PATIENT Dilemma Pain Control or Drug Seeking

PATIENT Dilemma Pain Control or Drug Seeking Behavior STUDENT Worksheet Angela Stevens, 28 years old Overview Is pain always what the patient says it is? Though the patient’s rating of pain is always relevant, the nurse must collect and cluster additional clinical data to make correct clinical judgments regarding pain control. In this dilemma, a post-operative patient with a history of narcotic tolerance and chemical dependency continues to require increasing amounts of narcotics for pain control. How to guide clinical decision making without being judgmental is the essence of this patient dilemma. © 2015 Keith Rischer/www.KeithRN.com Clinical Dilemma Activity: STUDENT Pain Control or Drug Seeking Behavior I. Scenario History of Present Problem: Angela Stevens is a 28-year-old woman who is post-operative day (POD) #2 after a small bowel resection and lysis of adhesions. She has chronic abdominal pain due to severe Crohn’s Disease and has developed narcotic tolerance and dependence as a result. She has been clinically stable post-op, but has been c/o increasing incisional pain despite the Fentanyl/Ropivicaine epidural drip being increased from 8 mL/hr to 12 mL/hr earlier today. She has hydromorphone (Dilaudid) 1mg IV push prn every 3 hours for abdominal pain that remains persistently greater than 6/10 on a 0-10 pain scale. Her pain goal is to be 4 or less. II. The Dilemma Begins… Current Concern: It is now POD #4 and the epidural drip was discontinued earlier today. She has been watching the clock and calls the nurse precisely every three hours when she can have her next dose of hydromorphone 1 mg IV push prn. Despite her high level of pain that she consistently rates as an eight, her heart rate is 70, and her blood pressure is 110/68. When the nurse observes the patient discreetly through a window, Angela is texting on her phone and appears in no acute distress. As soon as the nurse enters the room, she puts the phone down and begins to moan loudly because of her pain. What data from the current concern is important & RELEVANT; therefore it has clinical significance to the nurse? Personal/Social History: Angela is a single mother of two children ages three and one. She lives in her own apartment. She has struggled with chemical dependency in the past and denies any current problems. A routine urine drug screen before surgery was positive for benzodiazepines, even though she has no scheduled medications in this pharmacologic classification. She is estranged from her mother and has little support at home. What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: RELEVANT Data from Current Concern: Clinical Significance: © 2015 Keith Rischer/www.KeithRN.com III. Resolving the Dilemma 1. Identifying data that is RELEVANT, what is the essence of this current dilemma? 2.What additional information is needed by the nurse that would help clarify the current dilemma? 3.What additional members of the healthcare team could be used in this situation? Why? 4.What is the nursing priority? 5.What nursing interventions and/or principles can the nurse use to successfully resolve this clinical dilemma? 6. What is the expected response of the patient that indicate the nursing interventions were effective? 7. What response by the patient would indicate that a change in the plan of care and nursing interventions are needed? 8.What is the patient likely experiencing/feeling right now in this situation? 9.What can I do to engage myself with this patient’s experience, and show that she matters to me as a person? 10.What was learned from this case study that you will incorporate into your practice? SCIENCE HEALTH SCIENCE NURSING

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