(Disclaimer: So this turned out to be longer than I thought it would, and a bit of a rant. Sorry! But I think this is something that's relevant to all of us).
Some background: I work in a combined med surg ward, so we see a bit of everything. We have a young-ish girl, in her twenties, that has a VAC dressing in her leg following very deep self harm about two weeks ago. Her drug use has also given her 'meth mouth', and she's had at least one tooth removed about a week ago as well.
The issue is that she has a personality disorder, a history of aggression, is a known drug seeker and has had to have her VAC replaced twice now because she keeps sabotaging it - picking at it, poking and playing with it. Before it was put in she was seen physically pulling the edges of the wound apart with her hands also. She demands morphine roughly every hour for "ten out of ten" pain even though you can clearly see that she's not distressed in any way. She is charted for PRN morph and fentanyl, subcut (not allowed to have a cannula).
We always hear about the patients right to refuse; surely nurses have some way of objecting in a situation like this? Panadol (Tylenol), anti-inflammatories and endone all "don't do anything", even though it barely gets to two minutes after giving these before she buzzes and asks for "something better".
It's ridiculous; the patient knows she's playing us for fools and has said as much. Surely there comes a point where enough is enough and we stop giving in to people, especially people who don't want to help themselves. No wonder the state health system I work in is broke; It frustrates me to no end when we can't even afford more then one obs machine on the ward between thirty two patients, yet we will hand out expensive treatments to people who clearly don't want to get 'better', and dole out morphine like it's soda.
I know we need to cover pain relief somehow; I'm aware that vac dressings can be painful. But it's not like she can say we're not giving her anything at all. What are our options here? I'm not the only one with the same concern.
Sincerely, nurse who didn't become a nurse to be a drug dealer.
You do realize that some of the "pre-nursing" students have been nurses before in other countries? Even if they were not, they can judge the behavior of a nurse and determine what is appellate or not. There are those who have been in the trenches, so don't assume otherwise.
No, I did not. If that is the case, why wouldn't they identify themselves as such in their experience on their proifle?
And I'm sorry but it is truly impossible to determine who has been in the trenches and who hasn't. But if a certain profile says pre-nursing, I'm willing to be said user hasn't been in the trenches. They can judge all they want. But at the end of the day, they are judging as someone who has yet to be so incredibly frustrated that it leads them to make a post like this. It is clear that the OP comes from an angle of frustration. Hopefully, some of the helpful responses have resonated with her. By the way, if it isn't already obvious, when I say trenches, I mean trenches of providing patient care at the bedside as a licensed NURSE. That's the way I see it. I know I am not the only one who has voiced frustration on this topic either.
If it is ordered and there is no medical reason not to give it, you give it. Period.
I found once I quit trying to dictate the morality of others and just did my job, my life became much more peaceful and my opportunities to be therapeutic to my patients increased.
Probably the best thing said on this entire thread! OP, read not.done.yet's post and soak it up.
Specializes in orthopedic/trauma, Informatics, diabetes.
I work on an orthopedic floor. Some of the ortho trauma injuries are REALLY painful. This is NOT the time to rehab and "addict". They have real pain and they have a high tolerance of medications, we have to find a way to get past that. They are very difficult patients to treat, they are not always nice or even likable sometimes. But it is NOT the time. We too have an Acute Pain Service to consult and they have ketamine, lidocaine drips, regional nerve blocks. We do whatever we can to get them through the acute phase and then get other services involved.
Not a truly great analogy, but I drink coffee every day, if I have to go for a fasting blood test and can't have it, I get the worst headache that will not go away. sometimes for the whole day. Are you going to judge me for being a caffeine addict and make me suffer? Addiction is not a choice after you get hooked. There are physiological consequences. Do those of you who want to judge the addict feel the same way about an alcoholic? We have had to send patients to ICU for ETOH w/d and that is with treating them the best we can. People that smoke cigarettes are really crabby when they don't get to smoke. Again, a physiologic consequence.
Compassion is what we need to give whether we like the circumstance or not.
I recall from way back in my student days a young bloke who had a vac dressing in place and it caused him so much pain he had to be taken back to the OR and every dressing change had to be done under a GA
A coworker and dear friend endured a chest woundvac last year after a routine appliance placement went haywire and extruded itself from her chestwall. She had several surgical revisions ending up with a progressively larger wound, and eventually a woundvac was placed because the darned wound just would not heal.
What she endured regarding overall inconvenience to her life is a story for another time, but the pain was so severe for the first month of dressing changes that it took a while to find a workable Rx pain med and dosing schedule to take the edge off. This woman has the highest pain tolerance of anyone I personally know due to multiple spontaneous vertebrae fractures, and arthritis (she has taken 1/2 vicodin tab PO BID with excellent results for years) - she said the pain of QOD dressing changes made her cry like a baby with tears and snot running down her nose and face. She also said the noise while trying to sleep was Godawful (and no real shower for months).
The day it was finally removed she did a modified Happy Dance.
With tongue in cheek...isn't it all about PATIENT SATISFACTION????
I've been telling administration for years that the real answer to patient satisfaction is a jar of Percocet in our ER lobby on the honor system, with a big sign on it that says: "Just take one if your pain is a 10/10."
I've been telling administration for years that the real answer to patient satisfaction is a jar of Percocet in our ER lobby on the honor system, with a big sign on it that says: "Just take one if your pain is a 10/10."
Thanks to everyone who replied, but I'm done with this thread. I hoped to actually have a reasonable discussion, but I can see that just isn't possible here.
