Objective vs. Subjective

As nurses, we cannot document "this patient exhibits drug-seeking behaviors and is not experiencing any real pain at all, why the hell are we feeding their habit and allowing them to manipulate the system?"  Subjective documentation is a legal nightmare and will get you sued in a second, not to mention the fact that it may not always be accurate, as they are tainted by your perception of what happened.  All we may document is what the person says, and what we actually see.

So, this morning, my progress note looked something like this:

Pt c/o pain 8/10 "all over" and requested Dilaudid, no facial grimacing, pt smiling, laughing, ambulating in hallways with steady gait, full ROM and relaxed posture, talkative and conversational with staff, requesting snacks.  Given Dilaudid IV as ordered, encouraged to rest in bed and utilize positioning to assist with pain management, verbalized relief, will continue to monitor pain, sedation level and respiratory status.


Some physicians will prescribe the drugs just to shut the patient up.  And, if the patient states that their pain is above a certain level, and if the required span of time between doses has passed and there are no concrete contraindications for giving that dose, I must administer it.  Even when it is painfully obvious (bad pun) that they are high as a kite and horrendously addicted... even when the same pattern of behavior is seen again and again, each time they are admitted for a new complaint (which always turns out to be unfounded).

This particular patient will know the drug and the dose and how often they can get it, and they will stay up all night if they can, enjoying the high and watching the clock so that they can get their next dose as soon as possible. 

It turns my stomach.  And it also amazes me a little bit, as the large and frequent doses of Dilaudid we were giving to this person would be knocking me out into next week.  Long-time abusers build up such a tolerance...