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.
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.
Do you realize having a narcotic "in your pocket" is grounds for immediate dismissal?
I would have explained to the patient that prn pain medications are administered as needed not around the clock. Explain that you will give as soon as possible after she calls for pain medications.
I think a lot of patients set alarms because they are afraid of the pain coming back and not getting the pain medicine because we are busy. Explain that you will not wake her for pain medicine, but as soon as she wakes up and calls you will bring medication.
Do you realize having a narcotic "in your pocket" is grounds for immediate dismissal?
Not at my facility. If I had to immediately run back to the omni-cell every time a pt refused a narcotic or I had to hold a narcotic for some reason I would never get anything done. I work on a trauma floor so EVERYONE is getting narcotics.
People get into trouble with narcotics in their pockets because they forget about them and take them home.
I agree with TheCommuter, patients and their pain medications is a losing battle. If their vitals are WNL, just give it with a smile. However, don't forget to say, "Is there anything else I can do for you? I have the time." ((((SIGH))))
Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
If I had to immediately run back to the omni-cell every time a pt refused a narcotic or I had to hold a narcotic for some reason I would never get anything done. I work on a trauma floor so EVERYONE is getting narcotics.
You're fortunate. At my workplace, if an unused narcotic is not administered to the patient, wasted with a witness, or returned to the Pyxis within 30 minutes of being removed, the nurse will receive an admonishment (a.k.a. NastyGram) from our director of pharmacy and might receive a written warning.
One can be so exhausted from constant pain, plus other symptoms, that he falls asleep all the time and unable to keep eyes open for even 10 sec., and still be in pain 10/10, AEB non-changing vital signs.
Things like the OP described happen all the time in LTACH. Patients come from ICU and floors where personnel actually mandated to offer them "something for your pain" (I hate this phrase with deep passion) every hour, meaning, of course, more drugs every time.
I usually do not do anything actively for at least one shift, until I see what patient really looks like and get feeling of how he reacts on meds. Just give them their pills and pushes with a smile. Some of our patients are actually become addicted, but surprising number and their families are deeply concerned about addiction issues. They suspect, and rightly so, that this sort of "pain management" may become a big problem soon, and many know about side effects as well, but they either do not know what to do about it or afraid of pain/withdrawal/ing labeled, etc. When I "feel" the patient and/or notice that he experiences side effects of pain killers to the extent that his overall health status is compromiced (so sleepy that vent weaning is not possible), I call family and provider and we have a talk when all parties are as awake and lucid as possible. When patient and family trust the team and feel secure, about half of them eventually get off "setting the clock". Explaining why "intractable abdominal pain" with no known organic reason can be caused by opioids and active application of non-pharm pain relieving techniques, offered consistently and either between the doses or at the start of action works pretty good as well.
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.
Early in my shift she was heavily sedated.
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.
Just curious as to how other nurses would have handled this situation.
(partial quote)
Personally I'd think long and hard before requesting a lowered analgesics dose for a patient with intractable pain. Did this patient have a diagnosis, was the etiology of the pain known?
I would in all likelihood simply have administered this patient's morphine and monitored the effect. Her vitals seem fine to me. If this is a chronic pain condition it's entirely possible for a person to sleep or be sedated from pure exhaustion despite experiencing pain of 7/10 or even 10/10. Sleep doesn't necessarily mean that the pain is under control.
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.
In my experience this is pretty common behavior for a person experiencing chronic pain. First of all it's better to be one step ahead of pain rather than trying to treat it when it's already gotten really bad. I also think it's a matter of trying to assert some kind of control over a situation that has got to be quite stressful for the individual. How many of us think that experiencing severe pain 24/7 wouldn't affect our quality of life and how we behave, function and interact with others?
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.
Be careful so you don't use your power as a nurse to punish a person for their unpleasant behavior.
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.
I commend you for doing this "soul searching". The only way to learn and improve is to reflect over our actions and what motivated them. Was the concern about the patient's sedation the only reason you withheld the medication or did the patient's "annoying" habit of setting the alarm when the med was due and general abrasive disposition affect your decision at all? Only you know the answer to that. I don't.