Is this not a reasonable discussion because some answers were not supportive of your concerns? Are you thanking God for ativan for yourself or your patients? Do you have a right to refuse meds ordered by the provider? Not likely. Is it within your scope of practice to diagnose addiction? Doubtful. Are you comparable to a drug dealer for giving a patient who is in pain her prescribed pain meds? Not even close.
There is a great deal of judgment coming from your post, in my opinion of course, and very little compassion for addiction and mental illness, also my opinion. You stated that she has "meth mouth" because she had a tooth pulled, all mine need to be pulled and I've never even seen meth, you implied that she's playing you, and that she is drug seeking. These types of statements are a huge turn off for me given the epidemic of addiction we are facing and the complete lack of appropriate mental health care as the result of a badly broken system. Do you know what the success rate of inpatient drug treatment is? Let's just say it's a failed system. Do you know what the tolerance level is of a long time addict? She's in her twenties for God's sake, and she needs help, judgment and denying pain meds isn't going to help her. She is legitimately in pain, some is physical, some may me psychological, but it's pain non the less. She needs a 1:1, but giving IM pain meds q2 shouldn't really take up half your shift. She's a pain in the ass, but it doesn't have to be unlike any other pain in the ass patient if you can put your personal judgment aside, and see how sick she actually is. It could be worse, she could have slit her wrists or her throat and then no one would have to get her morphine that isn't helping anyway.
I didn't have time to read all the posts, so please excuse me if this has already been suggested. This patient sounds like a complete borderline personality disorder. IMO, they're the absolute worst psych patients to deal with. If it hasn't already been done, please suggest a psych consult for this one, or if there is a psych nurse available to consult with, talk with them. She needs a psych treatment plan. To allow her to lay there and open up her wounds, remove the vac, and whatever else she's doing is unacceptable. She needs consequences for her behavior, both good and bad. I understand your frustration with her. BPD's more than any other patient make me want to scream, but if you let them know that, then they have you and it only gets worse. A completely non-judgmental poker face is best when dealing with them. You don't have to lie to them, because they'll test you, but never let them see that they upset you. This is the best advice I can give. Good luck, and try to get your charge nurse to rotate this one every 4 hours so no one nurse is stuck with this frustrating mess.
From my understanding, you give the medications as ordered. If it says every 2 hours as needed, you give it at the 2 hour mark if the patient states they are in pain- the 2 hour mark and not a minute earlier. If they have anything that is ordeted for break through pain, my understanding is that that should be given, if it falls within the time parameters. I have not worked in the hospital setting, so my understanding comes from clinical experience during nursing school- so things may be a little different on the floor. But. Pain is whatever the patient says it is. I was told once that if the patient says 10/10, document that. But if they are do not appear to be in pain, document how they appear (I have been told about documenting there stated pain and their pain on the FACES Scale as it appears to us) and their vital signs (someone correct me if that is wrong).
Addict or not, it is our duty to care for our patients. After all, addicts can still be in pain. :-)
Americans make up 5% of the world's population and yet consume 80% of the world's pain medications.
Any other country she would get a morphine PCA pump and then told to get on with it.
Try asking the doc to order Toradol?
Actually, I'm almost certain this is in Australia (obs machine=vitals machine, cannula=IV, sub cut=subQ as well as the familiar problem of having less obs equipment than there are nurses). I have definitely seen a rise in prescription opioid dependance here in my short time in nursing. Interestingly from reading the boards I think some of you would be horrified at our pain management - I don't know any hospital here that allows IV pain meds on the floor in any form except a PCA (obviously OR ER ICU are different).
At my hospital one of the physicians does a lignocaine/ketamine subQ infusion over a number of days along with steroid injections etc to get people with chronic pain to a point where their pain is sufficiently addressed but their use of opioids is lower. OP I am not suggesting this for this young woman while she still has the VAC etc but I totally agree with the pain team suggestion if it's available. Our hospital only introduced it about 3 or 4 years ago but it's fantastic.
You don't have the right to refuse meds that are ordered for the patient and the patient is claiming pain. You also don't get to make medical or psychiatric diagnoses. However, if you believe they are not appropriate you can chart your evidence and help the doctor make an educated decision on correct treatment. I chart things like "Patient reported her pain was a "100" out of 10. Pt was eating Doritos and a McDonald's hamburger at the time." "Patient and I had a casual conversation about the episode of "Big Bang Theory" on her tv after she told me her migraine was a "20" out of 10." "Patient was observed laughing while talking on her phone while ambulationing the hallway when she stopped me in the hall to report her pain was a "10" again." "Patient said, "This is my first time trying this hospital. I thought I' see if it was as good as the commercials. Where is my PCA? I always get a PCA when I am admitted." "Patient told me that I have to give her anything she wants because her doctor said so." "Patient says her home pain meds all ran out on Monday. Patient said that her oxycotin dose was "the highest one possible" and frequency was "anytime I want it"."
All that said, I suspect that you educate yourself better on pain management and psychiatric diagnoses. Withholding her pain meds isn't going to change anything in her life except put her in pain on your shift. You won't stop an addiction issue with a shift or two (and do you really want do treat withdrawal issues on top of everything else?) And patient may just have a tolerance issue so she does need high doses to manage a real condition. Addicts and mentally ill deserve adequate pain management too.
skylark, BSN, RN
636 Posts
Some random thoughts -
Americans make up 5% of the world's population and yet consume 80% of the world's pain medications.
Any other country she would get a morphine PCA pump and then told to get on with it.
Try asking the doc to order Toradol?