Pain Control for a Penny
Clinical Exemplar #1
Kimberely S. Strickland
September 20, 2010
Several months ago, I cared for a patient named “Penny,” a nineteen-year old[KH1] woman who was suffering with agonizing abdominal pain. Unfortunately for Penny, her doctors were unable to find the cause of her pain. Another strike against Penny’s pain battle was the jaded attitude of some of the doctors and nurses. Because of the high number of drug seekers admitted to the hospital, many staff members have developed a callous demeanor toward anyone they believe is seeking narcotics.
In nursing school, I learned that pain is subjective. I also learned that no matter what signs and symptoms the patient displays, I should ask her to rate her pain on the 1-10 pain scale. According to my professors, I should then treat this pain according to the patient’s own rating.
I first met Penny after I had received report on my patients. I entered the room and introduced myself in my usual fashion, “Hi, I’m Kimberely and I’ll be your nurse until 7:00 tonight.” What I saw disturbed me. This young woman was in tears, holding her stomach. “What’s wrong?” I asked.
She strained to get the words out, “My stomach is killing me. I asked the nurse for pain medicine but she never brought any.”
At the bedside was Penny’s mother “Pearl.” Pearl was a middle-aged woman with proof of her age clearly visible in the lines on her face and the dark circles under her eyes. Pearl had her notebook computer on her lap as she sat in her chair by the window. My gaze returned to Penny and I asked her to rate her pain on the 1-10 scale. “Ten” she replied.
I told her, “I’ll check you med list and I’ll be back as soon as I can.”
The strongest pain medicine ordered for Penny was Percocet[KH2] . I was quite annoyed that a patient in this much pain had no intravenous pain medicine ordered. So, I called her physician, “Dr. Doubting.” I gave the standard SBAR-Q report (situation, background, assessment, recommendation, questions) and emphasized that the patient needed something intravenous for her pain in addition to the Percocet. Dr. Doubting said, “Well, I think Penny is a drug seeker and she’s putting on an act.”
I met his skepticism with my own opinion, “She is writhing in pain and crying like a baby. No drug seeker that I’ve ever seen has entertained me in this fashion. None of them has shown this much acting talent.”
After taking a deep breath, Dr. Doubting reluctantly ordered morphine one milligram IV every two hours for pain. Knowing that I would be calling him back shortly, I took the order, obtained the drug, and administered it to the patient along with the Percocet. She was still crying and holding her stomach. Her mother was standing over her offering comfort. This scene reinforced my belief in the patient’s pain.
I left the room with a promise to return shortly. I checked on my other patients and completed several tasks. Twenty minutes later, I checked on Penny and found her pain no better. “Rate your pain,” I asked.
“It’s still a ten,” she cried.
I called Dr. Doubting again and explained that Penny had no relief with the morphine. He gave another order for morphine two milligrams every two hours for pain. “First dose now?” I asked.
“First dose now,” was his reply.
I obtained the drug through a narcotic administration override and went directly to Penny’s room to administer it. I found no change in her condition. So, I administered the drug and sat on the bed with her. I took her hand and told her to look at me. “Focus, Penny. Look me in the eye and think about what I’m saying to you.”
She did.
“We’re going to beat this pain and you’re going to feel better. It’s just going to take a little while. I’ve given you a total of three milligrams of Morphine and a Percocet, and I’m going to continue to give you everything I can for your pain. Do you understand?”
Still crying, she nodded.
I continued with my pain pep talk, “I am going to check on my other patients, but I’ll be back for you. While I’m gone, I want you to think about going to the beach. Do you like the beach?”
She nodded again and I continued. “Think about going to the beach with your friends. You don’t have a care in the world. Sunning for a week at Myrtle Beach will give you a great tan. You can ride the waves in the ocean and dive in the pool afterwards. When the sun goes down, you can ride the strip and meet new people. Does that sound like fun?”
With tears in her eyes, she nodded again. So I continued, “I want you to think about that while I’m gone. How would you rate your pain now?”
Still crying, she said, “It’s about an eight now.”
I stepped out of the room and called Dr. Doubting again. He and I repeated the same ritual, and I obtained an order for a one-time dose of morphine three milligrams, first dose now. I administered the dose immediately. Within fifteen minutes, Penny reported that her pain had dropped to a four. I instructed her to keep her focus on Myrtle Beach, and she agreed to do so.
Meanwhile, I checked on my other patients but kept a close watch on the clock to ensure that Penny received another dose of morphine two milligrams when the two-hour time limit had expired. When the minute arrived, I had the medicine ready to push into Penny’s IV port. Within ten minutes, she was rating her pain at a two on the pain scale. An extra-added bonus for my efforts was her droopy eyelids. I am happy to report that Penny finally drifted off to sleep.
I left Penny to dream and her mother Pearl followed me out of the room. “Kimberely,” she began, “Penny has been in and out of the hospital for a lot of years but no nurse did what you did today. Most would have given up but you didn’t, and I want you to know how much I appreciate how much you helped my daughter.” She then gave me a big hug and returned to Penny’s room.
After my shift ended, I didn’t see Penny or Pearl anymore nor did I learn the source of Penny’s abdominal pain. I cared for Penny on my last day of the week and then was off for several days so I suppose I’ll never know.
As I was writing this exemplar, I realized that working with Penny taught me a lesson. For the first time in my nursing career, I did not let a doctor’s reluctance to treat a patient stop me from being an advocate for that patient. I did not care if he yelled at me or became upset. I made up my mind early in the day to keep calling Dr. Doubting until Penny’s pain was greatly relieved. I was quite proud when she fell asleep.
Although many drug seekers are admitted to our unit, this should not sway caretakers from giving patients the best pain control possible. In this situation, I utilized what I was taught in nursing school to help the patient achieve a more favorable and comfortable outcome. That teaching combined with persistence helped ensure a pain-free Penny.
Kimberely, what an exquisite exemplar. The care that you provided exemplified the standards of nursing practice. Advocacy is huge with our professional standards and with Nursing’s Social Policy Statement. I am hopeful you will look at those documents and place your exemplar into perspective using these as a framework. For writing, please review APA format for your title page: what items it should include, all 12 font, running head, page number, no bolds, and no tables. These are in the APA manual/Perrin. In our first class, I also added course title to be on the title page. Remember too that APA is left justified. Thank you for a nice paper. 14/15
[KH1]See APA format for age
[KH2]Use generic lower case
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