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Pain Dilemma Customer Service?

Nurses   (4,307 Views 26 Comments)
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Is it common practice to write a patient's prn pain medication schedule down for them? Lets say you have a pt that has several prn pain medications and also scheduled pain meds. The nurse from the previous shift tells you that they have been writing down this pt's prn pain medications for him/her since this pt "constantly rings for pain medication" and "gets upset if you are even a minute late with the medication". Is that common practice I guess to treat prn med's like scheduled pain meds (or should you wait for the pt to ring if they are starting to be in pain/offer prn dose if they are complaining of pain?)

Also lets say the day of d/c this same pt asks for an additional dose of IV pain medication. You have already given the prn IV med but they are requesting another dose (they are not complaining of pain at this time) but they want you to talk to the Dr. to have an additional IV medication as they say this is the only thing that works and they don't want to be in pain once they get home. You tell them that you will try to touch bases with the dr, but usually you remove the iv on the day of dc. At the same time another one of your patient's is coming back from surgery and is screaming in pain....you immediately go to assess this pt, he's screaming and swearing in pain but there is nothing ordered for pain med's ...he's screaming and youre trying to touch bases with the surgeon to get something ordered for him. Meanwhile the other patient is ****** because you are late with the the final prn pain med for him, another nurse d/c's this pt without this pt getting the IV med they wanted, and they end up complaining to your supervisor (that's the way you find out about it...nobody bothers to peak their head in the room with the screaming pt to let you know the other pt is requesting their medication...in fact the supervisor walks by without any regard to the fact that this pt is also in severe pain)... and all this is happening while your trying to get the second pt settled whose still screaming. Youre a bit concerned because this pt's site is bleeding more and more.

A few days later the supervisor fires you saying you did not adequately control the d/c'd pt's pain and purposely made them wait, accused you of calling this pt a drug seeker, (which you did not) and it should not be another nurse's responsibility to have given this pt the prn dose and to have d/c them for you. I guess being new to this career... is this fair? What should have been done differently? One suggestion another nurse made was to just give the pt the pain med without scanning it and run back to the screaming pt's room (but I would not have been comfortable with this as what if I would have made a mistake with the med also I did not realize the pt wanted the prn med at that time since I was never paged that they were requesting it or in pain).

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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.

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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.

Edited by SwansonRN

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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.

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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.

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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.

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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.

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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.

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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?

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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....

doc.gif mtpmedsurg.doc

doc.gif 1 patient float.doc‎

doc.gif 5 pt. shift.doc‎

doc.gif finalgraduateshiftreport.doc‎

doc.gif horshiftsheet.doc‎

doc.gif report sheet.doc‎

doc.gif day sheet 2 doc.doc

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Is this a real story? I mean pain is pain' date=' 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.[/quote']

Agree!!

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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!!!

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