One other thing to think about. Are you certain that it was the opioid that caused the sedation? Other meds and drug interactions is certainly a possibility. I remember one patient who had vital signs within normal limits (towards the high end even in some of them), was clearly sedated but kept requesting more pain meds. When that patient was switched from metoclopramide to ondansetron the sedation pretty much disappeared despite the patient receiving a higher opioid dose at the same intervals as before. Of course there's no way to be certain that the antiemetic was the culprit but it was the provider's guess in this particular case.
I haven't been a nurse long enough to not remember how it was like to be a recent graduate scared of overdosing my patients. Trust me, I understand. Just remember that pain is complex, as is pain management. Pain, especially chronic pain, doesn't always present how you'd expect it to. People in pain don't always behave the way you'd expect someone experiencing severe pain would.
Pain should always be treated/alleviated whenever it's in our power to do so and the patient wishes it.
Pain treatment should in my opinion be multimodal. Medications certainly are a big part of the treatment, especially in my specialties; pacu and anesthesia. But medications aren't the only available options, of course depending on the reason for a person's pain and all other relevant factors.
I think you did the right thing to hold the medication when the patient appeared to be over-sedated. People will experience signs of over-sedation before they experience respiratory compromise, so signs of over-sedation are a legitimate assessment finding and rationale for holding an opioid, because it can be a sign of impending respiratory compromise.
What I would not have done was to call the provider and ask for a lowered dosage. You painted yourself into a corner by doing that.
I would carefully chart the assessment findings/observations/rationale for holding the dose, and explain your rationale to the patient focusing on the safety issue.
I have told patients that I want to control their pain, but I don't want to harm them- that I will do what I can to make their pain tolerable, but that I might not be able to eliminate it completely without risking harming them. These medications are very powerful- they carry a high risk.
I will offer non-pharmacologic measures, such as positioning/extra pillows, warm compresses or ice packs, distraction, emotional support, comfort foods (herbal tea, ice cream, etc.) if they're allowed to eat.
I always remain kind and professional when having this discussion. It is about the safety of the patient, not about how I feel treated by them.
But no, if the person is nodding off in front of me and cannot keep their eyes open, I will not administer an opioid. That is my nursing judgment call to make, and I document accordingly.
I have never had anyone lodge a complaint against me for not giving an opioid, and I have never had to reverse someone that I have medicated.
Do you realize having a narcotic "in your pocket" is grounds for immediate dismissal?
It's not been at the facilities I've worked at. I carry things around for hours, sometimes. I admit it may not be the best practice, though, as there is a possibility of losing a medication. Luckily, that's never happened to me. I'm pretty obsessive about constantly checking to make sure it's still there.
Now, JCAHO is a different story. I don't think they want anything in anyone's pocket (if I remember correctly) ...even if you're on the way to that patient's room to administer the medication right away.
Specializes in ED, Cardiac-step down, tele, med surg.
It depends on their tolerance. Has she been on opiates a long time? I think I would have just held the dose and not called the MD for a lowered dose. When she was more awake I would have given the dose. I would have asked the charge nurse to change assignments for the next day because that lady seems like one of those patients that drain your energy like a vampire. Nothing is ever good enough.
At least that's the image I get when you describe what is going on. Another option is a PCA. If you're having to give meds every hour, ask for a PCA.
Maybe the patient needs a consult to a pain specialist. Opiates can actually worsen pain, it's called hyperalgesia and can be cause by using opiates for extended periods of time. It doesn't mean opiates will always cause this, but they can.
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?
It was an issue that she stated had started about a week prior. GI had been consulted, and cleared her. He suggested it was a muscular issue. I was giving her heat pads throughout the shift. She would say that they worked, and an example of our going back and forth, she complained that the were to small, didnt get hot enough, didnt last long enough, etc. would just complain literally the entire time I was in the room. Her family member at one point even told her to cool it, then she let him have it.
She asked for some hydrocortisone cream, and I told her I couldn't give it just yet and would need to call the MD for an order, her response was, what kind of hospital is this. Im sure you have it and are just being too lazy to go and get it.
she wanted the cream for her legs. she said she used it regularly at home, but it wasn't on her med rec either.
Been there,done that, ASN, RN
7,241 Posts
Do you realize having a narcotic "in your pocket" is grounds for immediate dismissal?