Question

SCENARIO : OPIOID WITHDRAWL please type your answer

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

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

Morphine withdrawal

Morphine is a crystalline alkaloid, extracted from Opium , the salts of which are soluble in water and are used as analgesics, anaesthetics and sedatives . Morphine Withdrawal is a type of metabolic shock the body undergoes, when a substance( morphine) , which a patient is addicted is withheld.

1. Response to the outgoing nurse report:

(My response ) : Thank you for providing the brief history of current problems of the patient and the assessment details. But I think, being professional nurses we should not comment on the patient negatively ,especially on their personal matters like family. Anyway I am not going to avoid her, but going to try my best to help her.)

2. A concern has to go to the in- charge nurse of the unit, that the ' outgoing nurse ' is subjectively criticising the patients and the patients are feeling rejected by the health team overall. This may affect the hospital reputation on patient care. One staff's unsympathetic behaviour towards the patient may influence the patient's attitude towards the entire health care organization.

3. Surely. Incoming nurse's communication towards patient was a therapeutic communication. Therapeutic communication is a communication between the nurse and patient, that focus on the physical and emotional well-being of the patient and it make use of several communication techniques. Some of the Therapeutic communication techniques are broad opening, Restating , silence ,clarification, summarizing, paraphrasing, Reflection, theme identification, suggesting, questioning, offering self, informing and Catharsis etc

Examples of Therapeutic communication techniques , incoming nurse used are:

Reflection: " it seems that you had a rough night and very uncomfortable ". Reflecting back the feelings of the patient.

questioning and exploring: for the symptoms detail

Active listening, Acceptance, Recognition, Acknowlodgement and Offering self( " I am here for you to support you ") are the other therapeutic communication techniques she used.

4. Patient and family teaching, out patient interventions:

* Family of the patient should know the causative factors of Opoid addiction, that half is from genetic factors and half from their environment.

* It is not a chronic disease, through adequate treatment and follow up and family support she can shine again.

* Remove the guilt feeling of the family members and the patient.

* Educate the client and family members about the Compliance to the drug.  

* Educate and encourage them to have the therapy sessions regularly .

* Encourage the patient to join to a support group Heroin Anonymous ( HA).

* Instruct the patient not to hang out with the same old friends and situation, that probe her for heroin intake.

* Teach the patient the risk and complications of Heroin intake parenterally.

* Encourage relaxation techniques, outside games and exercises.

* Instruct family members not to give too much stress to the patient.

5 Ethical dillemma: A circumstance in which a choice must be made between two or more alternatives that seem equally undesirable.

In this case scenario: Patient is in pain she is asking for painkiller Morphine but as she is an Opoid addict nurse or physician can't prescribe any of the opioid pain killers.

7. It is very important to listen to the patient's underlying problems, health care providers can use this data or informations for assessing, diagnosing patient condition. It also will help in planning the appropriate treatment and other intervention for the patient. Especially a problem related to their Mental health as well as their physical Health, a health care provider should actively listen to the patients problems and their description. Active listening may help the patient to feel accepted and the treatment will be easier and it will become effective.

8. (In my Opinion) Incoming nurse aappropriately responded to patient's concerns. She reported to the doctor also detaily regarding the patient's condition. She suggested the pain killers and even the medications for anxiety. Patient's response ( at last) reveal the satisfaction of patient care also.