Pain Dilemma Customer Service?

Altra, BSN, RN · Apr 18, 2013

Writing down med administration times is one strategy I have seen *sometimes* be successful in setting behavioral limits on certain patients. It can work when you approach it in a calm, matter-of-fact, nonjudgemental manner and continually reinforce the notion of reassessment and remedication AS NEEDED.

As far as the "one more shot before I go" ... you need to know your docs and their practices/preferences, your policies (such as the length of time a patient must be monitored after receiving IV narcotics, for example) and you need to always be thinking ahead for your patients who are likely to be discharged during your shift. Make sure to communicate with them ahead of time, laying out what the plan will be (transition from IV to p.o. meds, etc.).

Despite these approaches ... sometimes a patient will throw a tantrum anyway. This likely has zero to do with you -- he/she was likely determined to "pick a fight" and you happen to be an available target. Don't take it any more personally than that, because that's all it is.

SwansonRN · Apr 18, 2013

Is this a real story? I mean pain is pain, but unfortunately a fresh post op takes priority over a stable patient about to be discharged, so yes I would have done the same thing. The nurse that popped her head in the door? I would have asked her to do it or called charge. I agree with the previous poster as well, it depends what the med is. ER oxycodone vs IV dilaudid. This just seems a sticky situation.

missladyrn · Apr 18, 2013

Where I work we get a lot of "pain clinic" patients. The ones who know how to work the system and are frequent flyers, they know what to say to be admitted, but they don't get to stay forever. They often know their pain medication schedule and will ask to write it down. I don't do it for them, they can do it themselves if they like. I tell them they can not have anything else until x o clock. And they need to call me for it, it is not scheduled. I do plan ahead for it though knowing they will call.

On my unit, you are not allowed to be discharged if you are still taking iv pain medication so the dr dc's it the night before discharge. After iv pain meds we need to monitor the patient until it wears off. I think it is a liability thing. That night is usually awful for these types of patients since they scream and yell and are used to getting what they want. But once a Dr on my floor decides they are getting dc'd, it is only oral pain medication until the next day. I usually end up having to call the MD just for them to say no. These types of patients are the ones on droves of pain medications at home.

RNnur · Apr 18, 2013

The IV med was dilaudid actually and the pt wanted an additional dose....they also had PO oxycodone which was the prn dose that I was not in to give right away because I was focused on the other post op screaming and again concerned since the site was continually having more shadowing...the thing that bothers me though is the supervisor walked by the room I was in after talking to the pt c/o not having the prn dose...she never bothered to see what was going on or ask me if I needed help...she just walked by and talked to me a few shifts later that I did not handle the d/c'd patients pain well....

Thank you for the advice about thinking ahead...although I think this might take practice and times. Things were really happening fast and being a new nurse I guess I was not expecting the crap to hit the fan all at once and to ultimately get canned because it did.

anotherone, BSN, RN · Apr 18, 2013

Yes, complete BS. This happens all the time. What kind of surgeon doesn't order prn pain meds after surgery? We are supposed to write prn meds and how often pt can have them and what time this is per management. Some pts carry on if their prn meds are late a few minutes. WELL TOO BAD. I have to prioritize care for all of my patients. Unfortunately there isn't always a nurse to help by giving them and sometimes you are stuck with a lazy crew too.

applewhitern, BSN, RN · Apr 20, 2013

We are not allowed to write down times that prn pain meds can be "given again" or "due again." Our doctors pitched a fit when they found out that we were writing it down for the patients. They say that makes the patient "expect" it, even if they don't really need it. Anywhere I have ever worked, we would not give a "dose to go home with" unless it was p.o. We do not always have a charge nurse; most of the time the RN's are pretty much functioning on their own. I can't believe someone would get fired for this.

Bruce_Wayne, ASN, RN · Apr 20, 2013

Well super duper technically, we're encouraged to assess a pt's pain 30 minutes BEFORE a prn is due and ask them if they want the medication when it is due. If they don't need the medication at that time you reassess their pain an hour later during your q1h "deliberate rounds". I work on a surgical/ortho floor so we do hourly pain assessments. It's kind of BS.

If you have a fresh op in pain crisis and uncontrolled bleeding, they take priority and it would be inappropriate for you to tend to the more stable patient while that patient was still in pain and bleeding.

Is this a true story or a hypothetical situation? In any case you're probably better off not working there than you were working there.

BrandonLPN, LPN · Apr 20, 2013

Writing a pt's pain med schedule down on the white board is a logical strategy.

One thing I don't like about it, however, is it reinforces the idea that if the nurse isn't right there at 10:15 with the med, then he is "late" or "failed". This goes to the whole "you're not my only patient" discussion in another thread. Stuff happens. Other, more emergent situations can take priority. Where was this nurse manager when all this was going on? Where were your co-workers? What happened to team work? What happened to common sense?

Esme12, ASN, BSN, RN · Apr 20, 2013

This is CRAZY...what the heck has happened to nursing????? Have people completely LOST their minds???

In my honest opinion.....NEVER give an IV narcotic without an order. NEVER. Never give any meds...without an order(unless of course it's a emergency med)......and they really fired you? Unbelievable!

What idiot of a surgeon would operate on a patient and rder nothing for pain???

I am so sorry you are going through this....but if this facility is going to act like this...you are better off without them.

Going forward.....I would have told that patient that in the meantime that I would give them the po med, so they had "some relief" while we waited for the MD's return call and when they refused the po med...I would document that refusal and that the MD was paged/awaiting response, patient verbalizes understanding of POC....and care for the other patient.

The new surgical takes precedence over the patient being discharged.

For the future here are some brain sheets to help keep you organized....

FinalGraduateShiftReport.doc

DAY SHEET 2 doc.doc

weemsp · Apr 20, 2013

None of this makes sense to me. Starting with the pt being d/c'd still on IV pain meds ( I thought it was common practice that pt's should have all IV use dc at least 24 hours before d/c. ???

Secondly, when is a pt d/c higher priority than a new post op with more pressing concerns??

Thirdly, that you were terminated????

I'm very sorry to hear this...Good luck with your future positions!!!

martymoose, BSN, RN · Apr 20, 2013

I'd be on the phone with the doc and telling them the pt is requesting IV meds before he goes. Sounds like they aren't ready to be d'/c'd then. Stupid doc should have d/c'd the iv meds long before the pt was to be d/c'd

This is also known as " oh , I'd like to be as high as I can get before I leave here"

Yep, I'll give the med, but doc will be informed that I can't let the pt go home so soon after an IV med. Do they want to cancel the d/c?