought. You CAN CAN CAN kill patients by making them go through withdrawal without treatment. That is very poor nursing to say the least.