Question

SCENARIO : OPIOID WITHDRAWL

OUTGOING NURSE : So we have an Evet Ogam. She is a 34-year-old female brought in by ambulance, last night at 1800 for a heroin overdose.

She was given 2 doses of naloxone, 2mg each dose. She vomited twice following the naloxone. Following stabilization in the ER, she has been brought up to our floor for monitoring.

Pt is allergic to aspirin and has a history of back surgery in 2012,

Pt has been admitted twice before for heroin overdose and gone to rehab three times.

I’m guessing she became addicted to pain medication after her back surgery.

She did tell me that she is currently going through a divorce.

No surprise there.

Labs are pending for ETOH, urine toxicology, CBC, CMP,

Magnesium, and Phosphorous.

In terms of assessment, she is A&Ox3, lungs clear, pulses strong, abdomen tender.

She has track marks all over her extremities, no signs of cellulitis or abscesses yet. Keeps watch on her left forearm

We have her on 400 mg of ibuprofen every 6 hours for her back pain. Her next dose is at 8 am

She has been ringing the call bell every hour, is super anxious, and really   high maintenance so best to just avoid here. She is a drug seeker she will eat all your time.

I know you are trying to give me a heads up, but labeling the patient can be unproductive,

Most often these patients are under medication. What was her most recent COWS score.

OUTGOING NURSE: COWS score was 14.

OUTGOING: Good luck with her

INCOMING: Hello I am Sharon. I’m going to be your nurse today.

What would you like to be called?

PATIENT: Look! I have been in severe pain all night. All they gave me was Motrin. Motrin is fine for bee stings, but not do anything for the pain that is going to drive me thru that wall !

INCOMING: I’m sorry you feel bad, I am here to help you. Can you rate the pain on a scale of

1-10?

PATIENT: It feels like a Mack truck just ran over my back, backed up and ren back over it again!

A 25! Can I have some Morphine?

INCOMING: OK, I will see what I can do but first I have to do an assessment. I am going to ask you some questions? Are you feeling any other symptoms?

PATIENT: Besides being annoyed by twits, being ignored when I call for help, and being treated like a leper.

INCOMING: I’m sorry you feel this way, like you are being ignored. It seems like you had a rough night and are very uncomfortable. I am gonna to call the doctor to see if I can give you some more pain meds for your withdrawal symptoms, but first I am going to complete an assessment, Ok?

PATIENT: Whatever!

INCOMIMG: Do you have any tremors? I am going to check your heart rate.

I am going to look into your eyes, thank you. How many times have you vomited?

PATIENT: Three times since I got here.

INCOMING: Is it still clear liquid coming up?

PATIENT: Yea, Yea..

INCOMING: Have you had any diarrhea?

PATIENT: Yeah, soon all my insides will either have been sh__ed out or puked up. Can I have some OXY?

INCOMING: OK, I am going to call the doctor for you to get some more pain medicine, OK?

I have seen that you have sweated thru your gown, I am going to get you a new one. Some cool compresses and I have some nausea meds for you. Does that sound like a plan?

PATIENT: Whatever… I will believe it when I see it!

INCOMING: OK, I will be right back with that , OK?

INCOMING: Hi Doctor, I am calling from Montgomery Hospital regarding your patient

Ms. Evet Ogam in room 346

DOCTOR: YES, I remember her. What is happening with her?

INCOMIMG: She was admitted for heroin overdose yesterday. Her COWS score is a 35.

She has a history of depression, and back pain following surgery five years ago.

She appears to be in a lot of pain and is anxious and vomiting.

DOCTOR: What are her vital signs?

INCOMING: Bp 150/85, HR122, RR 22, Temp 98.6, Pulse Ox 100% on room air. She is due for her ibuprofen, but that does not seem to cover her back pain. I am worried she is withdrawing from heroin. I would like to have an order for an antianxiety med, and something besides the ibuprofen for her pain

DOCTOR: Any allergies?

INCOMING: Only to asprin.

DOCTOR: OK, Give her…

INCOMING: Your COWS is now 10. How are you feeling about your pain now?

PATIENT: I can manage, you know…. You’re the only one that has treated me like human being since I got here.

INCOMING: You know… Heroin withdrawal is no walk in the park. I see you have been through detox several times. We are going to help you get help when you leave here.

PATIENT: I can not keep doing this to my kids! They need me!

INCOMING: I am here for you! To support you. We are going to get you help and we are going look at all solutions that are possible.

You are not alone! We are all working together for you to feel better.

PATIENT: Thank you!

QUESTIONS PLEASE TYPE YOUR ANSWER

1. How would you have responded to the outgoing nurse report? (professionally)

2. Was there anything additional that you could have done to address the outgoing nurses behavior with management/leadership?

3. Was the incoming nurse's communication therapeutic? Give examples.

4. Discuss educational needs of the client and family. What are some of the outpatient options for opioid addiction clients?

5. Reflect on ethical dilemmas uncovered during scenario.

6. Have you ever been in a similar situation like the scenario? How did you handle it? (It can be in relation to any diagnosis).

7. How important is it to listen to your patients underlying problems. How can we utilize the things patients say to improve their care.

8. Did the incoming nurse appropriately address the patients concerns

Answer 1

1. The outgoing nurse is frustrated and not being empathetic to the patient who is going through withdrawal symptoms,pain and a divorce.

2. The outgoing nurse should be advised on behaviour management such as

Approaching the patient in an accepting and non judgemental manner.

Assist the patient with identifying situations that precipitate angry feelings.

Assisting in dealing with emotions.

Limit blaming while explaining the substance abuse problem.

3. Yes the incoming nurse's behaviour was therapeutic.

The incoming nurse was empathetic with the patient on being told of her pain and also on being ignored.

The incoming nurse also made the patient more comfortable by providing her with a new gown, cool compresses and nausea meds.

The incoming nurse also assured the patient of help and support which made the patient feel all the more comfortable and at peace.