"Your patient in 520 is in pain!"

[FireStarterRN]

You know what bugs me? You have a clock watching, narcotic loving type patient who is, well, whiney and somewhat manipulative. He's been on the light frequently.

So, you're super busy and along comes one of the ancillary personnel who comes to you with an accusatory tone of voice, informing you that one of your patients is "in a lot of pain", as if they are the big patient advocate and you are the neglectful, hard hearted nurse.

The 'patient advocate' then plops herself down somewhere, after sending you scurrying.

That bugs me...

[changeofpaceRN]

This post made me laugh.. I've had SO many of these patients, they would actually wake themselves up every 20 min or so out of their deep sleep to check the time. Or, they ask for their narc, you get it and go back in and they are completely asleep. I don't know about you but if I'm in that kind of severe pain where I need a narc, I'm not able to sleep! That being said, I still medicate them if they claim any type of pain as long as the order allows it.

I had a med seeking woman who asked for her pain meds. As I was standing at the cart (LTC) looking through the MAR, a CNA came running out saying so and so isn't breathing. I knew he was a full code. Anyway, I had to sort of do that first but the woman still called the DON from her room phone to tell her I made her suffer on purpose and that I took 40 min to get back to her. I almost got written up for it... yeah...

[kellyc034]

As it was posted earlier, I can't speak for all CNA's, but if I'm bugging you because a patient has pain it is because they are bugging me about the pain. They hit the call light, my phone rings (not yours), I pass the message.

Please don't misunderstand- I do get it. I've done this a long time, and I'm an RN student. I know some have logs of their meds and are waiting until exactly 1534 to call for their next push due. Or they are calling regularly even though they have no PRN's due.

The thing is though (at least where I work) it is my phone ringing to the call light, not the RN's. It is my phone that goes off 7 times, all while just trying to have a conversation with another patient or help someone to the bathroom. So, if I'm ever the CNA bugging you with the pain med request, I apologize in advance. But please, just think of this post. If I'm asking you more than once, it means I have been asked 10 times and I'm having a hard time doing my job because of it.

And I would never treat you (RN or "ancillary personnel") with disrespect. There is no reason to be rude to any coworker regardless of the situation.

[Virgo_RN, BSN, RN]

The thing is though (at least where I work) it is my phone ringing to the call light, not the RN's. It is my phone that goes off 7 times, all while just trying to have a conversation with another patient or help someone to the bathroom. So, if I'm ever the CNA bugging you with the pain med request, I apologize in advance. But please, just think of this post. If I'm asking you more than once, it means I have been asked 10 times and I'm having a hard time doing my job because of it.

And I would never treat you (RN or "ancillary personnel") with disrespect. There is no reason to be rude to any coworker regardless of the situation.

Fair enough. However, as the RN, perhaps my phone isn't ringing every time that patient puts on their call light, but it is ringing the second I put on gloves to dump a urnial or sanipan, the second I start pushing an IV med, while I'm drawing up insulin or a heparin bolus, while I'm elbow deep in poop, the moment I gown up and glove up to go into a contact precautions room, etc. My phone never stops ringing with the kitchen calling to clarify a diet order, radiology calling to ask how my patient transports, doctors calling to give me orders, family members calling because their loved one isn't answering the phone in their room and they expect me to just automatically know why, the monitor tech calling to inform me of ectopy or loose leads, bed alarms, and if the call light is on for a certain length of time, I get those as well, all while I am trying to do *my* job. In fact, aside from providing bedside nursing care, managing information, a.k.a. communication makes up a significant portion of my job.

As a CNA, there are several things you can do. You can offer nonpharmacologic pain management interventions, such as warm blankets, cold compresses, repositioning, extra pillows, herbal tea, soothing music, closing the drapes and keeping the environment low stimulus, etc. You can also set some limits with the patient, i.e. "Mr. X., I have informed the nurse of your pain, and s/he is aware. I will return to check on you in a little while.", and then do so. Make a point of showing your concern for their well being and comfort, but do not run to the nurse every time they ask for pain medications if the nurse has already told you that she or he cannot do anything about it. Take a proactive approach with this type of patient, checking on them frequently when their call light is NOT on instead of only going in there when they put on their call light. This worked well for me when I was a CNA.

[cjcsoon2bnp, MSN, RN, NP]

From a nurses perspective, I more than likely already know about the patient's pain, but maybe I can't give him more narcotics because it is not time, or I have much much worse things to deal with. This kind of patient is not satisfied with his dose of pain meds and will tell anyone and everyone how terrible his nurse is because this nurse can't give him the really good stuff anytime he wants it... like anytime he OPENS HIS EYES. This kind of patient has severe pain even blinking his eyes.

