IVDU pt kept asking for pain meds. Managment kept saying to just give it to her.

cleback · Jul 21, 2017

Next time you post, mention the objective data and leave the denigratory/demeaning remarks about the patient out. I think that is what turned off most of the posters (including myself). I really can't stand it when I hear health care providers make remarks like that. Now, with the additional information you added, then I agree, perhaps she was getting too much medication. I also agree that those orders could be cleaned up a bit because they are sloppy orders.

This. I know you have a history with the patient but it's important to remain cool, calm, and collected when communicating your assessment.

Could this be why the physician did not heed your concerns? Or your manager? I would reflect on your communication in this situation.

LovingLife123 · Jul 21, 2017

Stop bringing your license into this, first of all. Nothing is going to happen to your license fir following ordered pain med dosages.

I'm sorry, but you do come off as very judgemental in your post. You may not have intended to, but you do. On my unit, I come into contact with drug users every day. They are extremely tolerant to pain meds. It takes a lot. Spinal surgeries are painful.

But I will also say, the acute care setting is not the place for detox either. Are you prepared to detox this patient? Do you have the skills to do that? It will make their recovery process so much longer and won't be fun for you to detox this patient.

I deal with it all the time. Patients on tons of opiates and benzodiazepines outside the hospital. Certain physicians not adequately keeping up with their tolerance level. They start detoxing. It's awful. BP and HR go up. Patients agitated to the point where you are getting attacked. Constantly getting out of bed. Risk for falls and head bleeds. Seizures occur.

I will repeat, you do not want to detox these patients. Control their pain adequately. Don't overdose them, but stop your train of thinking and worrying about manipulation and what you think they need. Unless they are unresponsive and respirations going downhill, treat it.

ella2990 · Jul 21, 2017

This. I know you have a history with the patient but it's important to remain cool, calm, and collected when communicating your assessment.
Could this be why the physician did not heed your concerns? Or your manager? I would reflect on your communication in this situation.

Oh god no!! I never meant to demean the pt!! Let's just say I am the type of nurse that is very nervous questioning Dr's orders..I was nervous and not arrogant or aggessive towards the DR.

When you said hx with the patient? You mean bad blood between me and her? Oh no!! We might have had misunderstanding when I didn't giver meds q1hr like she wanted but no never ever held anything against a pt. In fact we greet each other when we see each other out in the hall way. I guees came out being an an ASS NURSE because of the way I presented my situation. i apologzie. That is just me being frustrated with me because I didn't know if I did the right thing or not. Yes the pain meds were ORDERED, therefore I should have given it -- but like I explained -- I was a new nurse, so I asked around if I should just give the pain meds or not. Majority said no. So I didn't

ella2990 · Jul 21, 2017

OP, you should have found out why the rapid response occurred before you assumed responsibility for the patient. There should be an established routine for this, whether it's giving verbal report at shift change or if it's reading up on the patient's chart. (A rapid response and the reason for it should of course be included in a patient's chart). You're now saying that this rapid response that you didn't really know all the details about, contributed to your worry/reluctance to give the prn meds as prescribed. You have to be in a situation where you base your decisions on all the pertinent and available information. The whole thing seems a bit disorganized.
(It would have been helpful if you've included the rapid response information in your original post).

Sorry, I meant to say --I did not get any information why she rapid on that day -- it was end of shift and NOC are wanting to start the reporting. I before I left the unit I asked the charge nurse if they needed anymore help with the pt.. she said no they got everything under control -- as curious as I was, I did not stick around that night to gossip.

But yes when I became her nurse, yes I asked why she rapid. I might as well explain what happened..

Tech was doing her vitals because pt requested that the tech check her temp because she felt like she's getting a fever.

I do not remember all the specifics I believe her bp is low but not below 90s rr was low. What I did remember was her PR was in the 1teens and spiked a temp of 103 orally. The nurses checked it the pt will flag as septic and she did - her wt count was elevated but that was not new since she was also being treated for klebsiella. They activated a sepsis code. Then they did what they needed to do during sepsis code. Then she started complaining of shortness of breath and started "shaking" so a rapid was activated. They did another set of vitals, they wanted take her temp rectally and the she apparently started screaming she is in so much pain and trashing and cursing all the responders. When they did her temp i believe was 98.9 or 99. They continued treating her - got all the specimens that were needed to be collected.

