I have been a CNA for 5 years. i am also a nursing student (BSN/RN) on my last quarter. i work as a registry CNA right now, so i see a lot of different nurses and units etc.
I was on an ICU unit with a elderly female pt who was there for encephalopathy after trauma to the head. she fell outside a liquor store. she has history of alcohol abuse but she denies recent consumption. the liquor store owner states she regularly buys alcohol. she takes anxiolytics at home for anxiety. shes also on SSRI antidepressants. she has a history of chronic lower back pain, neck pain, and states she has pain all over.
I was called in to sit with the patient. when i came she was really agitated and anxious and kept trying to get out of bed. she is A/O X4. shes been there for 5 days now. she continuously asked for her pain and anxiety meds. she had, tylenol q4hr prn (mild to moderate pain 1-6) norco q4hr prn (sever pian 7-10), lorazepam q2hr agitation (on a scale CIWA scale 0.5-2g).
she knows her meds but doesnt know what times theyre suppposed to be given. she asked the nurse but the nurse refused to give her the times because she thought the patient was addicted and drug seeking. the nurse would say "thats all you care about is your painkillers to get off. you dont ask about anything else".
i was sitting with her the whole time and she was shaking and visible anxious the whole time. the nurse would refuse to give her lorazepam or pain meds until she was literally ready to get out of bed.
based on her CIWA she was suppsoed to get at least 0.5 to 1g q2hr however she only gave it twice the whole shift. at the beginning and at the end.
the mobile xray came. from her xrays i saw she had plates pins and other surgical metals in her neck. so that explains the neck pain.
the nurses excuse for withholding the pt meds was that her blood pressure was too low and her respirations were too low. her blood pressure and respiration would naturally lower when she fell asleep but shot up to normal when she was awake. so the pt is anxious so is constantly looking at the clock, so i advised her to relax and try to sleep so that the time passes faster. now, the nurse comes in to assess the patient but every time she would come, the patient was napping. the nurse would write down pt's v/s and leave. then the pt would wake up and ask for her meds and anxiolytics. the nurse would come in and say that her v/s are too low even though they arent when shes awake. so this goes on for the whole shift. i told the nurse that shes axious and in pain but the nurse just shrugs it off and says shes an alcoholic, all she wants to do is get high.
this RN was floating from another unit to the ICU. shes from a medsurg floor.
in my head this is not ethical practice. is it? pain and anxiety are subjective. sometimes objective data can help us assess a patient's pain or anxiety but the patient's word should be taken as truth when it comes to pain or other subjective data. or at least thats what our nursing school teaches us. im always learning so please do provide constructive criticism thanks!
Specializes in Infusion Nursing, Home Health Infusion.
Grat response from Loving Life123.Well, It's either an addiction or a dependence.Not all patients with chronic pain syndromes are addicts or addicted. You do, however,get dependent on it and if you have a complete cessation of the dosing or a significant reduction you will go through withdrawals and it's not a pretty sight and quite miserable.Often misguided or ignorant nurses cruelly withold pain medication not realizing they are harming their patients.In fact, if they undergo a procedure or surgery they need not only their usual dosing but additional narcotics to get pain under control. I am not there to judge but I am there to make certain patients receive the same high standard of care and it's shamful to withold narcotics or anxiolytics because you think you are doing them a favor,punishing them or trying to rehab them. I do think the nurse was cruel in this instance and used her power to make the patient suffer.I could never have left another human being in my care in that state without trying to help. I understand your dilema though and I would have waited until she went on a meal brake and then went to tbe charge nurse and asked for him or her to assess the pt.
I would want to hear the nurse's point of view before I make any judgment as I know, when I was working as an aide and was in nursing school, I sometimes sat with patients and had no idea of the whole picture.
I am also interested in the nurse's side. I have sitters who want "99 injections" for a patient who requires any effort, at all.
Patients don't typically need a sitter if we're drugging them to oblivion. I am very liberal with meds, but I can't always safely give everything to everyone.
Specializes in Surgical, Home Infusions, HVU, PCU, Neuro.
