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.

[Steffy44]

You did NOTHING wrong and patient satisfaction score can go to...! I'm an ortho nurse as well and we deal in LOTS of pain meds too. We usually have the same choices you gave. I'd NEVER give that many pain meds that close. Most of my patients understand why. I always tell them breathing is important. I find if the docs or nurse navigators have TOLD the patient that yes it will hurt and you will not be painfree...they expect some discomfort. However the ones who were abusing their pain meds prior to surgery...you'll NEVER help them because we won't medicate to the level they are used to. However I know a nurse or 2 on nightshift who like their patients comatosed for the night. Not worth my license.

[Here.I.Stand, BSN, RN]

You did NOTHING wrong and patient satisfaction score can go to...! I'm an ortho nurse as well and we deal in LOTS of pain meds too. We usually have the same choices you gave. I'd NEVER give that many pain meds that close. Most of my patients understand why. I always tell them breathing is important. I find if the docs or nurse navigators have TOLD the patient that yes it will hurt and you will not be painfree...they expect some discomfort. However the ones who were abusing their pain meds prior to surgery...you'll NEVER help them because we won't medicate to the level they are used to. However I know a nurse or 2 on nightshift who like their patients comatosed for the night. Not worth my license.

Actually, a history of opiate abuse is precisely why higher doses are needed and why respiratory depression will not ensue the way it can with a 90lb opiate naive elder. It's true that you probably won't "help" them in the course of a postop surgery stay, but we absolutely can and must help them to be as comfortable as possible. Pain free, no -- but as comfortable as possible. What we must never EVER do is punish an addicted pt by expecting them to take the same drugs as a 90lb opioid naive elder.

And for the record: I never concern myself with pt satisfaction. I concern myself with practicing clinically excellent and COMPASSIONATE nursing care.

[MunoRN, RN]

You did NOTHING wrong and patient satisfaction score can go to...! I'm an ortho nurse as well and we deal in LOTS of pain meds too. We usually have the same choices you gave. I'd NEVER give that many pain meds that close. Most of my patients understand why. I always tell them breathing is important. I find if the docs or nurse navigators have TOLD the patient that yes it will hurt and you will not be painfree...they expect some discomfort. However the ones who were abusing their pain meds prior to surgery...you'll NEVER help them because we won't medicate to the level they are used to. However I know a nurse or 2 on nightshift who like their patients comatosed for the night. Not worth my license.

I would encourage you to re-think your post-op pain control practices and beliefs.

Keep in mind that intentionally under-medicating pain in post-op patients results in higher cumulative opiate use in their post op course and is associated with more adverse events. This is also what results in what we often view in "seeking" behaviors as patients lose confidence in relying on us to appropriately assess for and treat their pain with an appropriate balance of reducing risk as well as treating pain.

The frequency with which a patient receives pain medications has nothing to do with it's risk, and actually giving divided doses more frequently is both safer and more effective than giving an equivalent cumulative dose less frequently.

For chronic opiate users, the appropriate practice is to determine the maintenance dose that makes their baseline roughly equivalent to non-users, then treat post-op pain beyond that. To give a chronic opiate user less then what a maintenance dose would be is no different than giving a non-opiate user no pain meds at all, do you think a nursing board would see that as being good practice?

[Eileen68RN]

1. Her tolerance to pain meds will be extremely high so what seems like dangerously high doses aren't to her.

2. You are NOT going to fix her addiction problem during this admission. You may not like her, you may not like the fact she is an addict but the doctor gave orders, follow them.

3. Unless there are specific vs parameters for the meds, I would not go by that. Her bp probably isn't effected greatly by hourly doses, she is used to it. If you are worried, get parameters from the doctor then you can blame it on the doc and still have a working relationship with the patient. The fights with addicts aren't worth it.

[babychickens]

Thank goodness someone said it!!! All of this rambling from OP and never ONCE did she mention O2 sat or RR!! I would humbly suggest reading an article or two on chronic pain. Here's one for starters:

American Society for Pain Management Nursing Position Statement: Pain Management in Patients with Substance Use Disorders

June Oliver, MSN, CCNS, APN/CNS, Candace Coggins, MS, MA, RN-C, ACHPN, PMHNP-BC, Peggy Compton, RN, PhD, FAAN, Susan Hagan, MSN, ARNP-C, RN-BC, Deborah Matteliano, PhD, ANP, FNP, RN-BC, Marsha Stanton, PhD, RN, Barbara St. Marie, PhD, ANP, GNP, RN-BC, Stephen Strobbe, PhD, RN, NP, PMHCNS-BC, CARN-AP, and Helen N. Turner, DNP, RN-C, PCNS-BC, FAAN

[Tenebrae, BSN, RN]

What were the patients o2 and respirations OP?

[traumaRUs, MSN, APRN]

While AN encourages lively debate, personal attacks won't be tolerated. Several posters have brought up salient points for the original poster.

Also, several posts have been removed, either because they were incendiary or they quoted the incendiary post.

