Thoughts on patients and pain?

[TheOracle]

I work in a primary/urgent care private practice with a FNP as the provider and a physician collaborator. I've been bothered by the attitude the NP seems to display when a pt presents with pain. She seems to just check out of the conversation when I'm briefing her on my intake assessment and pain is involved. She has expressed doubts about pts experiencing pain and even states that they are probably seekers.

One example: we had a diabetic presenting on the weekend with leg pain. He was waiting for his appointment with a vascular surgeon a few weeks away and his M.D. was closed. The pt was reporting a pain of 9 out of 10 with elevated BP, HR, and RR. The NP moaned and groaned and said that he had a "pretty good story" and made me call his own and other local pharmacies for his Rx history before she saw him. (we operate in a smallish town, and the pharmacy count is manageable, but still sizable)

She went to lunch and one of her kids school parties one time leaving a pt complaining of pain to wait saying that "he could just wait."

This attitude and others I've seen working in hospital settings (usually from nurses) conflicts with what I was taught in school and that was that pain is what the patient says it is. I was taught not to doubt a patient or label them "seekers" and that often doctor shopping is the result of ineffective treatment or inadequate teaching on the part of nurses. Granted, I believe that reality is somewhere in the middle. A pt who requests pain medication specifically and refuses other tx and has no job, generally is less than honest about their condition.

I feel like as nurses we have enough to do without policing our patients. I wasted a great deal of time hunting down info on our diabetic's Rx history when I could have been seeing other patients. I don't agree with placing the pain patients in one basket as I worry that doing so will eventually affect the patient care.

I'm curious as to what other nurses opinions are on this subject? I'm getting the impression that while school may teach that pain is what the patient says it is, nurses get out into their careers and decide otherwise.

[canesdukegirl, BSN, RN]

We cannot know what our pt is experiencing in regards to pain. If the pt's HR was elevated along with the other VS that you described, my guess is that this pt is indeed experiencing pain. I think it would behoove you to have a chat with your director regarding your encounter with this pt and the resulting actions of the NP. For a diabetic pt (who obviously has compromised vasculature to the extremities) to complain of pain in an extremity would make me address this immediately.

[neuroms]

You certainly have a right to be concerned. Effective pain management has been shown to be one of the best ways to improve outcomes in a med-surg settings. If the NP truly suspects a specific patient of opiate, narcotic, etc. abuse, then she should make an evaluation as such. Part of your role may be to complete an investigative med history, although house pharms usually do this. I would recommend stringent documentation of your pt's pain evaluations and ask the NP to address, using tapering protocols if substance abuse is suspected. Ignoring pain/reports of pain is not a therapeutic approach.

[tencat]

Aaaannd....the insanity continues. Someone needs to set the FNP straight, and that someone needs to be the physician. I understand that there are people out there who do seek meds. Heck, I had one that the minute his oxycodone arrived at his home he went out and sold it or traded it out for whatever it was he wanted (drugs included). But I'm not going to let this person ruin it for the rest of my deserving patients. Pain is real. So many health practitioners don't believe that, and it irritates the snot out of me. And 1 mg of morphine isn't going to kill a gnat, much less make a patient quit breathing, and it isn't going to cut it with most people's pain, unless they're pediatric patients, and even THEN I've got my doubts.

[Flo., BSN, RN]

It sounds like she is burned out. Substance abusers can be very difficult to deal with and they can make you question pts with legit pain.

[steelydanfan]

The pt. was a diabetic, which would immediately made me suspicious for vascular pain/occlusion.

Give the pt. meds, and get him admittted immmediately for an US BLE.

[CharmedJ7]

I work inpatient (surgical onc) and I see this sort of attitude a lot. I have seen so many nurses who say "that pt is such a drug seeker" or get annoyed when someone asks for pain meds q4 on the dot etc. Now, there's an extent to which I can understand this, absolutely, there's nothing like the pt who the conversation goes like this:

Nurse: Are you in pain?

Pt: Oh, I'm pretty much ok

Nurse: But if you had to give it a number between 1-10, 10 being the worst pain ever?

