"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...

[zuzi]

Firestarer, you like a nurse, whatever one or another tell you or disturbe you, you need to go to asses and give pain meds IF are requested. If your assesment tell you that he/she is not in pain, even if is the time or not, you need to admit that patient IS in pain because he stated that and give it or obtain a new order for pain meds. The pain addicted ones know very well this and for this reason they come in hospital, they ask for pain meds and they will have pain meds. Is creepy but is PERFECT TRUE!

The only one solution to finish with this marry go around CNA- patinet- physical therapy, bla, bla, is to make pain meds on schedule talking with physician, or to have a order to setup a PCA, or for pain patch. Only someone who don't want to deal with that, will not deal with it. Count how many doses/grams he/she received PRN per day, Hx of pain meds abuse, Hx of Dx, Hx from MAR pain meds admin and talk with physician.

Be proactive my dear, plug an addicted, that could make to him self and to all of you the life miserable, is easy just be proactive.

[Magsulfate, BSN, RN]

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?

Yes, because I am perfect

[Jules A, MSN]

Yes, because I am perfect

Lol, my dear MGSO4 so now I have to watch out for threads from you complaining about how you are constantly sabatoged by everyone and the victim of numerous conspiracy theories?

[Virgo_RN, BSN, RN]

I actually wasn't talking about the techs here, they are usually with the program. It's other personnel, who don't really have a clue about the med orders or much else that's going on, such as the example of the EKG tech, a social worker, dietary aide, RT or someone other ancillary.

The CNAs are part of the nursing team, they are usually pretty on top of what's up.

Thank you for clarifying. Yes, it is annoying when someone does this. I had a social worker do that once; I had literally just medicated the patient right before the social worker arrived, so the pain pill had not taken effect yet. When she came out of the room, she hunted me down to tell me that the patient was having pain, and the expression on her face and her tone of voice did not reflect a "Just thought you should know" type of attitude, but more of a "How dare you allow your patient to hurt" type of attitude. Turns out the patient had short term memory issues and did not remember that I had *just* medicated them, and so they told the SW that I hadn't given them anything for their pain.

We all know that "pain is what the person experiencing it says it is and exists when they say it does". That is not the topic of this thread, folks. Some patients *are* manipulative and play staff against one another in a "divide and conquer" fashion. Some patients have psych issues, and some patients are just plain old jerks. It doesn't mean they're not having pain, and it doesn't mean they are, and it does not make controlling their pain any less legitimate. Again, I did not sense from the OP that this was the topic at hand.

When confronted by someone as described in the OP, I thank them politely for the information and go about my business. Now, if it's someone who has no need to know about the patient's pain control issues, I just say something like "Thanks for letting me know" and move on. If it's someone who is more involved in the patient's plan of care, like a social worker or family member, I let them know that I'm on top of the pain control issue by explaining the pain control strategy, including that if it doesn't work by a certain time, I will be on the phone with the doctor. If it's a family member, I attempt to enlist their help in making the patient comfortable. By taking this more collaborative approach (even if I am irritated on the inside), it shows that I am *not* the big bad meanie, but that I do have things in hand and am aware of the situation and have a defensible rationale and plan of action for what I am doing.

Pain control is both an art and a science. We have a lot of tools in the toolbox, and it can take some time and trial and error to get a satisfactory response. During that time of trial and error, the patient will be painful, but that does not mean I am not doing anything about it and that I don't have a solid plan. I am obligated to use all the tools at my disposal before calling the physician to say the current treatment strategy is not effective. In the meantime, it can look to someone on the outside like I am not doing anything about the patient's pain, when in reality a great deal of my mental energies have been focused on this issue.

Despite all of this, some patients will still behave in a manipulative fashion, and some ancillary personnel will still get sucked into it, and some perfectly legitimate vent threads will be turned into a Nursing 101 lecture on pain control.

[FireStarterRN, BSN, RN]

Perfectly stated Virgo. I couldn't have explained it better myself!

[highlandlass1592, BSN, RN]

Its Evidence Based Practice to give pain meds on schedule for exactly the reasons you described, in addition it has been shown that it is much harder to reduce pain than to prevent it. :nono:Why should nurses feel free to judge patients about their desire for pain meds? It seems some people can be awfully judgmental about others when it is THEIR JOB to take care of the patient, especially to address pain. The evidence indicates that pain is NOT being managed well:banghead:. Shouldn't nurses be trying to find ways to improve that, not taking negative or hostile positions towards patients and other staff providing information that identifies a specific incident of an ongoing problem? Regardless of one's personal feelings or our society's attitude towards drug use providing ADEQUATE pain relief is a part of nursing responsibility. Unless you are providing addiction treatment issues of "drug seeking" or drug tolerance are not a part of your professional responsibility except in that such information provides you with data that supports more pain medication.