[T-Bird78]

Pain is subjective. One of my nursing school clinical rotations was a pain managment seminar. People are afraid of pain meds for chronic pain sufferers. She gave us the acronym BABWACTO for managing chronic pain patients. Breakthrough pain dose, Around the clock dosing, Bowels (constipation), WHO ladder, Adjust dose if current dose not helping, Change med if not helping anymore, Time to allow PRN with scheduled, Orders. She had a patient who was on 3,000mg of dilaudid a day after a lengthy battle with spine issues, including several surgeries. When that pt had to go to the ER, the ER refused to administer that dose so the pt was lying there in pain on top of the ailment that brought them to the ER to begin with! It is not up to us to determine if someone is truly in pain or not. It's hard for us to comprehend that because we are so scared of decreased respiratory rate on pain meds, but for a chronic pain sufferer they've built up that tolerance to it.

[sarbo1010]

Okay, so looks like you did the right thing, but it's not the only right thing. #1 yes her b/p was on the low side, but is that where she lives? Did it drop lower after a dose. This lady is not narcotic naive, so chances of actually doing her in with drugs is unlikely. You are not going to change her. After 32 years of these kinds of patients, I choose the path of least resistance. Giving a patient meds every hour would just tick me off because with 6 patients I usually just don't have time. Thats when I call the doc and tell him I am not a human pca pump and this patient either needs a pca or pain management. But as long as the VS of the patient are at their baseline, I load them up. I don't have time to argue with management, patients, or doctors - just the reality of the situation we are faced with since payment is based on keeping these people happy. Had a patient last week who set the timer on her cell phone so she could have her pain meds on time and she would call me on the phone. She was happy, I am happy.

[JKL33]

I'm going to choose to be optimistic here. I think everything else has been said.

I will go out on a limb and say that I don't think the OP's reaction to this situation is all that unusual for anyone earlier in his/her nursing career (and 2 years is about enough to bring someone into the range of competent to proficient in basic nursing skills...NOT expert by any stretch). Hear me out with regard to where compassion fits in to all of this.

There is something to be said for reaching a point in one's career where s/he has, for all practical purposes, "seen it all" - and that point is going to differ widely based on prior life experiences.

I started my career on a unit where it felt like all I did all night was push various narcotics. The patients were very sick. I was stressed. I was handling it, but looking back I think I was probably close to being emotionally maxed. Back then we each had 12 acute care patients on the night shift and we each had a tech. Early in the night I answered a call light for a patient I hadn't yet assessed who needed pain medication. I did a quick assessment and went and got the med. The patient made conversation such as asking me if I was "new here" and told me that I needed to use the access port on the huber needle because that's the only way she could have the med. As I'm pushing the med, out of the corner of my eye I notice her arm slowly reaching around behind my back and she put the IV pump on hold. I turned it back on and proceeded.** I stayed calm and nothing escalated but I confess I felt furious inside. Really truly indignant. I thought perhaps she was a deplorable human being. I had thoughts such as "How DARE you try to play games with me just because I'm "new here" when I'm trying to HELP you - - and ELEVEN other people, several of whom are actually DYING?!"

The way I felt about that occurrence was a function of MY life experiences up to that point - I simply had not encountered anything like that before. And to some extent it was a function of the stress of learning to make good decisions as an RN, which I desperately wanted to do and I worked hard at. At those types of life junctures, I think it's fairly common to be a bit myopic. The NCLEX confers neither wisdom nor

experience - - both of which help with forming true and appropriate compassion as a nurse. You don't know what you don't know when you're "competent-but-not-yet-expert," and therefore you don't even know whether something is truly dangerous/scary (such as the OP scenario) or just different than the experiences you've cataloged so far.

I read the indignation in the OP. I am willing to bet there was an element of true fear/concern buried in there, along with a hefty dose of naivete. I hope I'm right.

OP - well, now you know. The question is, where will this experience (and this discussion) take you in your career? It can be an opportunity for growth if you let it. You have to let this be a turning point where you learn to consider another perspective and learn to let excellent nursing assessments and consideration of others' experiences guide your choices and interactions.

______________

**If anyone wonders what I actually said at that point: I saved face and didn't trash the rapport, by taking the kind and honest approach. "_________, I can see that you're in a bit of a situation here being hospitalized and in pain, and I'm kind of in a situation too, since, as you noticed, I haven't been doing this for 20 years just yet. So how about we make a deal - - I'll be here and I'll come right away when you call, but I need you to let me do things the way I was taught, and what I think is safe." It worked and the rest of the night went just fine, other than me thinking the whole situation was "UN-BE-LIEVABLE!"

[lindseylpn]

I think some people missed this so, for those of you who were asking OP said in a follow up comment:

RR 6-10

O2 sats high 80% - low 90%

Lethargic, could be aroused with touch

[canoehead, BSN, RN]

For this patient, I would have added 2lpm O2 via NP, put her on continuous O2 sat, called the provider for a fluid bolus, a prn Narcan order, and changed the IV doses to SQ (last longer, no rush with injection). I would hold meds for an hour if RR

You just can't kill an IVDU with po meds, I mean in theory, I suppose you could, but it's just not likely. It's the IV stuff that will push her over the edge, and it also gives the quick ups and downs that are terrible for managing continuous pain. Once you have a monitor on her, your worries about safety are addressed, the rest of my suggestions are just supportive care.