I am a RN with 2 years experience in Med-Surg and this is the first time this has happened to me. I was precepting a nurse new to our facility and we were taking care of this young patient for a kidney stone. She had came back from surgery and was sleeping. When she woke up I noticed she had tremors and was stuttering a lot.  (Interesting) Family said it was new to this admission but was doing that before surgery as well. 

A few hours later she started crying and reported 10/10 pain. So I had my orientee start by giving her 15mg of toradol IV. No relief, so then 2 tabs of 5/325 norco. Waited an hour or less, patient still crying, so we gave her 2mg of IV morphine.

Patient is now stating she can't breathe, we check her vitals, everything is normal except heart rate is 105 (I'm assuming from pain and crying). We put her on 2L of oxygen. The family tells me that she was receiving dilaudid at another hospital and that's all that works for her. (This patient is an adult but her parents were speaking for her).

I say OK I'll try calling the doctor and see if I can get an order for dilaudid. We called the doctor and he said no, give a one time dose of another 2mg of morphine, we wait a bit because we had just given morphine and then give the one time dose. Patient is asleep, family complain hand is swollen so I have my orientee stop the fluids for a bit and put ice on her hand.

It's now shift change, patient awake crying in pain again and family in room is yelling at my orientee that we are terrible and not helping her daughter. I'm hearing it from other family member on the phone as well. I explained to them that the doctor said no, and they told me to call a different doctor for the dilaudid.

Night shift nurse says "go home we'll handle it from here". I'm back to work again in 2 days (don't have the patient of course) but I'm hearing from the nurse who has the patient that they are going to write a complaint about my orientee and myself.

I am worried and lost some sleep over this because this is the first time this has happened to me and I'm nervous. Am I in the wrong and was there more I could have done? I feel guilty. 

Y’all both did just fine. You can’t force docs to change their minds or their orders. I had a pt call and report me to HR because I wouldn’t call the OR, pull their cardiologist out of surgery, and have him come to the office so the pt could see him that same day. I’d offered appts with other physicians or mid levels, or to go to the ER where her physician was on-call, but pt yelled and hung up on me and reported me for refusing to help her. I got fired and it was my very first nursing job. You’ll be just fine from this. 

Bella345 said:

I am a RN with 2 years experience in Med-Surg and this is the first time this has happened to me. I was precepting a nurse new to our facility and we were taking care of this young patient for a kidney stone. She had came back from surgery and was sleeping. When she woke up I noticed she had tremors and was stuttering a lot.  (Interesting) Family said it was new to this admission but was doing that before surgery as well. 

A few hours later she started crying and reported 10/10 pain. So I had my orientee start by giving her 15mg of toradol IV. No relief, so then 2 tabs of 5/325 norco. Waited an hour or less, patient still crying, so we gave her 2mg of IV morphine.

Patient is now stating she can't breathe, we check her vitals, everything is normal except heart rate is 105 (I'm assuming from pain and crying). We put her on 2L of oxygen. The family tells me that she was receiving dilaudid at another hospital and that's all that works for her. (This patient is an adult but her parents were speaking for her).

I say OK I'll try calling the doctor and see if I can get an order for dilaudid. We called the doctor and he said no, give a one time dose of another 2mg of morphine, we wait a bit because we had just given morphine and then give the one time dose. Patient is asleep, family complain hand is swollen so I have my orientee stop the fluids for a bit and put ice on her hand.

It's now shift change, patient awake crying in pain again and family in room is yelling at my orientee that we are terrible and not helping her daughter. I'm hearing it from other family member on the phone as well. I explained to them that the doctor said no, and they told me to call a different doctor for the dilaudid.

Night shift nurse says "go home we'll handle it from here". I'm back to work again in 2 days (don't have the patient of course) but I'm hearing from the nurse who has the patient that they are going to write a complaint about my orientee and myself.

I am worried and lost some sleep over this because this is the first time this has happened to me and I'm nervous. Am I in the wrong and was there more I could have done? I feel guilty. 

