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.....

[Fribblet]

Working in the ER, I may have a different perspective on pain and pain management.

I agree only somewhat with the sentiment of "pain is whatever the patient says it is." A patient who tells me their pain from their menstrual cramps hurts as bad as having their leg traumatically amputated while eating a doughnut is not going to be taken seriously by me or the doctor, and rightly so. Their "10/10" pain should not be treated with the kinds of medicine we give to patients who are having intense, serious pain. That would be doing that patient a disservice.

There are situations where throwing narcs at patients is NOT in their best interest, and there are times where the nurse can and should advocate for a patient in that regard.

The patient described in the OP, however, is not that patient. But to add to the discussion at hand, for your future reference, OP, if you find yourself in this situation again, advocate for better pain control, but also see if you can get a small, PRN order for Ativan. The calming effect of Ativan works well with the pain medication to provide increased analgesia. At least that has been my experience.

[tewdles, RN]

I think you did fine. I believe your assessment that your patient was in pain and required better pain relief. I think you followed your chain of command.

Frankly, I am a bit dissappointed in the floor nurse who was so disconnected from her patient that she wasn't even interested in a report of 9/10 pain.

[Cessna172]

I applaud you for advocating for that patient. I'm no expert on pain, but I've had my fair share of patients over the years. Some were flat out drug seekers, some were having genuine pain, and others were questionable. However, I pretty much have to take their word for it, because when doing a pain assessment and the pt reports pain, its my job to address that pain, just like addressing some other aspect of care. As much as I hate to give pain meds to the drug seeking patient (as we have sometimes labeled them), I still do if it is ordered. Predictably, that patient will want more, but he'll have to wait till next dosing time.

But, someone with a disease process, such as your patient is probably having chronic pain, and alot of the times I feel the MD didn't order a high enough dose or whatever (but we can call him to ask for an increase, it's his decision to increase or not). The nurse should keep in mind that with chronic pain, the patient may not have all the changes in vital signs you see with acute pain, such as a post-op patient would have . The reason I'm explaining it like this is to help you as a student, not to talk down to you or assume you don't know. Unfortunately, the nurse you were with, on the other hand has displayed a very poor example to you in pain control. Five hours is way to long to let that sort of pain go, when the med was ordered for more frequent dosing.

I can tell you that on numerous occasions I have gone to work, and the previous nurse thought he/she was the gatekeeper to the pain meds, thus my patient had a high pain rating like yours. On the other hand, when a patient gives me a high pain rating, such as a 10, I sometimes will have a gentle talk with them to explain that I really need them to be accurate, and explain that a 10 means the worst pain, and if that's their true pain then fine, but 9 times out of 10 they will think for a minute and give a lower number that we can manage, but as you said, it's whatever the pt says it is. Sometimes you have to explain that we usually can't make all your pain go away, but we will try to get it down to an acceptable level, and my patients are happy with that.

The point is, you did your best. You will be the nurse talking to a future student one day, remember the sound advice the talented nurses on this board gave you as noted by the many good posts above mine, and good luck in school.

[MiaNursingStudent]

Don't get me wrong, I completely understand what my professor meant by picking my battles-- it's just that I truly felt that this was one of those battles that I couldn't just stand down and watch as my patient remained in pain.

As for speaking with the Pain Management Nurse, I had done my previous rotation with her for my "specialty nursing" clinicals and she just so happened to be on the floor when I saw her. She is emancipated from that particular hospital and is the consultant RN for Pain Management-- I simply asked what her opinion was regarding a patient (I kept it anonymous) that had MS and Cancer and was on those particular meds-- she also suggested Lyrica or Neurontin to help with the nerve pain, but I did not skip anyone in the chain of command (I only report to my professor and the nurse) and by no means am I saying that I know more than the patient's nurse because I know I am still a nursing student and there is so much more that I haven't learned......

