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.
THIS! Some patients are high metabolizers and need huge amounts. 15 of Toradol is nothing. 30 IV or 60 IM is routine in the OR. If the patient says dilaudid works let her have it. But the failure here is the doc who refused. It's really important to keep your empathy but work on establishing good boundaries at the same time. Try to imagine a glass wall separating you from the patient. You can see what's going on but don't let others' maltreatment of you through that glass. Leave it behind when you leave work. You won't be a bad nurse for doing that! Don't ask for perfection from yourself....it's the enemy of good.
Yeah I'm side-eyeing the comment about wanting narcan on hand for 2 norco and 4 mg of morphine that were spaced out. For a kidney stone that's not all that exciting and it sounds like the patient was under-treated for pain. The MD should have come to assess the patient and if the 2mg of morphine helped, more is reasonable but if it did nothing a different narcotic would make sense. And if the 2mg needed to be repeated, I wouldn't wait to administer because that's the point of titrating to effect.
People with chronic pain learn the names of meds that work for them too, not just "drug seekers.” Heck after a few doses of each post surgery I know that the fentanyl helped a ton and the dilaudid left me in a lot of pain. I know that addicts and people with opioid tolerance have pain and deserve it to be treated so with a known painful condition and report of pain, it's not really my job to decide if the patient is faking it or not. The risk-benefit of doing that in an acute care setting doesn't really justify it- like on the one hand I prevent an addict from getting a fix but on the other I've left a patient in excruciating pain. There's a ton of research out there on how our implicit biases impact pain control (in particular for black women).
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.
Yeah as a peds nurse I want to know how many kg the patient was because 2mg is an appropriate dose for a 20kg child. 4mg is our standard adult dose. And for surgical pain we use PO opioids with IV for breakthrough….at standard dosing.
Thank you Emergent! I'm all for giving someone the benefit of the doubt when it comes to their pain response and need for analgesia. That said, the fact is that there are a lot of drug seeking patients gaming the system in an attempt to get their next fix. I can dress it up or say it in a more 'PC' way, but this enabling behavior, HCAHPS, and the 'Pain is the fifth vital sign' campaign BS has got us where we are.
Getting a kidney stone and having it surgically removed is a pretty intense way to game the system to get a fix. How’d they fake the stone? Or the procedure?
Specializes in Med/surg,orthopedics,emergency room,.
I pretty much agree with everything everyone else said. IF you have done EVERYTHING that you possibly can NEVER let family members make you feel guilty for ANYTHING!
Completely agree @morelostthanfound that some people aren't miserable at base line, and aren't happy until they drag everyone around them down as well. Don't do this to yourself, don't worry about this, and most importantly don't lose any sleep over this or otherwise let it impact your health. From what you wrote neither you, nor your orientee did anything wrong.
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.
I can attest to this. When I had a hysterectomy I had a Demerol PCA. It really didn't touch the pain, but it made me too goofy to express what I was feeling or complain. I later saw that nurses had charted that I rated my pain at 3/10, and frankly, I don't even think I was asked.
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.
Did you read that I started my comment with the words: "A GENERAL COMMENT about kidney stone pain APART from the situation described in the OP?" In the interest of clarity, of course.
I think this rather invalidates your comment above.
You did nothing wrong. You assessed the patient appropriately and reported your findings and concerns to the MD who declined to order the med the patient's family requested. The decision on what medications and what dose to use for pain control is not your to make. The only thing I can think of that you might have been able to do differently is ask the MD to physically come and assess the patient for pain himself [or herself] when it appeared that the ordered regimen wasn't effective.
try not to worry, you did everything right. You can't MAKE the provider change orders. We have residents on call, or an APP available to explain stuff that is out of our scope.
I got fussed at about a pt complaint and I said-that is the one that threatened me that she was "going to kick my a**" and I had security walk me to my car. I couldn't file a complaint because the girl wouldn't give her name.
You are fine!
She was a patient and you didn't know her name, but what about her room number?
Did you read that I started my comment with the words: "A GENERAL COMMENT about kidney stone pain APART from the situation described in the OP?" In the interest of clarity, of course. I think this rather invalidates your comment above.
Specializes in orthopedic/trauma, Informatics, diabetes.
On 12/11/2021 at 1:41 PM, Kooky Korky said:
She was a patient and you didn't know her name, but what about her room number?
Why was she threatening you?
I didn't know the visitor's name. She was upset because I was trying to enforce our visitor policy and she didn't like it. She complained about me, and I got called into the office, she kind of left out the fact that she threatened me.
HiddencatBSN, BSN
594 Posts
Yeah I'm side-eyeing the comment about wanting narcan on hand for 2 norco and 4 mg of morphine that were spaced out. For a kidney stone that's not all that exciting and it sounds like the patient was under-treated for pain. The MD should have come to assess the patient and if the 2mg of morphine helped, more is reasonable but if it did nothing a different narcotic would make sense. And if the 2mg needed to be repeated, I wouldn't wait to administer because that's the point of titrating to effect.
People with chronic pain learn the names of meds that work for them too, not just "drug seekers.” Heck after a few doses of each post surgery I know that the fentanyl helped a ton and the dilaudid left me in a lot of pain. I know that addicts and people with opioid tolerance have pain and deserve it to be treated so with a known painful condition and report of pain, it's not really my job to decide if the patient is faking it or not. The risk-benefit of doing that in an acute care setting doesn't really justify it- like on the one hand I prevent an addict from getting a fix but on the other I've left a patient in excruciating pain. There's a ton of research out there on how our implicit biases impact pain control (in particular for black women).