Ok...a little background of this particular patient: She's a 50 something y/o female w/ hx of cervical cancer admitted for pyelonephritis. I get warned by the charge nurse that she's tough to handle (that's all the info I get) as I get handed my assignment.
I notice she's very particular & needs to control everything. She refuses to void in the hat (she keeps putting it on the floor). She refuses to let us to empty her nephrostomy tube (she empties it on her own...but at least tells us the amt - of course we don't observe it ourselves). She wears foot pajamas (yes...I repeat she's a 50ish y/o) & has lymphedema in her legs but she refuses to remove them to allow me to assess them.
Anyhow....she has a double strength Fentanyl PCA pump & her pain remains a 9 (even after I got the Fentanyl up'd from a standard concentration). She's also taking Ativan Q6 & complains that the MD didn't order it Q4 as "he usually does" & is irritated with me b/c HE didn't order it the "right way".
The next morning the MD writes an order for a sleeping pill as requested by the patient. The following night I have her again (yay me) & at about 9 p.m. she asks for her ativan & her sleeping pill. Now, I'm still a newer nurse & wasn't totally comfortable administering her ativan + sleeping pill while she's on a double strength PCA (& still requesting boluses). I understand she may have a high pain tolerance but it's my first time taking care of her (she's well-known on our unit) so I make the mistake of asking her "Did you want to take the Ativan first & if you can't sleep we can give you the Restoril?"....aaaaaaaand she goes on a tirade: "Well, why can't I take both at the same time.....I always take both at the same time when I'm here" I try to tell her that her Fentanyl, ativan, & sleeping aid have an additive effect & her immediate response is "Am I gonna die?!?!?" I tried talking her down & she told me that I scared her and now she doesn't want to take them both at the same time if at all. I tried explaining to her that I was just trying to be safe & NOT scare her. And then she told me "I think you give too much information....I've never had any nurse tell me that before". I WANTED to say "Really?!?! You've been in the hospital sooo many times & you have no freakin' idea that taking all these narcs, benzos, & sleeping pills won't have an effect on you?!?!?"
So.........days later, I'm still wondering if I did give her too much information. The hospital wants to us to educate our patients...especially the meds we are giving them. I didn't offer all this information to begin with, she kept asking & then when I tell her...she claims I scared her. Turns out one of the other nurses said she told her the same thing last time she took care of her (about spacing out ativan & sleeping pills).
In the end, I want to give safe care & not lose my license. I just hate that with someone like that, she can easily go make a complaint about me & say I scared her, etc. & I don't know where that will leave me.
So many of our pt.s come into our facilities with med profiles that should have killed a team of oxen, yet they take it everyday; and somehow survive to live and gripe another day.
This. X10.
So many times I see nurses worry about giving x and y together. If they're getting x regularly, and it's not about to knock them out, there's really no reason to worry that all of the sudden y is going to take their respiratory rate from 18 to 0. Worry if they don't normally get any of it.
If I've got cancer, I don't care what would knock YOU out, I want what works for ME.
So many times I see nurses worry about giving x and y together. If they're getting x regularly, and it's not about to knock them out, there's really no reason to worry that all of the sudden y is going to take their respiratory rate from 18 to 0. Worry if they don't normally get any of it.
If I've got cancer, I don't care what would knock YOU out, I want what works for ME.
I have to agree with this. I work LTC, but it isn't old people we are taking care of any more. We see alot of pts with multiple issues and have a med list as long as my arm. Giving a pain med with .25 of xanax isn't going to klill them, but I've had nurses refuse do do just that.
Sounds like your pt had a history with these meds. Just because they are high up there in the dose range, doesn't mean she couldn't handle them...ask the hospice or onocology nurses about this and they will have a thought.
Unfortunately there are people in this world who will find something wrong with everything and never be happy. Sometimes an apology (even if you really don't have any reason to apologize) will placate them for example
"You're scaring me!"
"I'm sorry if I scared you that wasn't my intention."
You can try to give an explanation like "I want to keep you safe so you can get well" but I find that the attempts at "justifying" your behavior don't go over well either. So be as polite as possible, apologize for everything you do/did/or will do "wrong", and when you get to the point where you just want to reach into the bed, shake them, and say WHAT IS YOUR F***KING PROBLEM!!! keep as much distance as you can.
Specializes in M/S, Tele, Sub (stepdown), Hospice.
