Legitimate Pain or no?

[MiaNursingStudent]

I have never been so angry or frustrated in my nursing school career!! Please correct me if I'm wrong because I've been banging my head against the wall to understand the rationale that was given to me-- and I really want to know if I am in the wrong, receiving incorrect information, or just SOL.

Today during clinicals I was assigned a "difficult patient"-- which I believe was an incorrect label to give this patient because she was actually quite sweet and polite. I got the report from the nurse who was assigned that patient and she said "just so you know, this patient is going to ask for her pain medication everytime she sees you". Sure enough-- I went into the room to do the daily assessment and obtain vitals and she asked me for her pain medication.

Background info on my patient: She has remitting-relapsing MS and was admitted for an abdominal abcess. Since her admission (89 days ago) she has developed 3 pressure ulcers- a Stage II on her coccyx and two Stage I on her heels. She also has leiomyosarcoma with metastasis to the kidneys. Her Meds: She gets a Fentanyl patch (25mcg/hr) q72h and a Lidocaine patch daily. She is also taking Ativan 0.5 mg t.i.d. and her prn pain med is Dilaudid (0.25-0.5mg IVP q2h prn for pain). That's her meds for pain.

When I checked her chart to see when the Dilaudid was last given it was 5 hours ago. The patient ranked her pain as an 9 and so I went to ask the nurse if she could get it out of the pyxis for me because I was in charge of total patient care (but don't have access to the pyxis system). She said that my patient was just a drug seeker, that she didn't have legitimate pain, and that my patient was just trying to manipulate me into giving her some pain meds..... Correct me if I'm wrong, but isn't pain whatever the patient states that it is? And since she has an order for Dilaudid prn and it had been 5 hours since her last dose that we could give it as needed for pain? And for the nurse to tell me that my patient didn't have "legitimate pain" simply infuriated me! She has MS and Cancer for crying out loud!!! And in my opinion, the Dilaudid dose seems so low that I was surprised that she didn't ask for it more often. The rationale that the nurse gave me for withholding the prn pain med is that the patient is "psychologically dependant on the pain meds" (even though there wasn't a psych evaluation done on her) and "is just trying to get her drugs".

Anyways, long story short, I had to fight to get pain meds for my patient whose pain level never went below a 7. I talked to the Pain Management Nurse about it and got her opinion about it-- she thought that the dosage of pain medication was too low and that the patient could be experiencing breakthrough pain---- but when I went to my Professor about it she said "I'm glad you're being an advocate for your patient but you really should choose your battles because working on a floor has its politics"....... first they tell me to always be an advocate for my patient but then they want me to compromise my quality of care so that way I'm liked by the other nurses?

I'm just a nursing student--- so if anyone with ANY type of experience can please give me some guidance, I am so angry, confused, and let down right now. I really feel like I did the right thing by standing up for my patient because I believe she was in pain..... I'm just so lost.....

[LouisVRN, RN]

I have to agree with you and your frustrations. A lot of nurses seem to think they are personally in charge of controlling the narcotics. IMO if a doctor has ordered it and the patient has requested it, provided there is no change in status (decreased bp, increased sedation, etc) they may have it. I am not going to pick my battle over whether there pain is legitimate or not. That being said there are times I doubt my patient's pain is legitimate, for example if I ask once and they describe their pain as being dull abdominal pain, then next time its a bad headache, then next time its generalized aches, then its something else and yet they are going about their ADLs like nobody's business, asking to go to the cafeteria, walks off the floor, etc I start to wonder. However, even if I question the legitimacy of their claim to pain, I won't withhold medications. I will however ask for a pain management consult if the patient appears to be needing their pain for psychological issues rather than physical pain. I think you did the right thing in advocating for your patient.

[TheCommuter, BSN, RN]

first they tell me to always be an advocate for my patient but then they want me to compromise my quality of care so that way I'm liked by the other nurses?

Pain is whatever the patient says it is. If a patient states that his pain level is a 10, we're supposed to treat a pain level of 10. We are also supposed to serve as patient advocates, so you did the right thing.

However, I understand your instructor's words when she said, "Pick your battles." Students who develop a reputation for skipping the chain of command, making waves, and second-guessing the actions of the floor nurses might experience some trouble later on down the line. The nursing community is a small world, and certain students will never get hired in their local communities if too much negative feedback follows them. It's not about what you know; it's all about who you know.

Keep advocating for your patients, but do not skip the chain of command because corporate America frowns upon this, and your future coworkers can create a hostile work environment for you. A student is to report things to the floor nurse as well as his/her clinical instructor. Political trouble brews when you bring issues above the heads of these two people. Remember that.

[indigonurse]

Pts. do develop a tolerance to their pain meds and it takes more and more to keep them comfortable. Your pt. has deep pain. Every person has their own perception of this situation. Apply your knowledge from your education and from your patient and do the best you can do to keep the pt. comfortable.

[fromtheseaRN, BSN, RN]

Pain is whatever the patient says it is. If a patient states that his pain level is a 10, we're supposed to treat a pain level of 10. We are also supposed to serve as patient advocates, so you did the right thing.

However, I understand your instructor's words when she said, "Pick your battles." Students who develop a reputation for skipping the chain of command, making waves, and second-guessing the actions of the floor nurses might experience some trouble later on down the line. The nursing community is a small world, and certain students will never get hired in their local communities if too much negative feedback follows them. It's not about what you know; it's all about who you know.