Short story short the infectious dse thought it might be from the CL because the pt is known for picking at her CL line. The nurse that was giving me the report also said that the night nurse supervisor asked what the pt was on for pain meds. The supervisor was shocked that the pt is getting that much pain meds that often (granted she doesn't really know the pt's extensive hx).

FolksBtrippin, BSN, RN · Jul 21, 2017

I have a question, I'm a newbie nurse with only 2 years of experience. So, I work at a med/surg tele floor. I was assigned a pt who was very well known to be an IVDU and frequent flier. Pt was POD 7 from a spine surgery (totally forgot what the actual surgery was) and was getting pain med basically q1hr. She had orders for:
1. dilaudid PO 4mg q3hrs scheduled
2. dilaudid 2mg PO q4hrs PRN
3. diladid 2mg IV q2hrs for BTP PRN
4. oxycontin 10mg PO q12hrs scheduled
5. toradol 30mg IV q6hrs PRN
(**YES THERE ARE PAIN LEVEL PARAMETERS, but this pt is very manipulative and will do anything and I mean ANYTHING to get her beloved pain meds***)
So the nurse from previous shift was basically giving her pain meds every hour!! I did not feel that it was safe for her (and for my license) to be giving her all those pain med. It was a weekend and that particular surgeon who did her op was off. So I called their office and asked to for the on call dr. to be paged.
Dr. K came in to round on that pt, I told him my concern that Ms. so and so had been getting these kinds of pain meds basically every hour. The dr. was shocked when I told them all the kinds of pain meds and diff doses she was taking. He asked me who that pt was again and who was her primary ortho surgeon. I told him it's Dr. ***. Dr. K reacted very nonchalantly and said "Oh yeah she's known to our practice. She has high tolerance for pain meds since she's an IVDU. If she's still breathing just give it to her." I told him that her BP was low and his reply really caught me off guard, "I don't want to mess with whatever Dr. *** prescribe to her. Just wait for him to come back on Monday."
I was literally speechless!!! Pt's bp was already in the mid to low 90s, pt was not hooked up to tele.
Bottom line, I did not cater to her, I did not give her pain meds EVERY HOUR I made sure that atleast 2 hours has passed before I give her another pain meds. I explained her the legal side of nursing. Needless to say, she threw a **** show and threw the biggest tantrum a grown woman could every throw.
That pt filed a complaint against me to my director. My director talked to me and told me to just give her whatever MD ordered for her to have. I told her, NO it is my license on the line and not yours, if something were to happen to my pt it is not YOU AND YOUR LICENSE that would have to sit in front of the BON trying to explain why you did what you did. She said that it is very important that we earn pt's satisfaction.
I felt defeated and seemed like her priority was pt's satisfaction and not pt's and nurse's safety.
I told her and the charge nureses (whoever will be doing assigments) that I NEVER WANTED HER BACK as a pt.
DID I DO THE RIGHT THING? I MEAN I KNEW HER TOLERANCE FOR PAIN MEDS ARE HIGH GIVEN HER HX. BUT YOU REALLY NEVER KNOW WHAT WILL HAPPEN. 1 DAY SHE COULD BE FINE THE NEXT 2 FOR ALL I KNOW SHE'S OD from pain meds.

I disagree with you on this. She had spinal surgery and was definitely in pain, despite being a drug user. Addicts have a much higher tolerance for pain meds. It is your job to treat her pain safely. If she was screaming at you, she was definitely not at risk for OD. You assess, and if her respirations are ok, then you give the med. A systolic BP in the 90s is not an indication that a patient should not get pain meds. A depressed respiratory rate would be.

So yeah, you were wrong. A great deal of nurses treat their drug abusing patients with the same level of outrage and withholding though, so you will be in good company here.

ella2990 · Jul 21, 2017

So yeah, you were wrong. A great deal of nurses treat their drug abusing patients with the same level of outrage and withholding though, so you will be in good company here.

