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?
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.
i think the main issue here is that the patient was complaining that the morphine was not relieving his pain. the only way to change those orders would be for the anesthesiologist to take the time to reassess the patient and see what else could be done. a nurse pushing a pca button, where i come from, is completely against policy and grounds for termination. this was the rule for every hospital i did clinicals at as a student. i believe the student who originally posted this did the right thing. there is only so much you can do as a student!
I have to agree, the nurse (or family/friends either) is specifically NOT supposed to press the PCA button at any time for a patient. The PCA is what it is PATIENT CONTROLLED ANALGESIA! It makes sense that the patient is the one to press or not press the button. The only time I have ever pressed the button for a patient is when the patient asked me to, and that was while we were getting a patient up to go to the bathroom and the cord was wound around the pump out of his reach.
On another note, in my experience with PCAs on my stepdown unit, it is extremely rare for us to have a basal rate going. In fact, I have only seen that once, and it was a fentanyl PCA. The pt had a basal of 20mcg and I forget the other settings. We actually questioned having the basal rate at all on our unit as that is sticky territory when it comes to the p/p.
I think you did the right thing, OP. :) You listened to the patient, and went to your RN to report. She could've/should've gone to the room to assess the pt herself, and taken the time to educate him (which probably wouldn't have been effective since he already knew what it was and why, but had a problem with the actual med, not the how/whys of it) and then called the dr.
IMO, the RN should have stepped in to deflect the responsibility of this from you to her. She was the one who was ultimately responsible for this patient. You are a student, for goodness sakes! Geeeesh!
Don't let this get to you. It sounds like the anesthesiologist didn't take the time to listen to the patient. Sometimes the pts are afraid to say things to the doctor because they are the DOCTOR , and will meekly agree to what they tell them. I've had that experience way more times than I can count and it is frustrating. Pts who are loud, agressive and complaining about all sorts of stuff, and then the dr comes in and the pt is good as gold with no complaints. When the dr leaves, the complaining commences. I've told more than one patient to be SURE to tell the dr what they tell me, because I can't be responsible for what may or may not get done if they refuse to speak up. The dr will come out and look at me like I have 3 heads for calling him in the first place. "What do you mean, he had no complaints at all while I was in there!" Anyway, when I know a dr is coming to respond to complaints from a pt, I try to make it my business to be in the room now if at all possible so I can *gently* remind the pt to tell the doc about whateveritwas. :)
OK, where I work Anesthesiology would NEVER be involved in pain control of a pt once they left PACU (unless they were on an epidural). The Surgeon is alway the Doc managing pain issues post surgery. Am I wrong about that?
And Labcat01, you did nothing wrong, that you were blamed for this is absurd. The guy was 2 days out, the problem was not that he didn't know how to use the pump, it was that he didn't like it. Also, nowadays where I work, there is rarely a continuous dose going on those pumps to avoid over medicating patients. It is great that the Anesthesiologist came to assess the pt, but as far as I can tell from what you wrote he ignored that the pt did not like the Morphine. There are other drugs. Like another poster said, po meds may have been the best.... anyway, please don't let it bother you, but as you can see one issue in nursing can become so darn complex given all the different opinions we all have. When you start nursing, always address pt safety as a priority and document why you do whatever you do and you will be fine.
Specializes in med-surg/or/ambulatory/geriatric psyc.
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.
let me guess, you are a doctor on a nurses forum? oh, by the way.........yeah, you are not supposed to push the button on a patients pca pump..........you can encourage them to do it for relief, but you are not supposed to push it....................i think you are giving wrong information.
Specializes in Utilization Review/Case Management.
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) :no: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.
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.
i just wanted to repeat this:
pca = patient controlled analgesic
no one is to push the button except the patient. (of course if they ask because they can't reach, i will. because then it is still their choice to receive the med. even then, i will usually hand it to them if possible. i don't want anyone mis-interpreting why i pushed the button and not the patient)
also where i work, anesthesiologists don't prescribe pcas unless they are epidurals, and most pcas do not have a continuous dose, especially 2 days post-op. another thing to remember is "pain is what the patient says it is." and after 2 days, i think the patient knows whether the morphine is working as acceptable pain control.
to the op - sounds like you were trying to help your patient. good for you. the only thing you could have done was to try non-pharmaceutical interventions (heat/ice/positioning/ambulation/etc.)
(also, sounds to me like the anesthesiologst did not come to talk with the patient, but talk to the patient, big difference.)
oh, by the way.........yeah, you are not supposed to push the button on a patients pca pump..........you can encourage them to do it for relief, but you are not supposed to push it....................i think 
:no: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.
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NurseNayin07
17 Posts
i think the main issue here is that the patient was complaining that the morphine was not relieving his pain. the only way to change those orders would be for the anesthesiologist to take the time to reassess the patient and see what else could be done. a nurse pushing a pca button, where i come from, is completely against policy and grounds for termination. this was the rule for every hospital i did clinicals at as a student. i believe the student who originally posted this did the right thing. there is only so much you can do as a student!