Keep advocating for your patients, but do not skip the chain of command because corporate America frowns upon this, and your future coworkers can create a hostile work environment for you. A student is to report things to the floor nurse as well as his/her clinical instructor. Political trouble brews when you bring issues above the heads of these two people. Remember that.

i agree with the pick your battles because of this. however, if there were a battle to be picked, i would definitely pick this one. just go up the chain, and do it the right way. i'm also a student, and whenever i've questioned a nurses actions, i've always asked why they were doing it that way, because i was taught another way. i don't ask it in a condescending way, because of course they know more than i do, i ask out of sincere curiosity because i know that the real world is much different than school. however, in doing this, more than a few nurses have changed their minds after trying to explain their method. maybe in talking it out they realized they were off base?

[Spritenurse1210, BSN, RN]

You're in the right, but there are also many factors to look at. She may very well be experiencing breakthrough pain. As you said, she has MS and Cancer. Since you're just a student at the moment, let this be a lesson to you in the future about advocating for your patients and listening to/meeting their needs. Everywhere you go you're going to have to wade through the political swimming pool throughout your career from the director of nursing all the way down to the staff nurses you're working alongside. Pick and choose your battles wisely and when it comes your turn to take care of patients without supervision (once you graduate), you will be able to make your own clinical decisions. As one of my favorite mentors said, "Do what they (preceptor) want while they're sitting on top of you, and when you are on your own, do what you know is right."

[leslie :-D]

i do agree, that this pt needs advocacy...

and i salute you, for recognizing and being proactive in getting her proper tx.

but.

i also agree (with the commuter) that as a student, you need to proceed cautiously.

whether it's valid or not, if you're seen as a 'troublemaker', you're setting yourself up for potentially future trouble.

as a student, i would likely see if you/instructor, could work on getting her duragesic increased, let's say to 37.5 mcg.

and/or, if her pain is unrelieved, try to get scheduled meds for her.

this way, she doesn't have to be judged when asking for a prn.

there are ways around it...you just need someone on your side.

wishing you the very best.

and keep it going...you're clearly on the right path.

leslie

[Flonightingal]

Hi

Wow! I can imagine what a shock it must have been to you when the floor nurse did not jump up and immediately provide the patient with pain med. I also think your instructor should have elaborated a little more about "politics" of the floor; I'm assuming she didn't do that to your satisfaction because of your post. As a nursing student and one learning the ropes, as mentioned by thecommuter, I would limit my concerns to the patient's primary nurse and my instructor. It is then up to your instructor to address it further. It does not bode well for you to challenge the patient's nurse, and that is exactly how she will see it.

Now, when you become a Registered Nurse, and you will, your passion will serve you well. I encourage my nurses to advocate for patients as you do. Moreover, I expect them to go up the chain of command if the patient's situation warrants it.

First thing we learn in nursing school is that pain is subjective. You can never prove that the patient is not in pain, even if you suspect otherwise. Getting pain management involved is a great idea; next time get approval from your instructor first. It is true that after years of practice, experienced nurses can sometimes come across as jaded. Unfortunately, it is a "side effect" of long time nursing. It is something we all guard against and also something that a newbie will have a hard time understanding. It does not mean she cares any less. I hope you are feeling better by now. Despite the hurdles you may face, overall, nursing is a very rewarding and noble profession.

[ObtundedRN, BSN, RN]

Pain IS what the patient says it is. And it was wrong for the nurse to pass judgement on that patient. It wasn't her place to do this. From the history you posted, I would expect the patient to be in a lot of pain. If my patient has pain, and has an order for pain meds, You better believe I'll give it to them as long as I'm not worried about it changing their hemodynamics too much. And if my patient's pain isn't managed well with what is currently prescribed, I will call the MD in an instant, even if it is 2am.

I don't mind giving out the candy. I get pretty mad when I hear someone else is witholding pain meds because of their own personal judgements.

[Spidey's mom, ADN, BSN, RN]

I think this patient is being under dosed for pain in correlation to her condition. But I'm a hospice nurse and I routinely see higher dosing of Fentanyl patches (50, 75, 100 mcg). We also use liquid Morphine Sulfate (10 to 20 mg Q15 minutes). Or a CADD pump with sub-q Diluadid or Morphine.

Yes, use the chain of command.

But this patient needs a pain consult. If I were her nurse, I'd be chatting with her physician ASAP. Since you are a student, this needs to go through your instructor.

Don't let anyone tell you that being a patient advocate is NOT the hill to die on. Yes, it is.

Your heart and mind are telling you that there was something wrong - you are going to make a fine nurse.

steph

[Barras]

As long as the patient can handle the pain med, and it is within the appropriate time frame, I give it. However, I can understand both sides of this frustrating situation. On the one hand, we are taught that "pain is whatever the patient says it is" and on the other hand, you have to question the patient who is rating their pain a 10 out of 10, and is laughing and carrying on like they are more like a 1 or 2...or sometimes even a 0. Regardless, the doc ordered it, and if they can legitimately handle it, I'll give them what they want. In some cases though, sometimes a PCA is a good option for these pain patients...if it is the right drug/dose/timeframe.

[NurseLoveJoy88, ASN, RN]

I believe the OP did everything she was suppose to do. Maybe I miss read his/her post but she did go up the chain of command. She talked with the floor nurse, her instructor, and the pain mananagment nurse. I think the OP did a wonderful job advocating for the patient. This is also a battle I would of picked. Way to go future nurse !!!