Hmmm I love when people throw around the term "it's evidence based practice to do such and such". Instead of saying that, why not cite the study you feel is supporting your theory? Your comment about giving pain meds on a schedule doesn't take into account a lot of factors, including making an assessment of the patient before giving any pain med. Pain meds are ordered prn for a reason. Scheduled meds are ordered THAT way for a reason too. I' for one would be interested to read some studies that you say support the idea that pain meds should be scheduled.

[nursemike, ASN, RN]

I have what I consider a related beef. We sometimes assign "sitters" to patients as an alternative to restraints. When I was an orderly, I got this job pretty regularly. I usually disliked it. Eight hours of telling someone, "No, don't pull that," or "Please stay in bed," gets really old. But, as a nurse, I get pretty frustrated when one of my patients has a sitter who is on the call button every ten minutes to let me know that my patient is agitated and needs some ativan, or needs to be restrained, or needs pain meds because he is restless. And some of them can get as accusatory about it as those the OP described.

There are times when I'm amazed by the apparent inability of support staff--even aides--and ancillary staff, to think critically about patient care. I'm finding it harder and harder to think back to before I was a nurse, but I try to recall all the work that went into learning to think like a nurse. It really isn't as easy as it sounds, so I do try to be patient. But I'm with the OP--it does tick me off when people who aren't nurses feel like they can judge nurses. I'm not saying all nurses are good nurses, but ya know what: almost all nurses are good nurses. We all have different strengths, and some of us have very different ideas of what good care entails, but honestly, I have a hard time thinking of any nurse I know who isn't regularly doing what he or she believes is best for the patient.

[nerdtonurse?, BSN, RN]

We do have a lot of folks who are drug seekers where I work. I mean, can't keep straight where the pain is, can't stay awake long enough to hold out the arm with the IV site in it (and I mean, extend their hand and begin to snore...). If there's something wrong with you, I will move heaven and earth to help you. If you want me to be your drug dealer because you've ran out of crack before you ran out of month and come in positive for everything on the drug screen, I'm not impressed with your "10 out of 10 pain" -- I've seen the MRIs , the CTs, the PETs, the EEGs, the EKGs, the lab work, the consults from neurology...psychology...nephrology...and every other ology in the place. They unanimously state this person's problem is addiction. So what does my nursing assistant (who says she failed out of nursing school by 0.1 point, but can't understand that an esophageal bleed is NOT coming out of the lung...) do? I'm changing a stage 4 dressing on a little thing that came from home in such poor shape we called adult protective services and said she does NOT need to go back home, it's taking 3 of us to try to get the wound vacs (yup, plural folks, as in 3 sites, 2 machines) changed, and the NA comes in and snaps, "You need to stop messing around in here and go give 321 her pain meds, she's in agony." She uses that scolding tone that only my mom gets to use. I'm so mad I'm spitting because I mean, I've got my hand in this woman's sacrum past the my wrist bone, and she wants me to stop, leave this woman hanging, and go give the town drug addict her fix? I told the NA that I was busy and would see to her when I could. The NA said, "well, she says you haven't given her any meds all night!" I took a deep breath, told the NA again that the pt couldn't have any meds, she'd been getting them as scheduled,and the doc had dc'd the PRN meds. The NA opened her mouth again, and I snapped, "you want to wake up Dr. X at 0300 to tell him that YOU think he's not treating his patient correctly, be my guest, but I'd suggest you go ahead and clean your locker out if you do." She stomped off in a huff. I mean, when the doc tells you, "we're cutting her back to PO only in the morning, because I don't what her to cause you guys a problem tonight, but I think she'll AMA out when I do. She's not getting narcotics from me again" -- I'm not going to have that discussion with her over another patient (even though the pt with the wound vac was so demented she wouldn't have comprehended it, but its still not right). I mean, what do you do when you've got a NA (can't even pass the C part of CNA) who wants to act like a nurse without being one, and wants to come off like some great patient advocate when she's actually advocating for what the doc DOESN'T want to happen??