Listen, things like this are going to come up your entire career. You literally just have to brush things like this off and not second guess yourself. You can not do anything that you don't have a Drs order for. Are some people going to give you a hard time when they don't get what they think in their minds they need? Absolutely. You can't do anything about that. All you can do is follow your Drs orders and do everything that you already stated that you did and explain to the patient everything you're doing and why. You can't pull an order out of your a$$ every time a pt (OR FAMILY) doesn't like something. This is going to happen a lot. It sounds like you're doing a good though. To be honest, if I were that Dr, there's no way in hell I would of just said, "aww...she's got tremors and she's stuttering?? Yea, sure I'll just go straight to IV Dilaudid since that's what the family requested and make her stutter turn into a slur. " That's just ridiculous. (Side note, toradol normally works very well for kidney stones even though it's non narcotic. Maybe she needed 30mg??) Family members are just scared. Sometimes family members make the whole hospital stay so much worse than it needed to be. It's hard for people to handle seeing their loved ones in pain or in anything that isn't their norm. Some people Just don't know how to handle things well. They don't appreciate the care that you are actually giving to their loved one bc they don't see past the patient who is crying and shaking. You are not God. You can't fix everything that your patients and their family members are concerned about. All you can do is monitor them and maintain their stability and call the Dr when things come up...and follow your orders. And show care and compassion obviously. Anything else is outside your scope of practice. You're doing a good job. Keep that up. 

Specializes in Maternal Newborn and Denials Management.

I am a nurse with 30 years of experience. In that 30 years I have taken care of many patients with intractable pain due to cancer, chronic pain due to pinched nerves, Sickle Cell Crisis, intractable migraine, acute post-surgical pain and many more. I learned that every patient is different when it comes to what works for pain. People with chronic pain do know what medications work best. I always asked my patient's admitted with chronic conditions what medications work best for their pain.  I also learned that a patient can be asleep and still be in pain. This happened to me during childbirth. I was given Stadol during labor. This made me woozy/sleepy and did nothing for the pain. In the situation you were in I would have called the physician again after the Morphine did not work. If the physician refused to change the pain medication or come examine the patient I would have gotten the charge nurse and nursing supervisor involved. 

On 12/7/2021 at 5:53 PM, Susie2310 said:

A general comment about kidney stone pain apart from the situation described in the OP:  Kidney stone pain is known to be severe.  Frankly, if my family member was a patient and they were medicated for severe kidney stone pain with Morphine in a dosage that wouldn't be appropriate for their severe pain and their pain was unrelieved, and they still continued to complain of severe pain, I would be absolutely furious, and I would be complaining.  And I would take this situation further formally.  As nurses we are the patient's advocate.

I've debated making this comment...but, in the interest of clarity: The kidney stone situation that is most associated with significant, intolerable acute pain is a kidney stone in transit out of the kidney, ureter, etc. Not just "I have a kidney stone [in my kidney]" or "I just passed a kidney stone" or even "they just took a kidney stone out of me."

While none of us can know the degree of perceived post-op pain for this patient, the stories of "this is outrageous because I had a kidney stone and morphine didn't touch it!" are not really appropriate or necessarily even applicable.

I actually think that plenty of people don't make any distinctions at all when discussing kidney stones and mostly are only ever referring to the legitimate "I-can't-sit-still-this-is-worse-than-unmedicated-childbirth" situation of an acutely-in-transit kidney stone. Meanwhile they clearly wouldn't believe that pregnant people need an epidural to tolerate pregnancy and post-partum just because the pain of childbirth is so severe.

This is a post-op patient. While there's no question that the kidney stone experience can be exceedingly painful and surgeries can involve acute pain, it's very possible that this scenario is something like post-partum women being offered ibuprofen--no one expects that the strongest pain interventions we have available are going to be routinely needed after the fact. This isn't "she had a kidney stone and the nurse and doctor are blowing off the pain of kidney stones."

Even patients are confused about it all. That's why they come to the ED for "kidney stone pain" bringing their scans/reports showing their stone in their kidney. Some of them have figured out they should at least prick their finger and put some blood in their urine sample. Not saying the majority of patients are like this AT ALL. I'm just reminding people that "I had X so this is ridiculous patient treatment" is not a very wide assessment of the possibilities.

