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.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
On 9/2/2021 at 10:38 AM, morte said:
If you did this to my loved one, I would consider reporting you for delay of care.
SOOOOOOO his acting out physically is not threatening. WOW. Would YOU walk in there when someone is behaving violently? I don't think so. And he was NOT DUE his pain meds anyhow!
We do not reward this behavior. We get psych consults and medicate on schedule as long as our safety is not in jeopardy We report inadequate pain control to the prescribing physician.
I would not have done any differently so I guess you would report my butt too. So be it.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
9 hours ago, Nurse Beth said:
Not at all horrible! I love it ? You showed them respect.
I learned to have more empathy with drug seeking patients bc I reminded myself I did not know their childhood, experiences..and I didn't walk in their shoes.
They can be so annoying (just being real) but I said to myself "Beth, why would you expect an addict NOT to manipulate, lie, act out?"
This patient is beyond annoying. He is threatening.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
I think you could have handled this better. His pain meds were not adequate.
His behavior reflected that. Withholding his pain meds did not make you safer in this situation.
Concerns over the amount of pain meds we are giving should be based on patient presentation. If he was sleepy with a respiration rate of 10, then the dose may be too high and the PRN is not needed. But this was not the case. This patient was not in danger of overdosing. Why is his tolerance so high? Well, he might have been on these drugs for a long time because of chronic pain or he may be a recreational user. That answer matters for the long term plan for the patient but it is not significant to the acute problem you had going on in the moment.
The pain meds should not have been delayed and the doctor should have been called. I would have asked for an increase, the doc made the wrong decision.
The pain meds should not have been delayed and the doctor should have been called. I would have asked for an increase, the doc made the wrong decision.
Even if in your opinion the doc made the wrong choice it's still not the doc that is the one on the front line handling the patient's behavior. Unless the MD agrees to come to the patient's room and explain their reasoning for not increasing the dose it's going to be the nurse taking the brunt of the anger. How do you suggest nursing proceed in providing care without putting themselves in a dangerous position in that case?
Specializes in Neurosciences, stepdown, acute rehab, LTC.
I've never seen a similar situation ever where throwing more opiates at the problem was helpful. An increase is just a temporary bandaid. Often the person has opiate dependence and yet the opiates aren't doing anything to touch the pain. In the case of dependence, we can't just take the opiates away but we need to also find better solutions. We have a pain team at my hospital who use multiple modalities to manage pain and it STILL doesn't totally eliminate the pain. There are a lot of cases where adequate pain control is simply impossible with modern medicine. I often advocate for other types of pain meds along with the opiates as it can take the edge off a little better. I think people should also have options for meds for anxiety and to help them sleep and relax, because if they are having chronic pain being stressed and upset all the time makes it worse. Heat, baths, massages also help many people. I am far from a pain control expert but I imagine there are further options (like accupuncture) as well. Stronger meds are not always more effective. This guy needs a full care plan meeting.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
4 hours ago, kbrn2002 said:
Even if in your opinion the doc made the wrong choice it's still not the doc that is the one on the front line handling the patient's behavior. Unless the MD agrees to come to the patient's room and explain their reasoning for not increasing the dose it's going to be the nurse taking the brunt of the anger. How do you suggest nursing proceed in providing care without putting themselves in a dangerous position in that case?
It’s not dangerous to give a patient their pain meds when they are angry, yelling, etc because they are in pain and they want their pain meds. Generally you are in danger when you have to withhold something someone wants, not when you are giving them what they want.
Also, it is pointless to attempt rationalizations and bargaining with someone who is in that state of mind.
Sounds like a crappy situation all the way around. I wouldn't walk into the guys room either, especially after I was done playing games with the only thing (in his mind and nervous system) that was standing between him and the fires of hell.
You're a representative of the system, the point "man" in this instance, who's directly responsible for ALL this patients suffering right at this moment. Try empathizing with that. And no, you didn't create this situation. That started a long time before you two met. That end of your job is thankless and impossible and it sucks and I decided from the git go I wasn't going to do that. I work med-surge instead where I have quick constant access to Docs ( and only 4 or 5 patients, on a non Covid day) who are basically the only ones, if they are interested, who are able to do a damn thing about someone who's medically, or otherwise addicted to opioids, in the hospital.
Kudos to the full care plan convo idea.
Last, your education doesn't end with passing the NCLEX and bringing home your paycheck. You have an obligation to your patients to become the best damn nurse you can be.
Over and out.
Thank you. It was a pretty interesting experience and I learned a lot, actually.
I ended up taking care of that patient quite a bit over time. Once you can establish some kind of genuine trust everything is so much easier.
The patient requested I do other stuff I didn't think I should, for example slam the meds through the port nearest the huber needle, and applied more pressure by saying that everyone else did it. I just said, "Now you know I can't do that. Don't ask me to do things that you do know would not be what a nurse is supposed to do."
Actually most hospitals I have worked at (traveled med surg to 10 states) have policies for med administration, and administering the med at the closest available port to the patient is the standard appropriate intervention. And flushing after each medication with saline. Though this does not mean that you are going to push it faster than is appropriate, administering it at a safe speed through a close port means you are ensuring that their entire dose is administered in a timely fashion, and isn't delayed due to something like an IV line running at 20ml/hr.
Actually most hospitals I have worked at (traveled med surg to 10 states) have policies for med administration, and administering the med at the closest available port to the patient is the standard appropriate intervention.
Yes. My comment was solely about what I described.
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.
I think you should have called Security to stand by, very close by, like at your side close, while you or your designee got him his 2230 meds on time.
Why add fuel to the fire by making him wait so long?
And you probably do have a few minutes leeway - like give it to him 15 minutes early.
That said, where did he get that stick?
He needs a Psych consult and a good talking-to by his doctor.
And if he can exert all of that energy screaming and creating such havoc, he can probably be discharged or switched to non-narcotic meds.
Always follow your gut. It will almost always keep you safe, I think. Never worry if you have to get Security or another nurse to substitute for you or accompany you.
And don't make it the patient's problem that you have so many patients. If you were the patient, would you really care how busy your nurse is? You might understand and have some empathy, but that would not help your pain, especially if she was treating you like a child, which is pretty much what you did, I think.
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SmilingBluEyes
20,964 Posts
SOOOOOOO his acting out physically is not threatening. WOW. Would YOU walk in there when someone is behaving violently? I don't think so. And he was NOT DUE his pain meds anyhow!
We do not reward this behavior. We get psych consults and medicate on schedule as long as our safety is not in jeopardy We report inadequate pain control to the prescribing physician.
I would not have done any differently so I guess you would report my butt too. So be it.