And I am guessing you did not read my previous replies. I did not have anything against the pt at all. That was the first time EVER that I held pain medicines to a pt asking for it --because again based on my assessment it wasn't safe.

And yes, after reading all the post, I admit that what I did was wrong and it was a learning experience. and I appreciate the knowledge constructive or not although some I admit was rather harsh. I did what I did based on what was seen during my assessment and other nurses in our unit's opinion and NOT BASED ON MY PERSONAL BELIEF.

allnurses Guide · Jul 21, 2017

So you all knew that sooner or later I was going to chime in on this one. The comments I am about to make are directly to the op and they are from a nurse (myself) who is in recovery and has been treating addicts in one fashion or another for close to ten years. I also have fibromyalgia Inflammatory bowel disease and a couple of other very painful auto Immune disorders. I finally found a way to manage my pain without large quantities of opiates but that's a story for another day and not for this forum.

First and foremost OP quit calling your self a newbie nurse. You have two years of experience now and the excuse of calling yourself new gets old really fast.

While you say you are not at all biased your comments and use of acronyms clearly shows bias. Where I work calling someone an IVDU can get you terminated. Your bias may be unconscious but it's there. When you question her pain level because she's able to eat ice cream and watch a movie you show that you know nothing about the nature of Chronic vs Acute pain or the difference between dependence, tolerance and addiction. You said the neurologist evaluated her and said she had "Fake" seizures are you sure he didn't indicate a pseudo seizure which is different from a fake seizure. Addicts who fake seizures are usually doing it for benzo's not opiates. Addicts are by nature restless, irritable and discontented people they are also manipulative because that is a symptom of their disease the two go hand in hand.

If in fact this patient is using IV opiates such as heroin on the street q 1 hour dosing may be quite appropriate - do you have any idea how uncomfortable (Painful) opiate detox is? It is miserable and most addicts will do anything to prevent it. They are fearful which often presents as anger. You must always manage a post op patient's pain. not because of patient satisfaction scores but because it's the right thing to do. Pain management contracts are a good way to go and if done right gain the trust of the patient and often make them easier to work with. When I worked a short period in acute I always took the alcoholics and addicts and never had a problem with any of them. I even walked a doctor through how to safely detox an alcoholic in a nursing home for rehab after hip surgery. When I arrived for my shift that day there were snakes on the wall and bugs in the bed. By the time I left he was comfortable and happy.

There should always be vital sign parameters for opiate dosing but I know at least in the acute setting that I am not going to fix their addiction but I sure as heck can make sure they can turn, cough, deep breath and do their rehab and pt. With some patients when appropriate, Like if they say - I wish I could stop living this way? I will share my story offer them a Chemical dependency consult, arrange for an AA/NA member to stop in for a visit etc...

A Dr. who helped to save my life and sanity once told me in my darkest hour and profoundly suicidal that I was not a bad person. I was a sick person who needed to get well. I later found out that he was also and addict in recovery. Leave your bias at the door or get out of med-surg/ortho where there are people in pain.

I am very concerned that you took a patient who had had a rapid response and you don't know why? Don't you do report?

Then next time you have to do CEU's I suggest you do some on chemical dependency. Educate yourself and become the best nurse you can be.

I would like to clarify that I am an alcoholic in recovery who also suffered from opiate dependence (Because I was actually being treated for real chronic pain) Still my rehab counselor said calling yourself and alcoholic/addict is like calling yourself a dog/German shepherd. they are one in the same thing.

Peace and Namaste

Hppy

Purple_roses · Jul 21, 2017

You need to have a physiological reason for why you held a pain med. For instance, if she was A/O x 4 and now she's not, if respirations fall below 12, if spo2 dips, etc. Your reasoning for holding the med was purely subjective, and therefore technically not valid. If you hold a requested med, document an objective reason as to why you're holding it. Your license will not fall under fire if you assess and document in a way that shows you were monitoring neuro and resp responsibly. You should also document the time you spoke with the provider about the pain meds, the provider you spoke with, and what the proceeding orders were (or if there was no change to the orders).

