Reporting unnecessary pain

[erint91DC]

This week, one of my patients was in for compression fractures of the lumbar vertebrae due to osteoporosis. She had severe, "red hot searing" pain in her lower back whenever she attempted to move, even when we raised and lowered the head of bed. Despite looking through her chart and talking to the current nurses, I didn't know exactly how old these fractures were so it was somewhat difficult to gauge where she was in the healing process.

Due to my limitations as a student and the nurse's patient load, and despite my advocating for the patient, her pain management was not up to par today.

Near the end of the shift, the patient had slid down in her bed. The primary nurse and I decided to boost her up. When the nurse was lowering the HOB, it became stuck on a chair that the nurse had just moved. When the nurse moved the chair out of the way, it caused the HOB to fall about 6 inches. The patient SCREAMED in pain. I became adamant that the nurse administer the PRN hydromorphone that was supposed to be administered an hour prior. I was unable to administer it because it was an IV push med and I have not learned that skill yet. I assessed the patient's back after this, and it appeared normal.

Should I have submitted a report, as the patient was caused harm due to the HOB falling? This issue is complicated by the fact that our unit is quite cramped, so there was not much room for the chair to be moved away from the bed. If there are any recommendations for my performance during this event, it's also greatly appreciated.

Edit: In retrospect, it may have been helpful to obtain more orders for PRN pain meds. it seems silly to do that as I am a student and obtaining these orders would somewhat be for convenience. However, it still would have helped in our care for this patient. She only had PRN orders for acetaminophen PO and hydromorphone IV push, which is odd considering pain was the main foci for this patient. She also had scheduled acetaminophen and hydromorphone. I feel slightly disappointed that this did not occur to me while I was still on shift.. However, one of her concurrent health challenges contraindicated use of NSAIDs, so that would not have been an option for her treatment.

[heron, ASN, RN]

Some questions first.

You mentioned a prn that "was supposed to be given an hour earlier". Was the prn requested and the nurse did not give it? If so, what was the nurse's reason? Or does it mean that the prescribed dosing interval was passed an hour ago?

What does "I became adamant" mean? I'll tell you now that the phrase rubbed me the wrong way. It's not uncommon for students to take issue with a nurse's practice, but it's most appropriately discussed with your instructor who can either clarify the situation for you or address it with the nurse or her superiors. Taking it on yourself to give direction to a staff nurse, if that's what happened, is not a good idea.

To answer your question, no, an incident report is not appropriate unless you witnessed deliberate abuse - and again, should be discussed with your instructor first.

[Rose_Queen, BSN, MSN, RN]

Agree with heron- PRNs are on an as needed basis. Just because it could have been given earlier doesn't mean that the patient requested it and the nurse refused. When you "became adamant" about the nurse giving the pain medicine, had the patient requested it at that time? When I was a student, I had a terminal cancer patient who was having an abdominal assessment done by her physician. He told the nurse to go get pain medicine for the patient because the exam was painful. However, the patient refused the pain medication. It's about the patient, and you haven't given any insight into what the patient wanted done with PRN pain medication, only what you wanted done with it.

[windsurfer8, BSN, RN]

If a bed falls many patients may "scream" in pain. That doesn't instantly mean you give a PRN medication. My biggest problem is how did a HOB drop anyway? All beds I have worked with are mechanically raised and lowered which also prevents sudden drops. You could tell the Head nurse that the bed may be malfunctioning or that a different (semi modern?) bed may be needed.

Panic is not the time to give medications. You need to stay calm and ASSESS.

[heron, ASN, RN]

The OP is long gone ... Didn't really want to read what we had to say, I guess.

[nurseswholovenursing]

Ok, I am confused.

There were no xrays, MRI, CT scan, for this pt admitted with a dx of lumbar fxs? And there wasn't info from those scans saying whether the fxs were old or new?

And what made you think she was in any "stage of healing", you said osteoporosis right? And i know you were busy "advocating" for "your" pt, I guess the pts primary nurse was not. Thank God you were there!

And i know if a nursing student who had been assigned to me, became "adamant" that I administer an " 1 hour overdue" PRN pain medication (whatever that means), I would have went to your instructor, and informed he/she that your attitude definately needed to be addressed, and you needed to be educated on PRN medication, and on pain medication.

Then as for your "in retrospect " edit, you thought it would have been a good idea to get the pt more PRN pain meds, but in your mind, that would be just for "convenience anyway"...huh? Because your medication assessment was this gal ""ONLY had PRN Tylenol and Dilaudid ordered", but "ALSO had scheduled Tylenol and Dilaudid ordered too", WTH?? And how would this "have helped in the care of this pt"? Huh, what?

After the HOB dropped, you did an assessment of her back, and "it appeared normal"...what does appeared mean?

You said her pain management was not up to par that day, and you wished you had thought of getting more ordered PRN pain meds during your shift....I do think her pain meds definately needed a re-look, because something is not right, you needed to recheck perhaps, didn't make any sence. The f/u from taking another jolt to her body, a re-look via xray, ect....at least have the hospitalist take a look I would have collaborated with the primary nurse, to make sure...and I would bet the lady had least xrays on her chart from the ED from when she was admitted.

I assuming your heart is in the right place...but one day when you have been a nurse awhile, and have a nursing student with you who is out to impress their instructor, classmates, you, themselves.....you will understand how bad it made you look, and just how annoying your attitude was. Think before you speak, know what it is that your talking about, figure it out before clinical, you have that luxury right now, much diffetent in the real world. Continue to always put your pt 1st, but have some respect for the nurse that is working, and who just may know more than you do.

[nurseswholovenursing]

When I was a student, I didn't challange the nurses who had to put up with me. I knew I didn't know what I was doing, and i knew I was there to learn. There was an instructor there if I had any problems, i utilized her. Know your limitations, open your ears and eyes.