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

[ella2990]

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.

[tyvin, BSN, RN]

Judgemental...those doses aren't anywhere near what I've seen. I've worked with nurses like you and I come on shift to find some select patients who are suppose to be on routine pain meds writhing due to the attitude that you know better.

You would mean to have me believe that in over two years as a med-durg nurse, this is the first time you ran into this situation? Me thinks not.

You labled her the minute you saw her meds or heard from report that she was an addict. Was it fun playing God? Did you and the other staff laugh with the power of gossip over this human being at how mighty you were and what an addict she was? Were you patting yourself on the back every hour you didn't comply with her request? When she was screaming and begging; how did the power of control over someone you would regard as an addict feel? Did you chart her screaming or did you infer you own interpretation or just check off without leaving a note?

Some of the rugged responses against your proud post of action were rough, but I agree with them and they are in no way connected to my response.

Your post has allowed me to come to a decision that I've been pondering for a couple of years as this sites population slowly changes to people like you. You didn't come on here for advice; you did this so others could praise you.

Thank you for opening my eyes...I could have been more vitriolic in my response, but I believe one day you may grow up.

...

[bozmog1]

There seems to be alot of judgement in your letter about an IVDU. First of all there isn't enough information provided to make it clear that the patient's BP is the cause of the meds that are being given. Secondly, and IVDU has a chronic ADDICTION that many people in our field harshly judge as being a patient's choice. Would you judge a diabetic in the same way? Someone with heart disease or cancer? I think that many in the medical field know very little about addiction and have a negative bias toward those patients. It saddens me as a nurse practitioner to see a lack of compassion. I see it all the time.

[nursej22, MSN, RN]

Another good post. Sheeeeeesh I need to come here more often.

Ive been a patient recovering from back surgery. A failed one I might add. I am not a "dug user" of any thing illicit. But have had 30 some surgeries to keep me upright and walking with some kind of quality of life. I am one of "those" patients who need more pain meds, or more often anyway to deal with my pain. One of the things people like "us" worry about is going into withdrawals because a NEW nurse doesnt know "our" history and will fight giving us what is "ordered".

Ive had a nurse refuse a pain med (back then it was 125mg of demerol and 50mg of phenergan) because it was 15 minutes early and shes headed to report. I remember waiting for 90 minutes and being in tears because I hurt so bad. Ive since learned.....never tell a Nurse you're a Pain Mgmn Patient. Never tell em that your pain is 10 /10, they claim that's a dead give away for drug seekers. Never tell them what works or better yet what doesnt. Dont tell them your pain is thru the roof....they wont believe it and will say you're histrionic and there enters a whole new ballgame that wont have good results. Also, dont spend time telling them about what you'd call an allergy because the nurse will pound that home!!! Learn fast and hard that there is a difference between Allergy and Sensitivity.

It is very hard on everyone involved. Before I get flamed here let me add....I know some great nurses, in fact most are very suited for the job they do and they take a beating for it. I love to give kudos to ANY Nurse or even DR that will give me an even shake with my pain. Ive had nurses, LPN and RN alike....even the DON that would sit at my bedside and just talk to me. THAT lowered my pain level the best and didnt leave me feeling like pond scum.

So....with all that said (Im in a hella lot of pain lately) I give to each and every one of you that pays attention and listens to their patience major applause and kudos. YOU are the best of what seems to be a dying breed. PLEASE PLEASE dont give up on us.....we're human just like you....the only difference is we hurt so bad all the time and usually thru no fault of our own. My pain is a PIA for you and your attitude or judgment is a PIA for us.

I admire you for this post, and it rings true on so many levels. I do not have chronic pain nor am I an addict , but I learned a long time ago never to rate pain at a 10. All that gets you is a whole lot of eye rolls, and maybe a vicodin 4 hours later. Once, I was impertinent enough to report that my IV was infiltrated, which caused me to stop using my PCA for hours, because the nurse didn't believe me. I never tell anyone I am a nurse, never initiate talk of pain rx or dose, and make a point, when asked that I am not allergic to percocet, but i cannot tolerate it.

And I concur with sitting and talking to a patient, getting to know them, and helping them to relax and build some trust. It mostly likely is not possible to take the pain completely away, but distraction, imagery, heat application, a different mattress could help.

As other posters have pointed out, pain can be a sign that something is wrong, especially that far out. Put it together with decreasing bp, sounds like possible sepsis to me.

I am glad the "cater to her needs" was pointed out by some one else. I was attributing it a regional colloquialism, but I find it grating. Nurses are not maids, or servants. We provide care. And that care needs to take in the whole patient, as an individual-physical, psych-social, spiritual.

[gettingbsn2msn, MSN, RN]

You are a newer nurse. You will not win no matter what you do. We used to have patients leave ama and come back through the er. They had gotten pain meds down there. I had one of my regulars meet me at my car and beg to go upstairs to get pain meds (Dilaudid). She was 18 years old. Yet, as the OP stated the patient could code. Seen that too with too much Ativan and Dilaudid. You just have to watch these patients really close. Yes to a continuous pulse ox and yes to tele.

[MunoRN, RN]

Wrong , you don't have to follow orders if they aren't appropriate . OP stated patient was hypotensive, she could've called the MD and ask for clarification before administering. The way you come off is that you must follow MD orders no matter how ridiculous they are . Sorry , I've refused to follow orders and havent been taken to any board , I had a patient with an order for 60 of lantus with a wnl bg , called to clarify told me to give I refuse, charge gave and pt bg tanked to 40 . That's the difference between following orders needlessly and actually critically thinking .