As long as he is conscious, he is in pain. Even if he is slurring his speech and can barely stay awake, he is in such severe pain that he is about to die and will tell ANYONE that will listen about how bad he feels and how the nurse is treating him so badly and ignoring him. When in fact it is the opposite. He acts like this to get attention and get more narcotics because the nurse will get tired of it and eventually call the doctor and ask to increase the pain meds. It works. It happens more than any nurse would like to think. This kind of behaviour is how he gets what he wants.

This kind of patient takes up more of the nurses time, and gets much more attention than the less verbally abusive, non narcotic seeking patient. This patient has already run the nurse ragged. And that is why you get the reaction that you do from his nurse. She is worn out from trying to get his pain under control. She is at her wits end with this patient.

We, as nurses, assess our patients all day long. We do the best we can, and give narcotics when needed. It is the exception, not the rule, to deny a patient their narcotics. Only a mean, cold blooded nurse would do that. ANd personally, I have never met one. Most nurses want to give the narcotics to this kind of patient, but we can NEVER SATISFY HIM.

In turn, he makes us out to be lazy, uncaring and mean to everyone that comes into his room. Like I said, this behaviour works, and it plays on our compassion.

Trust me when I say that I definitely understand where your coming from about those types of patients. I am thinking of one patient in particular (he's a frequent flier on our unit) who is always complaining of pain no matter how much pain meds. you give him. I can't go anywhere near that room or even passing by it without being flagged down and told to get his nurse for pain, I go tell the nurse and if he flags me down again I tell him that I have already spoken with the nurse and the nurse will come by to see him in a little while. Just try to keep in mind that I don't think your a villian and your doing the best that you can with a difficult patient and just remember that I am doing my best to do my job with a patient who is making it their life's mission to have pain medication 24-7 and will stop and nothing to make me run and get it for them whenever they feel the need.

!Chris

[emnicams]

This SO hits home, as I was just complaining about something similar to my coworkers yesterday. We have an EKG tech that I HATE to see coming, because she will come out and find the nurse almost EVERY single time to find something to make you sound like you're doing a crappy job. I had just gotten report the other morning and here she came down the hall towards me. She says, "The urinal in room seven is half full." I just looked at her, like, are you for real? When I didn't respond like she wanted, she adds, "It makes it so much easier for the patient to spill it when you don't keep it emptied." Thanks for the newsflash! I had NO IDEA! Gahhh, that woman gets on my nerves...

[Jules A, MSN]

But please, just think of this post. If I'm asking you more than once, it means I have been asked 10 times and I'm having a hard time doing my job because of it.

And I would never treat you (RN or "ancillary personnel") with disrespect. There is no reason to be rude to any coworker regardless of the situation.

I agree and as a nurse I could care less if my patient is drug seeking. If they have the order I give them the medication as soon as I can and appreciate my techs keeping me in the loop. I'm not there to detox them and I suspect that drug abusers do have a lower pain threshold anyway. That really isn't my point in posting though. What is interesting to me is the people that constantly posting rants about their issues with patients, coworkers and supervisors without ever taking a look in the mirror. Is it always someone else in the wrong?

[canoehead, BSN, RN]

After someone requests pain meds I usually get right on it, but sometimes need to finish up what I'm doing, and then go find out what they can have for pain. Probably someone will ask me for something else during that time. I'd definitely like to be reminded if the meds aren't out in a timely fashion, but give me 30min just in case other stuff is getting in the way.

If something unusual is up, like the patient is writhing in pain, or you need them medicated to do other care, mention it and I'll try to put a rush on it. If what I'm doing doesn't make sense based on what you know of the patient just ask, "what's up with the pain meds and the pt in 502, I thought....?" It's less confrontational than "why didn't you medicate 502?"

[flightnurse2b, LPN]

as a nurse who was a tech for many years in the ER as well as on the floors, i can appreciate a CNA/PCT who is concerned for the patient and reminds me that they need pain meds. i'm not perfect, and i usually have 7 or 8 patients, so yes, i might have not jumped right on it.

i like to treat the techs i work with the same way i would have liked to have been treated when i was a tech. i pull them aside and have a little pow wow before each shift, telling them who needs accuchecks, who is getting golytely, who needs a nightly weight, who is on isolation and who might be on the call light every 5 mins for pain meds. i also tell them i will help do anything they need help with--turning, changing diapies, taking out trash, etc. i remember that phone ringing on my hip 200000 times while i was knee deep in your body fluid of choice with sweat pouring down my face and watching the nurses look over at me from their computer like "go do your job and answer the bell". i remember that feeling and it sucks.

