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.
That is a tough situation. I am a new nurse too and I have patients who ask for their PRN pain medications around the clock like that too. If they're really sleepy I won't wake them to give them PRN pain pills, you are using your nursing judgement. I have held pain medication before, someone asked for it then ended up sleeping for a few hours. This patient received their scheduled methadone, lyrica, tylenol, etc. before so I knew they were probably sleeping from the combination. Luckily when the patient woke up he asked for it politely and understood that I didn't give him his PRN pain meds, as he was asleep (snoring too). In my opinion you used your nursing judgement, she couldn't keep her eyes open. I wouldn't feel comfortable giving pain meds to someone who couldn't keep their eyes open either, I wouldn't. Try not to let her rude attitude affect your patient care, I know its hard. Just know its not you, she probably has a lot going on and doesn't mean to/doesn't care to take it out on you. It is nothing personal. Keep using your judgment, it is better to be cautious instead of having something potentially dangerous happen.
Did the pt say that the morphine actually relieved the pain? I understand that she complained a lot/was hard to please but maybe part of the problem was that her pain was unrelieved and that was why she's setting her alarm (I'm being the devil's advocate here- I'm more than aware that there are alternative reasons for setting an alarm for pain meds ). When you called the MD to update him/her, it may have been worth asking for an alternative analgesic if you think the morphine is not effectively treating the pain. Also, depending on your hospital policy, what about a low dose PCA? I know some MDs at my hospital refuse to prescribe PCAs unless the pt is comfort care or an oncology patient.
As far as giving the dose--Since her vitals are stable, I would have given it and just monitored her closely. I would try to space them out as far as I could/she would allow but you're going to be fighting a losing battle against her. As you gain more experience, you'll learn to pick your battles.
Also, just a thought-- was she actually sleeping?? If her personality is truly as persnickety as it sounds, maybe she was just faking it?
I do not wake a patient for PRN pain relief, scheduled - yes; PRN - no.
After a full pain assessment to find out why she was wanting at the times she set the alarm, I probably would have asked the Dr. to schedule the pain med for a few days. Then return to PRN to see how it goes.
I can say that I have been there with the pain management patients. One of my least favorite frequent fliers is always coming in for "asthma exacerbations" yet she is on RA and breath sounds clear. She wants dilaudid for various pain complaints but she has to have Phenergan and Benadryl with it because it makes her nauseous and itchy. She probably takes other stuff too; luckily I have avoided her as my patient lately. My point is there are patients that just irk you and get under your skin. The key to this is not letting your patient see. Do your best not to let it break your day or your attitude. I am all for sitting down with patients and families and setting them straight about dependency issues. I will involve the MD and even my charge nurse or manager into the situation if need be.
However, I think her vitals were stable for you to give the meds. Her BP and RR were WNL. I know you are new and there is a lot to process but don't let your stress get in the way giving your patients good care. Morphine is not as strong as dilaudid and if your patient were my patient I would have given her dilaudid if it were ordered and she wanted it. She was stable. I may have documented her behavior in a nursing note. I also would have sat down and had a conversation about how things work in the hospital because if you don't set the bar for her expectations, she will never be satisfied. Good luck to you.
Working in oncology with sometimes dying people, I typically am very, very liberal with pain medication. At patient request, it will be given if there's no medical reason to hold it and I have a reasonable order to back it up. I do not work with drug addicts in psych, but if I believe there is an addiction/seeking issue, I would put out a consult for addiction services. Really though that is a service I have seen utilized only a handful of times. I don't judge though - some patients have been on medication for years and some do have a history of addiction which lead to higher tolerance for acute pain events, but most of my patients take reasonable pain medicine amounts for those things. Chronic pain is a whole other story and I have seen some very high numbers but if they are stable, again, I feel like you should administer to help control.
I will definitely wake up patients who are regularly receiving pain meds on the rare occasion that I work night shift at 0300 to assess pain while I'm drawing labs. They may not wake up at 0300 in pain, but if they wait until 0900, they may be in 10/10 pain instead of their typical 6/10 by missing a dose.
I tell patients that pain is like a train...you can stay ahead of it or you get run over by it. Once you get run over, it's hard to catch back up and it takes even more pain medication at that point.
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.
And remember, nursing is a team sport. The first time there was a complaint, I would have asked for assistance from your charge nurse to deal with the dynamics of this patient.
If alarm goes off, patient rings, asks for meds, and you are taking vitals, you need to ask what the level of pain is. If the patient is asleep and can't answer, what are you to do with that? Ask. Right then. Especially if your charge is co-signing your medication removal/waste.
You really can ask for assistance with patients who are complicated to the nature as you describe. Especially if it is some proclaimed "VIP".
Although the vitals were well within range (and I would watch the RR if it was hanging around 14) that she couldn't verbalize a pain scale due to her sleeping would have been when I would ask for assistance.
As the jaded part of me is just so dumbfounded (
And going forward, I would ask for support and direction with these type of cases (and more than likely this is NOT the last you will see of this VIP).
Not to mention getting an invitation to your state BON.
As others and I have mentioned in this thread. No its not. State BONs do not have in their regulations how long a narcotic can be on a person, that is determined by facility policy. Which, as shown in this thread, varies from 30 mins to no limits. The state BON cares about nurses stealing narcotics. Lets stop derailing the thread about this subject and actually talk about the OP's issue.
OP: I have held narcotics from that are too sleepy that cannot even stay awake for the med, I just document it as the pt being too lethargic to take. I would not have requested a lower dose though. Just document, document, document. Do you guys use the RASS scale there?
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.
Yes, "immediate dismissal" would depend on the individual criteria of the facility.
I was referring to the BIG boys like Mayo and Kaiser. You would be wise to keep it in mind, that their guidelines will trickle down. Can you keep the unused narc in your pocket, until you go home? And what is the ramification/ action if you take it home?
You are then, in the possession of a stolen narcotic.
). When you called the MD to update him/her, it may have been worth asking for an alternative analgesic if you think the morphine is not effectively treating the pain. Also, depending on your hospital policy, what about a low dose PCA? I know some MDs at my hospital refuse to prescribe PCAs unless the pt is comfort care or an oncology patient. 
NutmeggeRN, BSN
2 Articles; 4,743 Posts
Gotta say that I don't think holding it in your pocket is best practice.