You're correct that nurses are not only allowed but expected to not follow orders they deem inappropriate, but there does have to be valid reasoning that it is inappropriate. Hypotension might be a valid reason, although by itself a number wouldn't be the only consideration, but it doesn't appear the OP ever claimed the patient was hypotensive.

[MunoRN, RN]

Wrong , you don't have to follow orders if they aren't appropriate . OP stated patient was hypotensive, she could've called the MD and ask for clarification before administering. The way you come off is that you must follow MD orders no matter how ridiculous they are . Sorry , I've refused to follow orders and havent been taken to any board , I had a patient with an order for 60 of lantus with a wnl bg , called to clarify told me to give I refuse, charge gave and pt bg tanked to 40 . That's the difference between following orders needlessly and actually critically thinking .

And as a side note, having a normal BG at the time it's due isn't by itself a reason to hold lantus, lantus is not a correctional coverage, if the lantus is dosed correctly the patient's BG will be normal before the next dose is given. Trends in terms the patient's BG throughout the day are more important.

[Kooky Korky, BSN, RN]

Awwww Man...I wish I could like this post about a million times.

Ive seen and dealt with so many Nurses like the OP. I always do my best to "lay a little education on them" rather than pick a fight (not in the literal sense of course)

Ive been judged by the best in this type of situation minus the drama and "fit-pitching". "WE" collectively know what people like the OP think of us or of our pain. Do you REALLY think we dont hear or see the whispers? Do you think we dont feel it in your facial expressions or attitude?

You cant know our pain, our history, our event causing Chronic Pain et al. But then you wouldnt believe it anyway because you've already decided that we dont need all that medication and you're going to be different and stop the "nonsense". Being reasonable is one thing, being judgmental is an entirely different beast. I would reckon that MY doctors know me better over the years than a nurse ever could.

You could be wrong in what you think you see or feel.

OP does not deserve the bashing she's been getting. She is right to be concerned about this patient, for whom she has cared on 2 previous occasions. She is right to factor in VS, LOC, a needle stuck in the central line by someone other than herself, and the rotten jumble of orders by unsupportive physicians.

OP, ignore the mess here and keep on doing what you know is right. Don't expect reward or appreciation, but protect yourself and your license/livelihood/family by protecting your sick patient.

[gcupid]

OP It depends on if you are a RN. Everyone knows that RN stands for "Refreshments and Narcotics!" I would most definitely report you if i were a coworker/patient.

[connectchoicecareme]

I have seen cases like that,when you have a patient with insatiable needs for narcotics. Then you have the doctors and management that kept saying" give it'.They can say give it but you have to use your head and protect your license and at the same time keep the patient safe and comfortable.Check their vital signs, encourage the use of incentive spirometer,explain to the patient what you are doing.

Sometimes patient might be complaining even if he or she is getting all those medications, probably it might not be working for him or her,so the doctor might need to reevaluate.Pain is subjective it is only the patient that could rate his or her pain.But on the other hand we could have a patient with high tolerance or a manipulative patient.When I have such situation I pray for doctor T.to be on call because he puts a stop to the nonsense immediately.Assessment, gather information, intervene and evaluate and make necessary changes.Do not loose your license.

[Workitinurfava, BSN, RN]

Give medications in a safe manner because you can't withhold them completely but at the same time you don't want to kill the patient. However IVDU's tend to have a higher tolerance for medications (narcotics) so keep this in mind.

[Nightnurselife]

The bottom line is this: if the pt is conscious with appropriate VS and able to ask for pain meds and she has a pain med ordered you can give at the time of asking, there is no legal obligation you have to hold that medication. In this situation, the best thing you can do is document the pt's demeanour when asking for pain medications and document her response to pain medications. Document any concerns you have relayed to the Dr and document his response to your concerns. You can lose your license for withholding ordered meds just as you can for giving medications when they aren't justified to give. Document that you educated the pt on indications and side effects of meds and never honor the request to wake a pt up to give pain meds "when it's due." Pain meds may be ordered every 4 hours or so, but that doesn't mean they have to be given every 4 hours. A pt must ask for them and they can be given if at least 4 hours has passed since last dose. Those pts that request to be woken up to be given a PRN pain med when it's "due" will usually set an alarm to wake them if you refuse to deliver their request. The best advice I can give is to Document as much as you can in an objective manner.

[Kooky Korky, BSN, RN]

I have seen cases like that,when you have a patient with insatiable needs for narcotics. Then you have the doctors and management that kept saying" give it'.They can say give it but you have to use your head and protect your license and at the same time keep the patient safe and comfortable.Check their vital signs, encourage the use of incentive spirometer,explain to the patient what you are doing.

Sometimes patient might be complaining even if he or she is getting all those medications, probably it might not be working for him or her,so the doctor might need to reevaluate.Pain is subjective it is only the patient that could rate his or her pain.But on the other hand we could have a patient with high tolerance or a manipulative patient.When I have such situation I pray for doctor T.to be on call because he puts a stop to the nonsense immediately.Assessment, gather information, intervene and evaluate and make necessary changes.Do not loose your license.

What do you do if Dr. T isn't on call?

If he is, how does he end the nonsense?