FTR, the answer here is not to choose either A or B (demand stronger medications or blow off the patient's reports). The answer is to assess the patient, have conversations/report to the physician, try interventions, reassess, etc. Which is what the OP did.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

The issue isn't that the nurse judged the patient's pain. The nurse listened to the patient.  The nurse gave the ordered pain medication, when that didn't work and understood that dilaudid worked the nurse informed the doctor.  

If at the end of the day if you know you've done your due diligence then let them complain.  I'm sure it's hard on them seeing their daughter cry and there's probably some dynamics there.  

There's probably very few of us that have pleased our patients or family 100% of the time and didn't get a complaint.  

 

Specializes in Med-Surg.

Thank you for replying. Yes we were trying to help the patient but the family felt like we weren’t and made my orientee and I feel guilty and angry. You are right, I need to just let this go but it is something I still struggle with.  Nursing gives me anxiety sometimes. 

One additional comment; if an otherwise healthy, young patient is having this much pain and requiring this much analgesia for renal colic then; A) They may have another, more serious etiology for their pain and need to be further evaluated by the MD  B) They have zero pain tolerance or are a hypochondriac or C) They are opioid tolerant and are likely drug seeking.  Not to be judgy here, but I'm jaded and having seen this before, my money is on the latter!

Specializes in retired LTC.

Am agreeing 110% with other respondents. Only thing I would consider doing would have been to alert the nsg super. Give Admin the heads up first BEFORE they hear it from the disgruntled family who will have FURTHUR blown things out of proportion.

Man, all those narcs and I'd be ready with a narcan!

Specializes in ER.

So glad I'm out of nursing!

On 11/29/2021 at 9:26 PM, Emergent said:

So glad I'm out of nursing!

Me too. I had anxiety just reading this and it set of all kinds of feels for me. I kind of only like animals now. 

morelostthanfound said:

Wow!  So sorry for this experience but you sound as if you are a very competent, attentive nurse and handled the situation brilliantly!!  My take; in terms of pain control, whenever I hear "it's the only thing that works"-HUGE, HUGE red flag for me!  I'm not suggesting that the patient is 'drug seeking', but with this comment it now becomes a definite bleep on my radar.  Personally, I wouldn't waste a minute of my time worrying about it.  The unfortunate fact is that people sometimes just suck and this is the end result of entitled, narcissistic people and hospital administrators expectation of a bed and breakfast treatment for patients.  If your documentation is supportive of your objective observations and interventions, let them complain!

Dilauded is, in fact, the ONLY thing that worked for my 10/10 kidney stone pain. Morphine is laughable. I think it's awful that your "radar" goes up bc a kidney stone pt KNOWS what works for them and what doesn't. Toradol was the miracle drug post surgery for me for the inflammation, no need for narcotics. Nice to know you're the nurse who doesn't advocate for your patients bc OMG what if they are addicted even though their pain still needs to be treated regardless. Awful. 

1 minute ago, Emergent said:

You seem to be taking this personally. You are extrapolating a whole lot from one statement about drug-seekers,  whose manipulative behaviors and entitled attitudes are perfectly illustrated in the opening post.

I know what severe pain is as well. I had a traumatic injury that damaged/severed nerves and tendons. I also had 6 homebirths. That never blinded me to the fact that some patients are looking for a fix. Our system has enabled them and it takes its toll on nursing. 

There is nothing wrong with me putting myself in the pt’s shoes and advocating for that pt. It is 100% ridiculous to prioritize your feelings over narcotics and addiction over what the pt is exhibiting. So who is taking this more personally? You with your doubts as to the pt’s pain based off YOUR experiences prevents the pt from receiving proper treatment. YOUR biased opinions. Pt was clinically presenting with severe pain and verified kidney stone, but oh no, your mind has to jump right to drug seeking. The nurse did nothing wrong in this situation, but the doctor was being ridiculous, and everyone jumping on the bandwagon of yeah, we gotta be careful with these drug seekers, even though this pt definitely has a kidney stone and v/s indicate pain. 

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