I recently took care of a pt with a foot fracture and he only had Tylenol for pain. I don't have any experience yet but I feel that this does nothing for pain of a foot fracture. And the pt is complaining that Tylenol does nothing for his pain...... However, there is an order that specifically states "Do not call the on-call MD for pain meds"...... Why? So the MD is aware of the pt's pain.... but does not want to give any other pain meds?
Sorry but I don't understand this situation... why not?
So now we have to tip toe around getting pain relief for our patients? Why did the physician simply wrote an alternative for increased pain? I would call I do not care about a MD being grumpy. You should have given more than just Tylenol. With all this customer service for reimbursement may be the hospitals should school these physicians instead of putting it on the nurses.
Asking the same question re OP....and have another.
Heron... In a case where a patient with a terminal illness, who is NOT actively working to remain sober, is in severe pain, why would you treat addiction at that point?
I'll give you an example, and please let me know your opinion on this...During that same period in time, I worked in a Family Practice clinic and had a patient who had a history of opioid addiction and was in the end-stages of HIV. One of his chronic infections included one of the diseases that cause diarrhea. He wore a diaper, had skin breakdown and an anal fissure. He could barely walk with weakness and pain and had to take a bus to get to our clinic. His primary, was sooooooooo concerned about his history of addiction, that he was only willing to prescribe 10 Tyco tabs every week. Made him come in weekly to check in and get the Rx. Would that seem overboard to you? I felt it was COMPLETLY devoid of compassion and common sense. If anything, the opioids might help the diarrhea, and if anyone would be in pain, this man was. No doubt...not a faker. He died a couple weeks later.
I'm assuming your first question referred to my mention of "end-stage AIDS". Back in the nineties, end-stage went on for months-to-years. Most of our population stayed on our unit for up to 18 months before death. In fact, the only time we used such a restriction on prescribing was when the individual was seeking in particularly blatant or abusive ways. We were committed to preventing withdrawal and treating pain at the same time, so the actively addicted people were all methadone maintenance unless they chose to detox. They also had a dedicated psych team attending to emotional and mental health issues. What we did not do was keep people stoned or allow inappropriate seeking behaviors. We did damn good work, too.
ETA: re your case example - opioids are not effective for cutaneous pain (assuming that tyco is Tylenol with codeine). A nerve block or topical preparation would have been more appropriate for what you describe. You did not mention other AIDS-related conditions, so it's impossible to say whether that med was appropriate or not. I have met addicts with AIDS who have adamantly refused strong narcotics right up to the end. The story you tell certainly implies a certain inappropriate rigidity and lack of perspective ... but I've been doing this too long to make a blanket statement.
This is one area where you really do have to individualize treatment.
So now we have to tip toe around getting pain relief for our patients? Why did the physician simply wrote an alternative for increased pain? I would call I do not care about a MD being grumpy. You should have given more than just Tylenol. With all this customer service for reimbursement may be the hospitals should school these physicians instead of putting it on the nurses.
Good grief, did you even read the thread? Or even the OP?
I'm assuming your first question referred to my mention of "end-stage AIDS". Back in the nineties, end-stage went on for months-to-years. Most of our population stayed on our unit for up to 18 months before death. In fact, the only time we used such a restriction on prescribing was when the individual was seeking in particularly blatant or abusive ways. We were committed to preventing withdrawal and treating pain at the same time, so the actively addicted people were all methadone maintenance unless they chose to detox. They also had a dedicated psych team attending to emotional and mental health issues. What we did not do was keep people stoned or allow inappropriate seeking behaviors. We did damn good work, too.
ETA: re your case example - opioids are not effective for cutaneous pain (assuming that tyco is Tylenol with codeine). A nerve block or topical preparation would have been more appropriate for what you describe. You did not mention other AIDS-related conditions, so it's impossible to say whether that med was appropriate or not. I have met addicts with AIDS who have adamantly refused strong narcotics right up to the end. The story you tell certainly implies a certain inappropriate rigidity and lack of perspective ... but I've been doing this too long to make a blanket statement.
This is one area where you really do have to individualize treatment.
Yes. TyCo being Tylenol with Codeine, and his pain was not cutaneous. I realize I didn't give enough detail and realize the variables that I did not include are important. I have no doubt you all did a great job with your patients. I was not criticizing your work.
I was remembering this particular patient and how much he struggled. It was this particular physician's attitude towards his past history that bothered me, as if that was most important, as opposed to finding a better plan/approach for him. I was simply giving an example
of how some nurses and doctors alike, allow their personal prejudices to influence how they handle pain control for those with addiction problems.
I have had fractures (foot, hand, pelvis) and extra-strength acetaminophen was more than sufficient. So do not assume the provider does not know what he or he is doing, it may be enough. It also may not be, everyone is different
Oh my goodness, for first, please let me apologize! I didn't realize that this thread has escalated to this point! I apologize, I am new and was simply confused by this order so I thought to just ask on here for input.
I left early that day after only few hours. But after I came back the next days, I asked the others who took care of about that patient and the order. They said it was regarding abuse history. It was my first time seeing such an order so I was simply confused.
Again, I apologize, I was behind on my time management that day and since I left early too, I did not make time to thoroughly read through the pt's notes to understand the big situation before posting this question onto here!
But thank you for everyone for your inputs to add to my own growing knowledge, I sincerely appreciate it!
Asking the same question re OP....and have another.
Heron... In a case where a patient with a terminal illness, who is NOT actively working to remain sober, is in severe pain, why would you treat addiction at that point?
I'll give you an example, and please let me know your opinion on this...During that same period in time, I worked in a Family Practice clinic and had a patient who had a history of opioid addiction and was in the end-stages of HIV. One of his chronic infections included one of the diseases that cause diarrhea. He wore a diaper, had skin breakdown and an anal fissure. He could barely walk with weakness and pain and had to take a bus to get to our clinic. His primary, was sooooooooo concerned about his history of addiction, that he was only willing to prescribe 10 Tyco tabs every week. Made him come in weekly to check in and get the Rx. Would that seem overboard to you? I felt it was COMPLETLY devoid of compassion and common sense. If anything, the opioids might help the diarrhea, and if anyone would be in pain, this man was. No doubt...not a faker. He died a couple weeks later.
I'm a hospice nurse. End-of-life decisions regarding pain control are rarely mixed in with fears of addiction unless the patient is concerned.
We regularly have patients with a history of addiction of one sort or another. And we manage their pain with Morphine Sulfate, Dilaudid, Methadone, Oxycontin, etc.
I think the patient you described should have been referred for palliative or hospice care.
I think non steroidals are ok if for acute, short term use. Calling for Ibuprofen, Toradol, even Tramadol, elevation, ice and using a surgical shoe when ambulating would be sufficient
danielle2000, MSN, RN
174 Posts
So now we have to tip toe around getting pain relief for our patients? Why did the physician simply wrote an alternative for increased pain? I would call I do not care about a MD being grumpy. You should have given more than just Tylenol. With all this customer service for reimbursement may be the hospitals should school these physicians instead of putting it on the nurses.