Was I in the Right Here?

[Grande_latte04]

I’ve been a nurse for 2 years. I generally think I’m a pretty decent bedside nurse. I’m thorough, I work hard and I care tremendously about people and their health. Lately I’ve been burning out. Tonight I think may be an example of how burnt out I have really become. 

Patient is a younger man in his late 20s. Came to our facility for pt/OT after an injury and surgery to both his legs. He’s been with us for a couple weeks. Came to us with massive amounts of pain meds to the point where our doctors were uncomfortable prescribing him that much and scaled him back a bit to OxyContin scheduled and oxycodon PRN.

9pm rolls around and he’s scheduled for his OxyContin. I give it to him at 925pm (I have 30+ patients, so I’m feeling pretty on track here). Facility policy we must wait +1hr before administering the oxycodon. Patient knows this and says he want his oxy at 1030. I tell him I will do my best but to put his call light on.

1000 rolls around and he’s calling for his pain med. It’s early and I am caught up helping other patients so I do not answer him but two CNA tell him I will be there as soon as I can.

By 1030, he is screaming and banging a stick against the wall. He’s calling me all sorts of names and screaming "pain meds, pain meds, pain meds" at the top of his lungs. I wait a little while hoping he will calm down and I can get in there and hand him his meds.

Well, it doesn’t happen.

He gets more verbally aggressive to the point where something tells me - don’t go in there. Just a weird gut feeling of not feeling safe around this man. So I start charting hoping he will tire and calm down. He eventually gets quiet so I pull his meds and walk to his room. As I’m almost there he starts screaming again and banging against the wall. I stand in his door way and tell him point blank: I do not feel safe walking into your room, so I’m not going to be helping you until you can behave in a way that shows me I can feel safe approaching you. Well this made him angry and I walk away. He proceeds to yell and scream for the next hour, calling me everything under the sun. Eventually he chills a bit and the charge nurse goes in and hands him his meds. 

I feel like I did the right thing here? But now I’m not sure. 

[Hoosier_RN, MSN]

You followed policy with your timing. You also told him about your discomfort re:safety with his actions, and getting charge involved. A MSW and MD need to be aware and get involved at this point, as his pain is not being managed by his (the patient's) standards. This is something his MD needs to manage and direct at this point

[Davey Do]

Outstandingly excellent method in dealing with this patient's inappropriate behavior, Grande_latte!

You gave him no more fuel for his fire, were direct, objective, and professional, and allowed another nurse to administer the meds so as not to rile him any more, rather than have a power play!

I cannot say enough how "right" you were following your gut!

Also- I do not believe you are burning out. You are merely acting prudently in the expenditure of your emotional energies. We have to put on our apathetic faces when dealing with emotionally charged situations.

I doff my proverbial hat to you, Grande_latte. I am your fan!

[JKL33]

I think you handled it fine. Good for you for keeping your composure.

I would inform his provider of his behavior and document neutrally but clearly in the chart. Wording such as "banging stick on wall and screaming obscenities towards staff."

His medical team needs to handle this. It is not appropriate for him to disturb the care of other patients in this manner.

Anyway--good job.

[Davey Do]

Regarding Hoosier's post, I informing the patient that his pain med regime needs to be managed would have been a good tact in de-escalating the patient's outburst.

For example, saying something to the patient something along the lines of, "I understand that you are upset and will be proactive in reviewing your pain management so that your needs can be adequately met".

This does not condone the patient's inappropriate behavior, but lets him know that you have heard his concerns and will be acting as his advocate. This act alone may have helped to quell the situation.

JKL's suggestion of objectively documenting the patients behavior is also an excellent one. Documentation would CYA and provide for informed, realistic continuity of care.

I love you nurses!

[Tweety, BSN, RN]

I'm not sure your response means you are experiencing burn out but that you were stressed by this particular situation.  I think you handled it well.  People like that need to understand that aggressive behavior can't be rewarded.  My guess is this is how he got to be on such massive doses of pain medications by carrying on until he got more.  On the other hand if his pain isn't being managed by the reduced dose, I agree with the above it should be reported to the MD.  I'm sure you documented well.

 

[Jedrnurse, BSN, RN]

2 hours ago, Hoosier_RN said:

 A MSW and MD need to be aware and get involved at this point, as his pain is not being managed by his (the patient's) standards. This is something his MD needs to manage and direct at this point

This may well be, but I suspect that it's more than just pain that needs to be managed.

[Hoosier_RN, MSN]

5 minutes ago, Jedrnurse said:

This may well be, but I suspect that it's more than just pain that needs to be managed.

That's why I suggested MSW and MD. There needs to be referrals to other resources, and that falls unto these 2 scopes of practice. It was my nice, non-judgmental way of saying it ?

[Davey Do]

Focusing on the pain med management is a little off the mark.

Having been in a similar situation as a patient at about the same age with, among others, multiple orthopedic surgeries, a slight addiction to narcotics was one thing with which I had to deal.

As nurses, we have witnessed first hand that patients get dependent upon narcotic medications. When those narcotics are, as in this case, not given on the spot, right on time, pain can be unable to be stood.

But, come on now- an inappropriate emotional explosive display when a reason for the delay is given is not totally pain control.

This patient has the earmarks of being an addicted brat who demands immediate gratification. That's one reason I gave multiple kudos to Grande_latte who handled the patient's inappropriate behavior like I would have handled an acting out psych patient who wasn't getting their way. 

[anewsns]

YES!!! Great work! I can see why you are burnt out but your response to the situation was very healthy. 

[JKL33]

@anewsns - not picking on you, but your post made me go back to what the OP said about burning out. And I do have something to say about it. ?

20 hours ago, Grande_latte04 said:

Lately I’ve been burning out. Tonight I think may be an example of how burnt out I have really become. 

On second take, I am curious what burning/burnt out means to you. Is it something like feeling fed up? Feeling like you don't care? Or something else?

And, is there a particular thing that someone who is not feeling burned out would have done differently in this scenario?

Since written word often doesn't convey intent/feeling, be assured that my motivation for asking is only to discuss an interesting topic, hopefully in a way that might be of use to you. ?

[Grande_latte04]

@JKL33 I think when I saw burnt out I mean fed up with my current position. Not to complain about my job…. But because you asked… I feel fed up with the constant understaffing, feeling like I can not help people like they need to be helped, like they should be helped. I just can’t do it with 33 patients. I feel myself physically and emotionally dragging under the weight of so many peoples needs. We have some easy patients and we have some exhausting ones- the ones who need round the clock pain meds, the psych patients who have complex medical needs as well who want to go AMA. I just feel tired. I feel bad for the people I can not help like they need. I feel tired with covid, I feel tired with my boss who calls me at all hours of the day and night asking me to cover shifts on my day off.