BTW, she doesn't take Ativan or sleeping pills at home & she only takes Norco for pain so she is taking quite a bit in the hospital compared to what she normally takes at home.
I did apologize to her & told her it wasn't my intention to scare her. I did continue to smile & be kind to her.
I feel for her....really I do - but honestly, it doesn't give her the right to talk to me that way. It wasn't an "off day" for her...she's continuously like this. When I first entered her room that first day & asked her about her pain level, she sighed heavily & said "I already told the other nurse" & she refused to tell me where her pain is, etc. I mean....she's here on a darn Fentanyl PCA & her main issue seems to be pain control yet she won't give me any information.
Bottom line is this: Do you think me telling her why I didn't feel comfortable giving her the ativan/restoril at the same time (additive effect, etc.) was appropriate or was I saying too much?? She literally told me "I think you're giving your patients too much information"
Bottom line is this: Do you think me telling her why I didn't feel comfortable giving her the ativan/restoril at the same time (additive effect, etc.) was appropriate or was I saying too much?? She literally told me "I think you're giving your patients too much information"
*sigh*
Nah, not at all; certainly wouldn't be for a reasonable person. Your only mistake was in not recognizing that your patient cannot be reasoned with. You gave her information that she was not interested in having, because she wants her own way, and you can't find that out except by trial and error.
If the Dr prescribes what she demands, it's your duty as a patient advocate to advise her of the pros and cons, but it's her business if she chooses to reject your advice. Stop worrying about it.
There are obviously some very serious emotional issues here that are prompting some strange behavior. I'm certainly not a psych expert, but even I can see that footie pjs could be this patients's mechanism to 'cover up' and serve as a barrier to unwanted intrusion. Remember Maslow? - When you have so many serious issues to cope with, it is difficult to focus on anything except day-to-day survival.... maybe her only goal is to be left alone and not hurt so much.
I think it would be appropriate to get a psych consult/evalution. It is obvious that this patient is not coping well with multiple disease processes and chronic pain.... honestly, I don't know of any ideal patients - does anyone?
There are patients who take a great many pain meds and demand amounts that can scare you. These patients usually demand pain meds by TIME not by pain score, ostensibly so they can AVOID the pain that they say is coming. Pre-emptively. You have to assess them frequently if not constantly. I would recommend a pain consult with the hospital's Pain Management Team. Although a patient's pain is what they say it is and where they say it is you need some guidelines/orders, particularly when they start "stacking" their meds: Q4 Q6 PCA IM, HS. For instance, you have a patient on frequent morphine who is developing twitches (toxicity) and yet demanding more. When you are worried and don't know what to do-yes-that is a sign that you need more resources and more expert advice or direction, i.e pain consult, well-written DR orders (not to exceed x in 24 hrs, not w/in 6hrs of x, etc). You also have to use the FACES score for pain sometimes rather than self reported 1-10 scale. This is a very difficult ethical decision and it may just be discussed by a team in the hospital. You have to use diversion of attention and guided imagery and provide other activities to get he patient away from their pain. Pillow fluffing and snacks and let them talk. Chronic pain can lead to terrible social skills and a person who just is difficult to be around. Well, this is just one reason that Nurses are exhausted at the end of their shift!
Oh, and I forgot to add that PAIN itself is not necessarily a priority in triage, but the patient in pain can take up a lot of time. The person on a drip needs your attention more. Jeesh.
These patients usually demand pain meds by TIME not by pain score, ostensibly so they can AVOID the pain that they say is coming. Pre-emptively.
Which is a worthy goal. Easier to keep pain controlled than bring it down. I'm not going to make someone have pain for a bit just so I can chart a pain score before I give their medication. It's why sickle cell patients, if they have competent MDs/midlevels, will have their pain meds scheduled around the clock rather than prn. Because some nurses insist on waiting for the patient to have pain rather than keeping their pain under control.
You also have to use the FACES score for pain sometimes rather than self reported 1-10 scale.
FACES is a self-reported scale. The kid should point to the face that mirrors how they feel. It's not for us to look at the patient and match their frown.
wooh, BSN, RN
1 Article; 4,383 Posts
This. X10.
So many times I see nurses worry about giving x and y together. If they're getting x regularly, and it's not about to knock them out, there's really no reason to worry that all of the sudden y is going to take their respiratory rate from 18 to 0. Worry if they don't normally get any of it.
If I've got cancer, I don't care what would knock YOU out, I want what works for ME.