i try my best to advocate the importance of each player on the team i work with each night. if the CNA is my first line of eyes and ears to any change in the patient, why the hell would i brush them off? a good tech to me makes or breaks my shift and i appreciate them saying to me "hey, i know you were just in there, but now room 312 is acting weird. can you come back and check it out?" even if it's nothing, i'd rather be alerted than not, and have the patient code because the CNA was afraid to tell me because they thought i would get mad.

the techs on my floor have a whole wing to themselves, which include 20 patients or so, and i can see the other side of the fence where the patient on the bell every 5 minutes hinders your job. i can't expect them to go in every patients room who is having pain and make them tea or give them a back rub until i can get there, because i cannot expect this reasonably of myself unless i am having a really good night.

i dunno. devils advocate i guess.

i suppose if you feel the tech is being condescending or something, privately pull them aside and say "i appreciate you wanting room 502 to be more comfortable, but please tell them that i will be there as soon as i possibly can and that you have made me aware they have pain." maybe that will open the lines of communication a bit more... perhaps the tech feels that her insight on the situation is not valid or something? i don't know.

our jobs are all hard and our patients almost all the time are so difficult and of high accuity. so working together and communicating is key for me.

[nicu4me]

Just wanted to post this although most of you probably already do this but the CNA's can too. On the white board in their rooms I put on there the name of the pain medication the time that they got it and the time that it is due again. Now when we are doing dilaudid IV and a norco po med combo its a little harder for them to figure it out. Add that to a PCA. However, it's proof that you gave it, it can be reinforced, it's teaching at the same time, etc. However for the CNA's i never realized I did this until I started working and found myself saying to the PCT in a familiar tired sounding voice that we all get "It's not time yet, tell them I just gave it to them, etc." So the PCT has to go back in there and say it. Well, it's probably really my job to go back in there and acknowledge it or educate again on the pca button usage, etc. But I realized that I may be giving off an I don't care attitude with the PCT's because I was usually in the middle of something else and they hated to interrupt but were only doing their job --- reporting the patient's pain. So be kind to the pct's but they can also go back and reinforce the white board or the sheet of paper that was handed out. As well as the non pharmacy methods...... however, be careful about heat/ice, as this usually takes an MD order!!

[vashtee, RN]

I don't mind the CNAs telling me my when my patients are requesting pain meds (it's only happend rarely, anyway, because I try to answer my own call lights). What I don't understand is why physicians continue to write narcotic orders for frequent-flyer drug seekers. It seems unethical to me. Isn't there anything else that can be done? (Sincere question; I'm a new nurse.)

[Batman24]

Some patients try and take advantage of whoever they can. These are the ones who know they are at their pain med limit and know it's been discussed with the doc and no more drugs are coming until they are due them again. More drugs and they'll be in distress or a coma.

You get to know who the prob patients are pretty quick and if a CNA comes to me I let them know the deal so the patient won't try to manipulate them either. "X I spoke with your nurse and pain meds can't be given again until X time." The CNA can then offer the bath, water, blanket, etc. and then move on. If they know meds can't be given again and why they can be more firm when asked again. And our CNAs know that if anything looks to have changed to get us immediately.

[Duranie]

What I don't understand is why physicians continue to write narcotic orders for frequent-flyer drug seekers. It seems unethical to me. Isn't there anything else that can be done? (Sincere question; I'm a new nurse.)

In some cases it is because they have a legitimate reason to be in pain, like post-op or kidney stone, etc. It is unethical to allow a patient, even an addict, to be in uncontrolled pain (unless it is b/c you need to avoid sedation for eval of CHI, etc) Some docs will try non-narc meds first (i.e.torodol & APAP) or even other modalaties such as TENS or epidural anesthesia. If you are concerned, bring it up with the doc next time they round (as a concern in the interest of the pt., not accusatory;))

I personally think PCA is a good compromise if the pt is truely in pain (after lengthy discussion of this topic with an experienced anesthesiologist)... a small loading dose, then small frequent doses when they push a button, erring on the lower end of what may be needed, and increasing if there are objective s/s of pain... it's the larger amts of narc hitting their system all at once that creates the high -- given in small amts over time, diminishes that rush.

Keep in mind though, that pts who are opioid dependent for any reason (pain pt. vs. addict) will need larger than typical doses to do any good. Sometimes enough to make you go !! In some hospitals, a "Pain Team" or anesthesiology will manage these pts.

Sorry this ended up being so long....