I am curious as well on how the CNA/sitter is so knowledgeable as to the patient's home medications, and stories concerning the patient given by a third party that is presumably not involved in the patient's care. Even if that is beside the point.
If the patient's BP was too "low" for the medications to be given, it could have been that the BP had been running low in relation to the precious trends recorded. This could also have been an excuse and the BP was in fact within a reasonable range to give the medication safely to the patient. If the patient was taking the same dose of Norco before admission, I would think that the same orders, or at least close too, would be given for the inpatient setting, modified of course if there were other medications given that could cause harm ( I.e. IV pain medication etc.) When patients take medication on a daily basis, typically they do not receive the same relief with a dose that is no different then what they are already taking, thus requiring a larger dose or another medication to treat the pain they are having in the hospital, if there had been something that was causing an acute pain. If the patient did not have anything to warrant an increase in pain, then I would have expected the orders to have at least the home medications available to the patient.
The CIWA score is something to use as a guide to assess patients that have been deemed a risk to suffer from withdraw, DT's etc. When using this tool the frequency should include a schedule and a prn assessment. For instance, if you assessed your patient at 10 and they were sleeping in bed, resps even and unlabored, etc. there would not be any intervention needed as far as the CIWA score goes. If your patient wakes up at 10:20, noticeably agitated, anxious etc- the CIWA score should be reevaluated, even though there was only a 20-minute difference.
It sounds like the patient was an overflow waiting on a floor bed. This may be why the Med Surg nurse was assigned this patient in particular. Just speculating. As disheartening as it is to see someone treat a patient like this, it happens more than it should. The probability that the patient is going to "get high" on the same dose of medications that she takes at home, seems a little far-fetched to me. The ICU is not a detox center, not giving medication due to stereotyping a patient is morally and ethically wrong in my opinion. Our jobs in acute care is not to pass judgments on those under our care. Our job is to provide safe and appropriate care to those we get assigned. If this happened the way described, it truely is a disheartening situation and just take away from the situation what you do not want to do in your practice.
I totally missed this, but maybe it was a typo in the OP.
However, there are a bunch of other things really don't seem to make much sense. How does the sitter know that the liquor store owner said that the pt often comes in to buy liquor? How does the sitter know the home meds? How does the sitter know what the PRN Ativan orders are? How does the sitter know why the RN is withholding the meds? My biggest question: why is a medsurg nurse being floated to the ICU to take care of a critically ill patient?
Maybe there are perfectly reasonable explanations for all of this, and I invite the OP to come back and explain these.
It may have been a typo but more than once, OP lists the lorazepam dose in grams. We're trying to prevent DTs here, not kill a small horse.
I also have the same questions you have. When I worked in the hospital, our aides did not have access to our MARs therefore would have no idea what was ordered for medications for a patient they were helping with or sitting with. Same story when I was an aide in the hospital in nursing school. I only had access to the I&Os and VS. And I NEVER would have known this extensive of a history of a patient I was sitting with, just "Patient in bed 4C needs a sitter because she keeps trying to climb out of bed and fell." I had one patient once who I knew was in alcohol withdrawal and kept hallucinating but that's all I knew about her, even though I sat with her for 8 hrs. I had no idea what medications she was ordered for or the frequency nor would I have necessarily known which medications the nurse was giving when she medicated the patient.
It's not particularly the dosing of the meds that concerns me, though I do hope that the indication of a 0.5 to 1 g dose of Ativan was a typo. What concerns me is the verbal responses to the patient. I don't know if I could be quiet about a nurse talking to a patient like that, it's simply inexcusable.
Grat response from Loving Life123.Well, It's either an addiction or a dependence.Not all patients with chronic pain syndromes are addicts or addicted. You do, however,get dependent on it and if you have a complete cessation of the dosing or a significant reduction you will go through withdrawals and it's not a pretty sight and quite miserable.Often misguided or ignorant nurses cruelly withold pain medication not realizing they are harming their patients.In fact, if they undergo a procedure or surgery they need not only their usual dosing but additional narcotics to get pain under control. I am not there to judge but I am there to make certain patients receive the same high standard of care and it's shamful to withold narcotics or anxiolytics because you think you are doing them a favor,punishing them or trying to rehab them. I do think the nurse was cruel in this instance and used her power to make the patient suffer.I could never have left another human being in my care in that state without trying to help. I understand your dilema though and I would have waited until she went on a meal brake and then went to tbe charge nurse and asked for him or her to assess the pt.
