Is this my fault?

[labcat01, BSN, RN]

Hi all,

I wasn't sure where to put this but here it goes:

I'm a nursing student on my second day of Med/Surg clinicals. I had a pt that was day 2 post op and complaining of pain for abdominal surgery. He was on a PCA pump but would not push the button because he says he hates morphine and it doesn't take his pain away it only makes him sleepy. I went to my primary nurse and told her and she pages the anesthesiologist.

He comes down and gives the patient a bolus of morphine and tells him to push the button when he's in pain. Then, the doctor goes out and tells my nursing instructor that it is my fault the patient is in pain because I didn't teach him to push the button and that I'm not doing my job correctly because the patient isn't educated.

Tell me wise and experienced nurses...is this guy's pain my fault. What should I have done to make it better?

Thanks in advance.

[icuwant2rn]

You could of tried educating the patient, but that should have already been done. Sounds like he had previous experience with Morphine. But the only real way to know would have been to ask. However, I can not see how this was your fault. You did what you are taught to do in school, you informed the primary nurse. Don't sweat it!

[Jolie, BSN]

Hi all I had a pt that was day 2 post op and complaining of pain for abdominal surgery. He was on a PCA pump but would not push the button because he says he hates morphine and it doesn't take his pain away it only makes him sleepy. I went to my primary nurse and told her and she pages the anesthesiologist.

He comes down and gives the patient a bolus of morphine and tells him to push the button when he's in pain.

...is this guy's pain my fault. What should I have done to make it better?

Thanks in advance.

The only thing you could have done to make it better was to call another anesthesiologist, which is out of your scope as a student nurse.

The patient clearly indicated that morphine did NOT relieve his pain, but rather than address this valid complaint, the anesthesiologist chose to snow the guy and ignore his pain. What a jerk! G*d forbid he actually spend 5 minute assessing the patient's pain, considering alternative and more effective medications, and responding to the patient's needs by altering his plan of care.

I don't know the type of surgery this man had, but many patients get good relief with oral medications by the second day post-op. If oral meds were not sufficient, there are certainly many IV options other than morphine. I know that morphine is the "gold standard" for pain relief, but speaking from experience with 2 surgeries, it did NOTHING for me.

You did your best and followed the chain of command. If the patient continued to complain of unrelieved pain, it would be the primary nurse's responsibility to re-contact the anesthesiologist and go up his chain of command if necessary. There is no excuse for failing to adequately relieve pain in a post-op patient.

[vamedic4, EMT-P]

The only thing you could have done to make it better was to call another anesthesiologist, which is out of your scope as a student nurse.

The patient clearly indicated that morphine did NOT relieve his pain, but rather than address this valid complaint, the anesthesiologist chose to snow the guy and ignore his pain. What a jerk! G*d forbid he actually spend 5 minute assessing the patient's pain, considering alternative and more effective medications, and responding to the patient's needs by altering his plan of care.

I don't know the type of surgery this man had, but many patients get good relief with oral medications by the second day post-op. If oral meds were not sufficient, there are certainly many IV options other than morphine. I know that morphine is the "gold standard" for pain relief, but speaking from experience with 2 surgeries, it did NOTHING for me.

You did your best and followed the chain of command. If the patient continued to complain of unrelieved pain, it would be the primary nurse's responsibility to re-contact the anesthesiologist and go up his chain of command if necessary. There is no excuse for failing to adequately relieve pain in a post-op patient.

:yeahthat: :yeahthat: :yeahthat:

Exactly what jolie said...

Having had brain surgery twice in the last 6 years, I too, can attest to the inadequacy of morphine as a pain reliever. Remember, each patient is different...and what works for one may not work for another - as we see in this case. Once they started giving me another med PO, I felt MUCH better and was able to be d/c'd later that day.

You did nothing wrong- you did exactly what you were supposed to do. Obviously this anesthesiologist has a bit to learn about pain management himself.

vamedic4;)

[KellNY, RN]

First of all, you're a nursing STUDENT. if you could legally or ethically be relied upon to provide full pt education....well, then you wouldn't be a student, you'd be a licensed professional. Not to mention it's your 2nd day.

Second of all, Anesthesia should have explained all this to him either before the surgery and/or when the PCA was initiated. If anyone "failed" this pt, it was him.

Third of all, you merely relayed a message to an RN that a Pt was not satified with his pain relief medication. (FTR, I think she made the right call by paging anesthesia...I would have gone to personally assess Pt 1st, but not a biggie, IMO). You followed the chain of command corectly.

Fourth of all-Ugh. Obviously this man needs to LISTEN to his Pts. A monkey could have done what he did.

[labcat01, BSN, RN]

Thanks you guys for your support. It really makes me feel a lot better! I am so sorry that you've all had such bad experiences with pain. This is stuff that I have not been told in school....I always thought morphine was so great.

[Daytonite, BSN, RN]

i think the anesthesiologist was a little harsh. who knows what the primary nurse told him on the phone that made him come up to talk to the patient. usually the pca pumps are set to deliver a regular amount of the analgesic. the patient presses the button to give themselves more for breakthrough pain.

i would have checked the pca orders in the chart and if the patient was already receiving a regular pca dose i would have dosed the patient (pressed the button for him) and explained that he has been getting the morphine all along and done some teaching with him and then gone back and reassessed his pain level a short time later. read up on pca and how it works.

patients are going to tell you all kinds of things based on their past experiences with medications. however, you always have to assess what is going on first. assessment always includes checking the doctors orders in the medical records as well as listening to the patient and putting all the information together before drawing a conclusion.

part of the problem here was the patient's primary nurse. she should have assessed the patient herself before paging the anesthesiologist. that was a mistake on her part not to have done that. i think the bigger lesson to learn here is to never call a doctor based upon information someone gives you without verifying it's correctness by physically assessing a patient yourself.

how come you didn't post this on the nursing student forums? some of these posters are giving you wrong information. not all anesthesiologists routinely instruct patients in the use of the pca pumps. the nurses in the post anesthesia recovery unit do if the patient is alert and awake enough to understand and remember what they are being told. it's also extremely disrespectful for someone else to be calling this doctor a jerk. especially when he took the time to come up to talk with your patient.

