bad day at work again. Maybe I'm just asking for it, lol. This is a rant but I also have some questions for you. I wanna know what you would have done. You guys should know by know that I work at a nursing home, I was working 10-6 sunday night. I had a patient that has a very extensive GI/Abdominal Hx. Colon cancer, had part of his colon removed, paralytic illeus, Hx of obstruction. He also has back pain a lot, takes Darvocet N-100 for the back pain. Never has complained to me about any abdominal pain whatsoever. Well, at about 0200 in the morning he es screaming out in pain, has Right Upper quadrant pain. He is moaning, extremely restless, rates 10/10. I have never seen him so misserable. Now my med-nurse asked me if she should go ahead and give the Darvocet to him. Every place, hospital, and especially ER I have ever worked at says not to give Narcotics for abdominal pain, they mask the pain, and if it gets worse it will be harder to catch. Thats what I was thought in Nursing school too. At this point with the distress that man was going through, a transfer to the hospital was not out of the question in my mind. So here I am, its 0200 in the morning, I have a patient with a very complicated GI Hx, only a narcotic to give (doesn't even have an order for Tylenon). I decided to call the Doctor, did not feel comfortable giving a narcotic that was ordered for a different kind of pain in this situation. If he tells me to give it I'm fine with it, but I wanted him to be aware of the situation. He is very rude to me on the phone, told me to give the DCN, and send him to his office in the morning.
Well I come in to work at 10 yesterday, and I look through his chart to see what his doctor said, and on his progress note is this written "Nurse called last night about patient in pain, affraid to give pain meds. Told nurse to give pain meds if patient is hurting" and under his new orders, in big fat letters "GIVE PAIN MED IF PATIENT IN PAIN". Now that just majorly pissed me off, it is not that I was sitting here scared to give a DCN. I just thought that most places have a policy against giving Narcs for abd pain. And I just wanted him to be aware of the situation, since his patient has such a complicated Hx. Anyway, here is my questions:
1. What would you have done?
2. Was I wrong regarding the policy of narcs r/t abd pain?
3. Am i just to carefull or what?
I know I have only been an LPN for a little over 4 months, so I'm still learning every day. Should I have handled it differently. I think that doctor is just pissed off because I called him at 0200 in the morning. He is the same doctor that has called my administrator saying he might as well work in the building if we keep on calling him so much.
Kind of had this experience last night. Called doc...."Doc. your patient who had clear lungs per your note has changes, no sounds on the left, coorifice throughout, urine output about 15-20 cc/hr"....Doc to "I'm not worried about his lungs, and if you're worried about urine then call his renal doc.". Renal doc "I'm not worried about his urine output!!! Why are you calling me? If you're worried about his lungs, call his primary."
This is a very sick patient and nothing they can do for him really. But he's a full code and full treatment. Nonetheless, I always report a change in condition.
Been there and done that...I think ALL of us have had to deal with a doctor with a 'Jesus' complex....too bad...sooo sad..that's why He gets paid the big bucks.
You did the right thing by calling the doctor. Don't ever let him intimidate you so that you don't call him when you need clarification on anything! Makes no difference whether it pisses him off or not. He was trying to make you look foolish...but actually, everyone that read that note in the patients chart probably thought.."Oh, Dr So-and-So was on a roll again I see!" roll their eyes, and snicker at His childish behavior..
My question to the doctor would have been..."Pt says its 10/10 pain and all he has ordered is Darvocet. Can I have an order for a more effective pain med?"
I know he hurt your feelings...but forget about it...you did the right thing!
First of all, nobody can make you feel like an idiot without your consent. You have to trust your nursing judgment.
I'd also like to say that all MDs/NPs/PAs aren't like that. I personally don't mind being called, its my job. You might remind the doc of that.
One of the biggest problems I've seen with staff nurses in recent years is a reluctance to assert themselves. Be confident in your skills. I'd have to ask how you phrased your question, though: did you just say that your patient is complaining of pain should you give the Darvocet, or did you elaborate on the type of pain, the pain rating, the new onset, the inappropriateness of Darvocet for this type of pain without a workup, etc?
Next time I'd send the patient out and then call that doc.