As a person with chronic pain, I completely agree with this. There are responsible narcotic users out there.
I totally missed this, but maybe it was a typo in the OP.
However, there are a bunch of other things really don't seem to make much sense. How does the sitter know that the liquor store owner said that the pt often comes in to buy liquor? How does the sitter know the home meds? How does the sitter know what the PRN Ativan orders are? How does the sitter know why the RN is withholding the meds? My biggest question: why is a medsurg nurse being floated to the ICU to take care of a critically ill patient?
Maybe there are perfectly reasonable explanations for all of this, and I invite the OP to come back and explain these.
It sounds to me like someone's nose is where it doesn't belong....in the chart.
ive met sitters/CNAs and nurses who are like that. i however am not like that. i a nursing student and i fully understand that we cant give everything all at once or everything thats ordered. we have to asses and use our judgement. they might need an increase in pain meds.
I understand the nurse being aggravated with the patient. A lot of people look down upon and are disgusted by and angry at drug addicts and alcoholics.
HOWEVER - if I heard someone talk that way to another living being, I would be hard-pressed to not pull that nurse aside and give a gentle reminder that we are all imperfect. We are all in need of the grace of almighty, merciful God, we all fall short of perfection.
I think a person who maltreats a patient by spewing such venom upon him or her is in need of prayer herself. She needs some encouragement to remember that even she has feet of clay. "None of us is perfect, Susie. None of us" might be sufficient to get her to re-think her attitude and tone down her viciousness.
And she needs to be reminded that her patient needs her to be at least neutral toward him. Positive is even better.
She needs to remember that she has it in her power to be helpful, compassionate, and a reliever of her patient's suffering.
She needs to be reported if she doesn't shape up, too.
I understand OP's reluctance to report her. It's just a miserable situation all around, but at least he kept the pt from falling.
i saw all of that in the H&P and the MAR i have access to the patient's EHR. im a nursing student so i wanted to learn everything i can about my pt
i saw all of that in the H&P and the MAR i have access to the patient's EHR. im a nursing student so i wanted to learn everything i can about my pt
Oh, I'm certain that's where you got it from. I just find it ironic that your title mentions ethics. Meanwhile, you violated HIPAA. You stated you're in your last year of nursing school. You should know by now why this violates HIPAA.
If everything went the way you said it did, yes. She's wrong in her behavior. It's great you want to be a patient advocate. I'm just not getting too much into this as we don't have the nurse's side of the story. Just wanted to point out the HIPAA violation. Being a nursing student doesn't legally give you the right to access parts of the chart that do not pertain to your care as the sitter. There are plenty of people who have been fired for this.
You also really shouldn't have posted such an in depth history of this patient on a public forum. You need to be careful
iluvivt, BSN, RN
2,774 Posts
Grat response from Loving Life123.Well, It's either an addiction or a dependence.Not all patients with chronic pain syndromes are addicts or addicted. You do, however,get dependent on it and if you have a complete cessation of the dosing or a significant reduction you will go through withdrawals and it's not a pretty sight and quite miserable.Often misguided or ignorant nurses cruelly withold pain medication not realizing they are harming their patients.In fact, if they undergo a procedure or surgery they need not only their usual dosing but additional narcotics to get pain under control. I am not there to judge but I am there to make certain patients receive the same high standard of care and it's shamful to withold narcotics or anxiolytics because you think you are doing them a favor,punishing them or trying to rehab them. I do think the nurse was cruel in this instance and used her power to make the patient suffer.I could never have left another human being in my care in that state without trying to help. I understand your dilema though and I would have waited until she went on a meal brake and then went to tbe charge nurse and asked for him or her to assess the pt.