Patient safety and narcotics

[jay082]

As a new nurse, I am learning new things every time I go to work. A patient recently complained to my nurse manager, as well as my department director. Since I have only been on my own for 2 months now, they are keeping a very close eye on me. I wasn't reprimanded, but it was a very long, drawn out, meeting between the three of us about a bunch of stuff that I had already gone over in orientation. I believe I made the right choices during this patients care, but I would appreciate some feedback on how some other nurses would have handled this situation.

50 year old women admitted for intractable abdominal pain.

I don't remember the exact dose of her script, but she was getting IV morphine.

So she was setting an alarm to keep her prn pain medications "on time" and would call 5 mins before she could have her next dose. Early in my shift she was heavily sedated. She calls and I go in. As I am starting the computer up, she falls asleep. Her respirations are 14. I take her BP and it is around 110/70. She doesn't wake up for this. So I return the medication. I also put in a call to the provider to ask for a lowered dose. She later begins to call and complain that I missed her medication, but she can have it now, so I agree to give it. She doesn't want the lower dose, and asks for the original dose. I give it.

The next time she is able to have it, the same thing that happened earlier happens again. Shes too sedated for more pain medication, yet demands the stronger prescription. I literally told her, "if you can keep your eyes open for 20 seconds, I will give it to you."( In hindsight, that probably wasn't professional, but I was getting frustrated) She can't, and falls back asleep. So I return it again. This went on throughout the day. Turns out she is related to some really important person in our company and that is why I believe her complaint was given any attention to.

Just curious as to how other nurses would have handled this situation.

[TheCommuter, BSN, RN]

I would have administered the medication, regardless of how much she slept. Her respirations were 14, far from the danger zone. Her BP was stable at 110/70, I assume.

As a nurse with 10 years of experience, I pick my battles accordingly and go out of the way to avoid complaints to upper management. If a patient wants pain medications around the clock, the best way to keep them happy is to give them as ordered as long as the respiratory rate and BP are not too low.

I know my nursing practice is not politically correct, but nowadays I fly under management's radar by simply doing what the patient wants. In this era of 'customer service,' you aren't making any patients happy by going out of your way to reduce their pain medication dosage.

[OCNRN63, RN]

I think I would have tried to talk to her when she was lucid and get an in-depth pain assessment. It's obvious that what she's getting right now isn't working if she's resorting to setting an alarm clock to get more pain meds.

Perhaps her pain would be better controlled if she had a combination of her narcotic and non-narcotic adjuvant meds. If she's already getting this, then maybe the meds needed to be adjusted, even changed altogether. I've seen patients get little relief from one med, but get much better relief from another equianalgesic medication. Perhaps a consult with pain management would be in order.

Going back to the clock setting for a minute...I would have discussed that with her too. Is she setting the clock because she's worried you'll get too busy and won't be available to give her pain medication? Are there other staff members who don't give her pain meds when she asks for them?

I would avoid labeling this pt with a dependency issue. (I'm not saying you did, but it happens.). Drug addiction is a complex diagnosis, and it really should be made by a physician who has experience in addictionology.

She may benefit from talking to psych if this is a chronic issue. Psych could teach her some coping and relaxation techniques to help her deal with her pain.

Those are a few of the things I would have done to try to help make her comfortable. I hope this was helpful.

[jay082]

Asking for a another medication entirely is a really good idea, if the current one is not working at all. I wouldn't have labeled her as drug seeking, I was just really worried about her not being able to stay awake for more than a couple of minutes.

[jay082]

I forgot to add some details. Again, in hide sight, her attitude was awful and may have played a role in the care I gave. She was very mean and belittling and complained about literally everything.

I know her attitude shouldn't have effected me as much as it did, but this is why I reflect on my weeks worth and try to figure out things I could have done better.

[canoehead, BSN, RN]

If she falls asleep by the time you get back with the medication, I agree, hold the dose until she is more awake. I would not have called for a lower dose, but once you did, you don't have the option to give her the previous higher dose. The order has changed (unless the doc gave you a range). I certainly understand a previous poster's statement that you just give the patient what they want, so long as it doesn't kill them...but I guess I'm just not that beaten down yet. I'd also put a sat moniter on her, if she's that sleepy.

[OCNRN63, RN]

It's really difficult to deal with patients with that personality type. In spite of what your patient says, from your description of the situation it sounds like you were doing the best you could. It's easy to get frustrated when people press your buttons.

[SleeepyRN]

The nurses at my work were recently inserviced on a similar situation. A patient was telling the nurses he wanted to be woken up at a certain time for his pain medication. Apparently the nurses were doing as the patient requested and somehow our nurse managers found out. So we all were inserviced on the issue, that we are not to wake someone to give pain meds. They must wake up themselves and ask for it. In your situation If I didn't feel safe giving a med, I wouldn't give it. Period. Regardless of what upper management were to tell me. That's MY license. MY clinical judgement. I decide.

[Pangea Reunited, ASN, RN]

When this happens to me, I hold the dose, but keep in in my pocket. When the patient wakes up, I give it right away and explain that I've been checking on them and have found them to be sleeping very well. I also let them know that they shouldn't worry if they doze off as I won't keep them waiting when they wake up and call. I've never called to get a dose lowered. I find that behavior strange.

I have given pain medication to very drowsy (but stable) patients in the past. I've also had them wake up more fully later and not remember getting it. For that reason, I'm a bit more cautious these days.

[mmc51264, BSN, MSN, RN]

We do wake pts up for 0000 doses of tylenol that are ordered as scheduled. (they usually have 0000 VS ordered anyway). I would not wake someone up for prn narcotics, though. We had a float nurse that told me the only issues she had with a pt was pain. Then I noticed she didn't give the ORDERED tylenol. She told me she didn't wake people up for tylenol. On an ortho floor, we do because it can take hours to reign in 10/10 pain once it gets that bad. Tylenol is very underrated.

[Karou]

I probably would have done the same thing as you. If a patient can't keep their eyes open for 20 seconds or stay awake long enough for you to assess their pain, then scan and administer the medication, then they sound over sedated. This isn't always true, but it can be. What was the medication and what was the dose?

You notified the doctor of the change in LOC (patient is drowsy, sleeping between care, unable to keep eyes open for 20 seconds) and the doctor agreed to lower the dose. That sounds reasonable. I regularly see orders that specify "hold for sedation" or "hold for drowsiness".

Our facility is specific that patients are not to be woken for prn pain medication. In your scenario, if the patient was asleep when you got to the room or fell asleep while drawing up mediation, then we could not administer it. Now, I may be sure to knock loudly in the door or make some noise to wake them if I think it's appropriate. It just depends on the patient and the situation.

[Been there,done that, ASN, RN]

What was the cause of the abdominal pain? Is this a chronic issue?

You are making this all about you, not the patient . "her attitude was awful and may have played a role in the care I gave." People experiencing pain may not have the best of attitudes.

She may have been afraid of the pain returning and trying to gain control over it.

Did you offer any other methods of pain control ? Or did you just fight with her over the scheduled narc dose?