[KellNY, RN]

i would have checked the pca orders in the chart and if the patient was already receiving a regular pca dose i would have dosed the patient (pressed the button for him) and explained that he has been getting the morphine all along and done some teaching with him and then gone back and reassessed his pain level a short time later. read up on pca and how it works.

and i would have been pissed if i were the pt and you had done that after i told you it made me tired. the continuous dosing may have had little effect, but pushing the pca each time he had pain (lockouts taken into account) may have been enough to make him feel zonked.

and if anesthesia is going to be prescribing a pca pump, they should have explained this to the patient before surgery if it were planned then. i don't care if anesthesia doesn't routinely inform their patients about meds they're prescribing-they're supposed to be doing it for each pt.

[Jolie, BSN]

i think the anesthesiologist was a little harsh. who knows what the primary nurse told him on the phone that made him come up to talk to the patient.

i am a little puzzled by this statement. the op stated that the patient complained that morphine doesn't take his pain away, only makes him sleepy. why would the primary nurse tell him anything other than that? would you not expect the anesthesiologist come up to see a patient who complains of unsatisfactory pain relief 2 days post-op?

i would have checked the pca orders in the chart and if the patient was already receiving a regular pca dose i would have dosed the patient (pressed the button for him) and explained that he has been getting the morphine all along and done some teaching with him and then gone back and reassessed his pain level a short time later. read up on pca and how it works.

why would you bolus a patient with a medication that he has indicated is unsatisfactory to him, especially when he has stated that he does not wish to bolus himself? doesn't that amount to forcing a dose of medication on a patient who has refused it?

patients are going to tell you all kinds of things based on their past experiences with medications. however, you always have to assess what is going on first. assessment always includes checking the doctors orders in the medical records as well as listening to the patient and putting all the information together before drawing a conclusion.

i don't disagree with this. however, i think it is shortsighted and unwise to assume that this patient's current complaints about morphine are based on past experiences. he was 2 days post-op, apparently had been receiving pca morphine for those 2 days, and was complaining that it was not providing satisfactory relief. i think it is rather presumptive of the nurse to assume that these complaints are based on past experience. and regardless of whether past experience was "clouding" his impression of morphine, he was not getting adequate relief, and was experiencing side-effects that were unacceptable to him. to dose him with more morphine in light of those complaints and his expressed desire not to dose himself would be irresponsible, in my opinion.

part of the problem here was the patient's primary nurse. she should have assessed the patient herself before paging the anesthesiologist. that was a mistake on her part not to have done that. i think the bigger lesson to learn here is to never call a doctor based upon information someone gives you without verifying it's correctness by physically assessing a patient yourself.

how come you didn't post this on the nursing student forums? some of these posters are giving you wrong information. not all anesthesiologists routinely instruct patients in the use of the pca pumps. the nurses in the post anesthesia recovery unit do if the patient is alert and awake enough to understand and remember what they are being told.

this patient was 2 days post-op. reinforcing patient teaching is always a good idea, and is the responsibility of every nurse, however i think it is safe to assume that this patient knew how to use the pca, especially since he expressed a desire not to bolus himself.

it's also extremely disrespectful for someone else to be calling this doctor a jerk.

ok, i agree that i should not have used that language, not because the doctor was kind enough to come up and see the patient, but because it was disrespectful on my part. it stems from my own experiences with anesthesiologists refusing to acknowledge my complaints that morphine was not effective for my post-op pain either. coming up to see the patient is his job. it is a shame that while he was there, he didn't take the time to do anything more than dose the patient with ineffective medication and yell at the student nurse.

[Noryn]

i would have checked the pca orders in the chart and if the patient was already receiving a regular pca dose i would have dosed the patient (pressed the button for him) and explained that he has been getting the morphine all along and done some teaching with him and then gone back and reassessed his pain level a short time later. read up on pca and how it works.

are you serious? you never should push that button without the pt's permission especially when he has told the student it is not helping but only makes him sleepy.

wow, i am amazed at that statement. in my experience a nurse who would do that would likely get fired.

in my opinion the student absolutely did the right thing. i have had patients tell me that morphine did little for their pain but and only made them cloudy headed.

the anesthesiologist acted like a jerk, if the shoe fits.....anyway this was the anethesiologist's patient too and i can guarantee you he was compensated very well to take care of this patient.

[MIA-RN1, RN]

I think I would have assessed the patient and then reviewed his orders. Maybe the pain was something else---maybe he needed hot packs, simethicone, colace...something else might have helped. And I probably would have seen if there were any pain meds to give concurrently--toradol, motrin etc.

Then I would have called anesthesiology and just asked if we could d/c the pca since he got no relief and asked for vicoden or perc.

Thats me as an RN though; As a student...I would have done exactly what you did, although I can still hear my instructor in my head telling me to try non-pharmocologic tx and assess first.

[talondora1]

It's hard at first when you are doing clinicals. You are still feeling your way around a floor that is known to be chaotic by nature let alone being "new" in the field. It is true that we are all responsible to reinforce teaching. Many times these patients are nervous and not able to process the learning that they need. Never assume that someone else has gone over the use of PCAs with them and that they understand it. As far as Morphine not working for him, that should have been addressed Pre-Op. The blame is shared, not owned by one. You did the best you could under the circumstances. Next time it will come easier for you and you'll know how to help him.