Sorry, it just really, really frosted me.....

[vashtee, RN]

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.

Yes, the problem (as I understand it) is that giving ever-increasing doses of drugs to addicts doesn't help them in the end because use of narcotics trigger the development of new pain pathways, so the using patient will NEVER be pain free. That's why I don't understand why doctors will continually prescribe meds for chronic drug seekers. (And I'm not talking post-surgical patients - I mean the ones that no doctor can find anything wrong with, and no - I don't withhold meds that were ordered PRN if the patient asks for them, even when I want to, unless they are already sedated.)

Ugh. I had a drug seeker today that I had to call a rapid response on because her pain meds bottomed out her blood pressure and O2 SATs. The same thing happened to her a week ago, apparently. She was faint and dizzy, but she sure mustered up the energy to tell us she didn't want Narcan. :icon_roll She ended up back in ICU.

[zuzi]

Hmmm I love when people throw around the term "it's evidence based practice to do such and such". Instead of saying that, why not cite the study you feel is supporting your theory? Your comment about giving pain meds on a schedule doesn't take into account a lot of factors, including making an assessment of the patient before giving any pain med. Pain meds are ordered prn for a reason. Scheduled meds are ordered THAT way for a reason too. I' for one would be interested to read some studies that you say support the idea that pain meds should be scheduled.

I love also when people jump out before to try to comunicate in a constructive way.. well... are a lot of studies done and on going... in pain management, and are anesthesiologists with better knowledges than us ....,,who use this approach case by case and assesment by assesment....

For reading ..just one article... are many others more concludent......(for statistical explanation of terms I waiting your private messages, loooool)..... (I'm so sorry but the tone of your message make me to replay in this way). All the best for you to clarify the differences beetwen "as need" versus "scheduled dosing" and "efficacy vs safety"

"Efficacy and Safety of Scheduled Dosing of Opioid Analgesics: A Quality Improvement Study

The Journal of Pain, Volume 6, Issue 10, Pages 639-643

J.Paice, G.Noskin, A.Vanagunas, S.Shott

Abstract

Scheduled dosing of opioids is believed to provide more effective analgesia when compared to as needed (PRN) administration of the drug; however, few studies have evaluated the value of this approach. Therefore, a quality improvement study was conducted to determine the efficacy and safety of scheduled dosing of opioid analgesics, using a 2-group parallel design. One medical unit in a large urban academic medical center employed scheduled dosing, whereas a comparable unit used PRN dosing. The primary outcome indicators included pain intensity ratings and opioid doses, along with adverse events. Scheduled dosing was associated with decreased pain intensity ratings. There were no statistically significant differences in the amount of opioid ordered, or the amount administered when comparing scheduled vs. PRN dosing. However, when the amount of opioid given was expressed as a percentage of the amount ordered, the difference between scheduled (70.8%) and PRN (38%) dosing was statistically significant (P = .0001). There was no difference in adverse events between the 2 groups. These findings suggest that scheduled dosing of opioids in an inpatient medical population provides improved analgesia with no increased risk of adverse events.

Perspective Scheduled dosing of opioids in an inpatient medical population improves analgesia, theoretically by overcoming barriers to drug administration, as well as providing more stable plasma levels of the opioid."

[florianslove]

bravo to the CNA's who care enough to "bother" the RN's. The CNA's are the first line of defense many of these patients have. Salute them.

[Virgo_RN, BSN, RN]

bravo to the CNA's who care enough to "bother" the RN's. The CNA's are the first line of defense many of these patients have. Salute them.

Your post makes no sense in the context of this thread. First line of defense against what, exactly? Perhaps in long term care, where job tasks are more clearly delineated and CNAs really do spend more time with the residents than licensed nurses do, then the CNAs would be the first ones to notice a change in condition. However, in acute care this is not the case. Sure, I appreciate a smart CNA who will draw my attention to something that is not WNL, but in general, I spend more time with my patients than the CNAs do, and my assessment and knowledge of that patient's condition is far more in depth. I'd rather have a CNA draw my attention to something that turns out to be unimportant than neglect to inform me of something I should know about, but that is not the topic of this thread. The topic of this thread has to do with someone who lacks the in depth knowledge of the patient's condition making assumptions about the nursing care based on inadequate information. I make every effort not to shoot the messenger, but when the messenger has a chip on their shoulder from the start and really doesn't know what they're talking about, it's natural to be just a tad defensive.