I just wanted to say, you did the right thing. And secondly, the not should be brought to the attention of somebody in administration because in most facilities writing notes (whether by the MD or nurse) that is accusatory or tries makes a staff member look they were negligent/incompetent is a BIG DEAL. The administrators care about the almighty dollar, and writing something like that puts the facility in a position of liability. They dont care if he "brings the facility money", if he puts them in a position where a family can sue, than the money he "brings in" will all be lost. We actually had a resident fired from our ER because he wrote a derogatory remark in the patients chart about the nurse not being "fast enough". (From what I hear, if you are fired from a residency you are pretty much blacklisted...)
One of the biggest problems I've seen with staff nurses in recent years is a reluctance to assert themselves. Be confident in your skills. I'd have to ask how you phrased your question, though: did you just say that your patient is complaining of pain should you give the Darvocet, or did you elaborate on the type of pain, the pain rating, the new onset, the inappropriateness of Darvocet for this type of pain without a workup, etc?
And don't you love the one's who say "I'm sorry for bothering you......"
Last night a nurse said "I'm sorry for bothering you on Christmas Eve, but........" The but, was the day shift had called him twice with no called back. Why apologize....grrrrr.....
To the OP, sorry for highjacking your thread. Carryon with confidence!
You did good. The one thing I do before calling the doc is to do a thorough assessment and vitals and chart them quickly. Example: C/O sudden onset right upper abdominal pain rated 10 on pain scale of 1-10. Bowel sounds present all 4 quads (or hypoactive). Last BM 12/25 ect... ect....
This way if something is off- such as not hearing bowel sounds or very hyperactive BS (possible perferation)- or very liquid stool (seen sometimes with bowel obstructions) than you can report this to the doc and give him some evidence of why this is important- and or to CYA.
Feel like an idiot? Been there, done that and I suspect we all have. I would rather feel like an idiot than be intimidated into not calling the doc. The last thing you need on your conscience is thinking that you let your patient down because you were intimidated by a rude doctor. You will probally need to call him again in the future. So be very prepared and give him all the info he needs so that he doesn't blow you off next time.
a friend of mine was experiencing acute abdominal pain. a doctor did a house call, and gave her a shot of either morpine or demerol. she slept after that, only to wake up in a cold sweat, feeling weak as a kitten, and still in pain. she barely had the strength to pull back the covers, but when she did, her husband saw..... the bed was soaked with blood! !
her husband called the ambulance, and she was taken to the er with a ruptured fallopian tube from a tubal pregnancy. she had bled so much that they almost lost her (she had an out-of-body experience while they were trying to save her...saw this beautiful angel sitting on a cloud, beckoning to her!)
so, this is why you do not give narcs for acute abdominal pain! never mind the fact that if someone is prone to paralytic ileus, the narcs will slow the movement of the bowel even more!
you did the right thing. that doctor should have told you to send the patient to the e.r., imo.
The comments that doc wrote were out of line, period. If he is getting called at night for inappropriate reasons, then he needs to address that with the DON; she can schedule an in-service, if necessary.
If the Darvocet was specifically ordered for back pain, then you really should not be giving it for anything other than that. Otherwise, you could be guilty of practicing medicine without a license (you would be "prescribing" the Darvocet for something other than the original intention).
Darvocet is a really crappy drug, anyway. It's a very weak opioid (analgesic equivalent of a couple Tylenol) that has a lot of serious side-effects.
I'm not so sure that the concern about "masking" pain is as big an issue these days. Most of the surgeons I dealt with when I was an ED nurse didn't really worry about it. Maybe it was more of an issue when there were fewer sophisticated diagnostic tools.
Tweety, BSN, RN
36,262 Posts
Kind of had this experience last night. Called doc...."Doc. your patient who had clear lungs per your note has changes, no sounds on the left, coorifice throughout, urine output about 15-20 cc/hr"....Doc to "I'm not worried about his lungs, and if you're worried about urine then call his renal doc.". Renal doc "I'm not worried about his urine output!!! Why are you calling me? If you're worried about his lungs, call his primary."
This is a very sick patient and nothing they can do for him really. But he's a full code and full treatment. Nonetheless, I always report a change in condition.