I do completely understand where you're coming from. While it's true that drug users have an increased tolerance, I think sometimes it's easy to spot someone who isn't truly in pain (and when I say this, I mean absolutely no indications that the patient is in pain...wants the norco on the way out the door....argues with you when you say the med has to be taken and swallowed at the hospital). You didn't have sufficient evidence to back your belief that the patient wasn't in pain by the way. But I do believe that you were truly worried for your patient's wellbeing, and maybe a bit illogically worried about your license (assess and document, rinse, repeat).

Purple_roses · Jul 21, 2017

I probably didn't explain myself well enough. In no way was I bias. I do not have anything against IVDU. I had her way before her 3rd surgery. Her first surgery she was wayyy worst. We were all catering to her needs and what not. I was one of the nurses who NEVER, I repeat NEVER bad mouthed her. As unprofessional as it may sound, our former charge nurse and some colleagues were very nasty to her and would always huddle around nurses station talking about how they hated her and that she's a "whiny little *****". I believe that addiction is a disease, and I feel sorry for the pt. Like I said this was her THIRD surgery. Her 1st one she stayed in our unit for 6 months for abx tx. She was sent to a facility to help with rehab. After 3 weeks she left the facility and went back to the streets. She came back to the ED and requested to be admitted to our unit with osteomyelitis on her R foot where she was shooting her drugs. Again she had PCA and all sorts of meds. I didn't have her days after her sx. I had her about 4 weeks after surgeons signed off on her. She stayed in our unit again for more than 1 month for abx tx for septicemia. 2 weeks before she left AMA I had her and always catered to her needs what so ever. I NEVER had any issues giving her pain meds because I know that it was safe.
She was getting dilaudid 4mg PO q3hrs toradol 30mg IV q6hrs and oxycontin 10mg q12hrs (which she refused to take in the morning so she can get her 4mg dilaudid PO). I felt comfortable giving her all those pain medicine because they are spaced out enough.
Then she left AMA right AFTER (like in 5 mins) when her bf came in and "spoke" with her. Our own unit director even suspected her bf that he was persuading her to get back in the street. Again that did not come out of my mouth although I had an inkling.
not even 2 months she was back again, another surgery done because she was shooting again and apparently developed an abscess.
Pt was put on PCA for more than 1 week. When the surgeon ordered to dc the PCA she threw a **** show again. She "faked" a convulsion just so they'd put her back on PCA. (I say faked because a neurologist saw her and he specifically wrote on his note that it was not a real convulsion/seizure after he assessed her).
Despite neurologist's note, the surgeon put her back on PCA.
I don't know when and how it happened, but at shift change they were doing bedside reporting and doing iTRACE, so apparently they found an empty syringe hooked in her distal port of CL. So my director suspected drug diversion and had to do investigation. I don't know how it all went down since I was not the primary nurse and the details of the investigation was only made available to the nurse who had her that night and incoming nurse that witnessed everything.
They DC'd her PCA and put her on multiple pain meds.
So again the nurses who had her after that incident were catering her needs of pain meds q1hr just to avoid her tantrums. Then 10 mins before shift change they had to call a rapid on her. I was not involved in the rapid because I was asked to man the nurse's station because our DA left early while the charge nurse was running the code. So I did not get the whole story on what led her to a rapid response.
After that I was afraid to give her pain meds every hour.

Careful with HIPAA here. You're giving enough history for someone (probably another nurse at your facility) to ID who you're talking about.