Pt: Well, I'd say a 9 then

And yeah, there's a lot of people, especially younger ones I've found, who every time you walk in all they say is "is it time for pain meds yet?"

BUT. At the same time, some pts really seem to take to heart the idea of 'staying ahead of the pain' which is why they try to be assiduous on getting it q4 etc and also I think a lot of pts don't really 'get' the scale, so it's annoying when meds are ordered "1 tab for pain 1-5, 2 for 6-10'. My basic feeling is, I explain the risks and benefits of the pain meds, give it as requested and ordered, but also I focus more on, is your pain control adequate? Does your pain keep you from moving, deep breathing, etc? as opposed to numbers - if it's still a 7 but now they're smiling and getting up to the bathroom, we've done something.

I had a pt once who was in withdrawal from heroin who would request percocet all the time since it was what he had ordered for pain, even though he wasn't in pain from the surgery. The report I was given from the previous nurse was that he was a drug seeker, but I got the impression more that the narcotics calmed his withdrawal symptoms somewhat - in retrospect, I think I should've gotten the team to get clonidine or something on board to counter those symptoms, but at the time I didn't know.

I stick with what I learned in nursing school - if you really think the pt is a seeker, get a psych consult, don't withhold meds - it's not our place to decide those things. I don't fight with patients over pain meds unless it's to get them to be less stoic. In primary care, where I volunteer, it upsets me when people write off those coming in for "just pain", esp in walk-in clinics - it's like, this person is worried enough to come and sit potentially all day in a clinic, at least give them the time of day! I dunno.

Incidentally, this is a funny take on the pain scale: http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html

[suanna]

We can do so little fro so many of our patients needs. Pain, on the other hand is something we have marvelous medications and therapy to address. Many times this is one problem we can completely obliterate, but some nurses are still reluctant to address this problem effectively. I don't care if someone is a drug seeker- I'm OK with maxing out thier ordered meds. I can't tell you how often I've followed a nurse with "they just want drugs..." attitude who has had an really bad day trying to get a patient to comply with a post op activity plan. I come on and max out the meds- as well as assure the patient I will be bringing the max dose on the most often schedule I can until they tell me to stop- and presto! I have a quiet night with a plesant, cooperative (all-be-it slightly stoned)patient. What is the fear?- that the patient will be stopping by our house for meds after they are discharged?? If they have a drug problem, when they are having a period of acute pain they are not likely to effectively treat it. Treat what the patient wants treated right now. It isn't helpful in any way to restrict a patients meds when you have an order to give them.

[classicdame, MSN, EdD]

When we ask a patient to rate their pain we are asking them to compare it memories of past pain -THEIRS, not ours. Just because a nurse has seen worse suffering does not mean this patient is not suffering. I get really irritated with nurses and docs who label people as seekers. If I were in pain I would be seeking relief too. Do they think they will create a behavioral change by withholding the med? Are they punishing the patient for perceived bad behavior? BTW- research states that people in chronic pain do not always have VS changes, as the body is compensating. So BELIEVE the patient. Why not? What harm is there in making someone comfortable???

[INLPN93]

In your setting how does she know the client is drug seeking?

In LTC and a hospital stay of any length may give it away by the on the minute request for the next pill, and even then it still isn't a concrete give away.

I know EDs try to keep up with repeat offenders looking for drugs.

But, really how do we know for sure?

Pain is now considered the 5th vital sign, and is to be assessed.

If she truly knows for a complete fact the client is lying then give something light, or a very limited dose Rx and a follow up with PCP for more.

The whole dismissal of pain and making them wait would irritate me to no end because there are ways to address pain without giving away a pharmacy of Lortabs. Good nursing care and judement looks for an intervention not a dismissal.

[iNurseUK, RN]

Any patient with a history of drug abuse, especially of the opiates, is going to have a higher tolerance for these analgesics when they are actually in pain and really do need pain relief.

I'd much rather give medication to a suspected "drug seeker" than withhold it from a patient who may be in pain whatever their history.