Nalbuphine

POOR MANAGEMENT

Putting teamwork into play

My wife is in the military and we just relocated to a rural area, where I'm working as a staff nurse at the local community hospital. Although all my previous experience is in large medical centers, I'm enjoying the friendly atmosphere and flexible hours this facility offers.

So what's the problem? My unit's nurse-manager is chronically disorganized. I suspect she was promoted based on seniority, not leadership skills. She can't seem to cope when the unit gets busy or a code or other emergency disrupts the routine.

Don't get me wrong; I love bedside nursing and don't want her job. But having worked in well-organized units in the past, I feel frustrated when the day spirals out of control. Any advice?-J.C., TEX.

If you're going to have to work under this manager for the next few years, you'd better help her bring some order to the unit. Start by analyzing your working day. What's the chief cause of the disorganization? How might it be corrected? Recall how you (or the nurse-manager) handled crisis situations at other hospitals where you've worked and see if you can adapt those strategies to your current circumstances.

When you've developed some workable solutions, share them with your nurse-manager in a positive, nonthreatening way. You might tell her, for example, that your previous experience in large facilities has given you some ideas about improving the unit's work flow. Make sure she knows that you're a team player who wants to support her, not take her job. We suspect she'll welcome all the help she can get.

ANALGESIC REGIMEN

Treating a pain in the neck

In the family practice where I work, we treat a 57-year-old patient for chronic neck pain from arthritis. He takes an array of analgesics, including ketorolac (Toradol) and Vicodin ES (acetaminophen and hydrocodone). At least once a week, this patient comes to the office complaining of neck pain (which he always rates as a 10 on a 0-to-10 pain scale) and asking for an injection of the opioid nalbuphine (Nubain). The physician gives the injection and sends him on his way. I believe he also gets these injections at the local ED between office visits.

This patient's reliance on an opioid makes me suspect he has more than a pain control problem. I've told the physician that I'm concerned about his drug-seeking behavior, but she brushes me off. What does your pain consultant say?-K.A., WIS.

She thinks poorly controlled pain is at the root of this patient's problem and suggests overhauling his medication regimen. Nalbuphine is a popular choice for outpatient pain control because this mixed agonist/antagonist is less likely to cause respiratory depression than many opioids. But it also has the ability to reverse the analgesic effects of other opioids, such as the hydrocodone contained in Vicodin. Ironically, this patient may be losing pain relief by combining the two.

If the patient rates his pain at 10 every time, his current medication regimen clearly isn't doing the job-and no wonder. Aside from intermittent nalbuphine, none of the drugs in his regimen are indicated for severe pain. Refer him to a pain specialist or pain clinic for a complete evaluation and treatment plan.

Current guidelines issued by the American Pain Society say that patients with severe arthritis pain should be offered opioid treatment if they're not benefiting from a less intensive regimen. If the patient is having severe pain all day and night, a pain specialist may prescribe an extended-release opioid, such as oxycodone (OxyContin) or morphine sulfate (MS Contin), along with Vicodin for breakthrough pain. Adding a nonsteroidal anti-inflammatory drug (NSAID) such as celecoxib (Celebrex) and adjunctive treatments such as relaxation, heat, and physical therapy may enhance relief. (The NSAID ketorolac isn't recommended for long-term use and should be removed from his regimen.) This patient may need I.V. drug therapy to get his pain under control before beginning an oral regimen.

For more information, visit the American Pain Society Web site at http://www. ampainsoc.org.

NEW GRADUATE

"Another world" in the OR

I'm a nursing student who's also working as a nursing assistant in my hometown hospital. I'd love to work in the OR after I graduate, but the experienced nurses I work with say the OR is "another world" where I won't be able to use (or hone) many of the bedside skills I'm learning in school. What do you think? -D.S., N.Y.

Our consultant agrees with the nurses you've spoken with. She recommends completing at least 1 year in a medical/surgical unit before specializing. She feels this is especially important for new graduates of a college (AD or BSN) program, which may not offer extensive clinical experience compared with hospital-based nursing programs.

Besides letting you accumulate valuable hands-on experience, your time as a medical/surgical staff nurse will give you the chance to network with colleagues and explore other specialties and opportunities the hospital offers. Instead of the OR, maybe you'll fall in love with obstetrics or oncology.

And don't forget medical/surgical nursing is also a specialty that offers unique challenges and rewards. Who knows? After a year you may decide it's where you want to be after all.

UNDERSTAFFING

Floating-or sinking?

I normally work in the telemetry unit, but last week I was pulled to the ICU. Initially, I was assigned to patients who were clinically stable. But halfway through the shift, one of my patients experienced a cardiac event and began to have problems. At that point I no longer felt competent to care for him, given his changed status and the complexity of the care he needed. But the charge nurse said she couldn't change my assignment because of the staffing situation.

Thankfully the patient stabilized by the end of my shift, but the incident really shook me up. What should I do if this happens again?-E.R., CALIF.

You acted properly when you promptly notified the charge nurse about the change in your patient's status. She's responsible for ensuring safe patient care. That means adjusting patient assignments, if necessary, to ensure that an unstable patient gets the care he needs. Understaffing is never an excuse for unsafe patient care. If the charge nurse doesn't take action, follow the chain of command to the nurse-manager, nursing supervisor, and so forth, until someone addresses your concerns.

Your hospital should have a policy and procedure on floating that covers changes in a patient's condition. Make sure you review it before your next float assignment.

Copyright Springhouse Corporation Sep 2004
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