ella2990 · Jul 21, 2017

So you all knew that sooner or later I was going to chime in on this one. The comments I am about to make are directly to the op and they are from a nurse (myself) who is in recovery and has been treating addicts in one fashion or another for close to ten years. I also have fibromyalgia Inflammatory bowel disease and a couple of other very painful auto Immune disorders. I finally found a way to manage my pain without large quantities of opiates but that's a story for another day and not for this forum.
First and foremost OP quit calling your self a newbie nurse. You have two years of experience now and the excuse of calling yourself new gets old really fast.
While you say you are not at all biased your comments and use of acronyms clearly shows bias. Where I work calling someone an IVDU can get you terminated. Your bias may be unconscious but it's there. When you question her pain level because she's able to eat ice cream and watch a movie you show that you know nothing about the nature of Chronic vs Acute pain or the difference between dependence, tolerance and addiction. You said the neurologist evaluated her and said she had "Fake" seizures are you sure he didn't indicate a pseudo seizure which is different from a fake seizure. Addicts who fake seizures are usually doing it for benzo's not opiates. Addicts are by nature restless, irritable and discontented people they are also manipulative because that is a symptom of their disease the two go hand in hand.
If in fact this patient is using IV opiates such as heroin on the street q 1 hour dosing may be quite appropriate - do you have any idea how uncomfortable (Painful) opiate detox is? It is miserable and most addicts will do anything to prevent it. They are fearful which often presents as anger. You must always manage a post op patient's pain. not because of patient satisfaction scores but because it's the right thing to do. Pain management contracts are a good way to go and if done right gain the trust of the patient and often make them easier to work with. When I worked a short period in acute I always took the alcoholics and addicts and never had a problem with any of them. I even walked a doctor through how to safely detox an alcoholic in a nursing home for rehab after hip surgery. When I arrived for my shift that day there were snakes on the wall and bugs in the bed. By the time I left he was comfortable and happy.
There should always be vital sign parameters for opiate dosing but I know at least in the acute setting that I am not going to fix their addiction but I sure as heck can make sure they can turn, cough, deep breath and do their rehab and pt. With some patients when appropriate, Like if they say - I wish I could stop living this way? I will share my story offer them a Chemical dependency consult, arrange for an AA/NA member to stop in for a visit etc...
A Dr. who helped to save my life and sanity once told me in my darkest hour and profoundly suicidal that I was not a bad person. I was a sick person who needed to get well. I later found out that he was also and addict in recovery. Leave your bias at the door or get out of med-surg/ortho where there are people in pain.
I am very concerned that you took a patient who had had a rapid response and you don't know why? Don't you do report?
Then next time you have to do CEU's I suggest you do some on chemical dependency. Educate yourself and become the best nurse you can be.
I would like to clarify that I am an alcoholic in recovery who also suffered from opiate dependence (Because I was actually being treated for real chronic pain) Still my rehab counselor said calling yourself and alcoholic/addict is like calling yourself a dog/German shepherd. they are one in the same thing.
Peace and Namaste
Hppy

Yes we do reporting and I did explain why she rapid in my previous replies.

When I say I am a new nurse, I am not looking for an excuse, IMO 2 yrs of experience is nothing compare to 5 or 10. So yes I have a lot to learn and a long way to go. Like I said our unit is very young 70% of the nurses in our unit are new grads and our most seasoned nurse has 4 years of experience. So I didn't really get the kind of advice that I got here when I asked around our unit for opinion.

I really do appreciate all the post here as it did shed new light on how to handle pain management. And I never really knew how high their pain tolerance is because most of my pts who were post op only required a low dose of pain meds. So when I saw the dosage and frequency I freaked.

AGAIN THANK YOU ALL FOR TELLING ME YOUR EXPERIENCES.

Sour Lemon · Jul 21, 2017

OP, you do have some sympathy and understanding from me. One of my previous jobs was on a unit where almost every patient was a drug addict and a placement issue. At the suburban hospital I'm at now, it's far less common. I know they can be difficult in their attempts to obtain drugs and I know how difficult they can be when they don't get the drugs they want/need. Nobody liked floating to my unit. Nobody.

If I didn't have such extensive experience with that type of patient, they'd probably scare me too.

mjaybx · Jul 21, 2017

Reading through this thread I'm just disgusted on how nurses are bashing the OP, it's obvious OP is burnt out from working the floor. I won't judge you since I use to work a post op unit and dealt with the same issues and see your side . I wouldn't ask other nurses for their opinion since this profession has become so jaded , I worked with physicians and don't see this type of calling out someone and putting them down behavior as I see in nursing. OP, I understand you are concerned for your license since people don't die from pain but will die from respiratory depression í ½í±Œí ¼í¿½ I suggest you get out of Med Surg floor and go into a specialty where you can get some respect .