I guess I was just dissatisfied with the rationale that she gave me for withholding a patient's prn pain med: "because she doesn't have legitimate pain"....... so I was questioning if I was given incorrect information by my school regarding pain management (I was told it's purely subjective and that you should believe the patient), or if I am in the wrong for even being upset by the rationale she gave me. (I tried to not be upset by it and I tried not to let it get to me, but at the end of my clinicals I sat in my car and cried for a bit because I felt helpless...... I felt like I could've done better for my patient. after all-- if it were my mom or someone I truly loved I would want them to be well taken care of)

[Batman25]

You were right and the nurse was wrong. The dosage does seem too low. I would expect this patient to have quite a bit of pain given her circumstances. Unfortunately some nurses can go on a power trip where meds are concerned. This situation reeks of that. Shameful. If the meds are ordered and the patient can tolerate them then you give them. You were a good advocate today. I have a hunch you will be a wonderful nurse one day.

[MiaNursingStudent]

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.

I did ask the patient's nurse if there was a recent pain consult (since she was admitted on the 1st of September and I didn't see one in her chart) and she told me that it was not her place to ask the doctor to schedule a pain consultation and that it obviously wasn't ordered because the doctor probably didn't see a need for one--- at that point I realized that the nurse was pretty much burnt out on this patient and with me.... is it always this hard?!?

[Batman25]

As a nurse you can most certainly ask the doctor about a pain consult. We do it quite a bit.

[hiddencatRN, BSN, RN]

she told me that it was not her place to ask the doctor to schedule a pain consultation and that it obviously wasn't ordered because the doctor probably didn't see a need for one

That is really sad and frustrating. But the thing about experiences like this is that they teach you so much about what NOT to do and how NOT to be. I have a couple of nurses who I worked with as a student that I hold close to my heart as examples of the kind of nurse I never want to become.

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

I did ask the patient's nurse if there was a recent pain consult (since she was admitted on the 1st of September and I didn't see one in her chart) and she told me that it was not her place to ask the doctor to schedule a pain consultation and that it obviously wasn't ordered because the doctor probably didn't see a need for one--- at that point I realized that the nurse was pretty much burnt out on this patient and with me.... is it always this hard?!?

Yes, it can get that hard. I'm sorry that the patient's nurse is in that position.

Obviously - with the assessment of your patient's condition, there should be a lot of pain. I'm having a bit of a hard time understanding why this particular patient wasn't seen as legit.

Honestly, in the ER sometimes I've felt a bit jaded and I did have one frequent flyer drug addict who was very difficult to manage. And so yes, I didn't take her pain complaints quite as seriously although I did medicate her as ordered.

It is the nurse's place to talk to a physician and ask about a pain consult.

Live and learn and take away lessons on what kind of nurse you want to be. I am haunted by your description of your patient - she needs help.

steph

[DC Collins, ASN]

Sweet Jesus, SO WHAT if she is psychologically dependent on the meds. Pain is pain, especially with what your pt is going through.

As a recent grad and new ED RN, I am *proud* of you for fighting for your patient. The bulk of our job, in one way or another, is to advocate for our patients.

If you are "just a student", then we need More students working with patients!

If you can't tell, I am angry for you. Keep standing up for your patients. Someone will see that and it will come back in your favor eventually. If it doesn't, then the facility you are in right now is not the place you want to work anyway.

DC, ED RN :)

[DC Collins, ASN]

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.

I couldn't have put it better!

[DC Collins, ASN]

...and she told me that it was not her place to ask the doctor to schedule a pain consultation and that it obviously wasn't ordered because the doctor probably didn't see a need for one?!?

Burnt out is right. As a nurse it is *exactly* your place to ask the doctor such questions. You do so with utmost respect to the doctor. You present it in SBAR format, explaining your rationale. Any *halfway* decent doc will, if disagreeing with you, explain why. And you move on from there.

Just be sure, once you are a nurse on your own, to approach the docs with full info and rationale for your position. They will respect you for it. I don't just say this as an RN, but it also worked for me as a student.

DC, ED RN :)