burn pain management

  1. 0 Hello all. I have a question. My little 12 y/o brother has 1st, 2nd and 3rd degree burns over his chest covering about 8% of his body. He has been sent home in my care to perform debridement and dressing changes bid. I am a new grad with no burn experience. He has been prescribed Lortab 7.5 mg before dressing changes and silvadene creme. The problem is that the Lortab doesn't seem to be easing his pain at all. The majority of the burns are 2nd degree, so they are very painful. This kid weighs 115 lbs so he's not exactly small, and I just wanted to know if in your experience this is the kind of pain management that is used for such painful burns. I know it's not MAJOR, he's not an ICU pt, but he still hurts, and I can't stand hurting him. SO, is there anything else I can ask his Dr. for to control his pain? The dr. suggested motrin in between dressing changes, and that's fine, it's just during the dressing changes that my brother screams and cries. ANy suggestions would be appreciated.
    Thanks!
  2. Visit  nekhismom profile page

    About nekhismom

    From 'Where people are sanely in-sane!'; Joined Jun '03; Posts: 2,639; Likes: 15.

    19 Comments so far...

  3. Visit  renerian profile page
    0
    I have never had a burn myself but did float to burn and I really do not think Loratabs are the correct med at all. Ask for a very strong med. I hope the burn nurses taught you well.

    Poor guy and poor you for having to do that.

    renerian
  4. Visit  jnette profile page
    0
    Wow. How I hate this for you and him. Poor little guy.

    Burns are extremely painful, I've had several. I would think he should be getting something to spare him this pain. Please talk with his doc.

    It would be the compassionate thing to do for both your lil' brother AND you !

    I wouldn't want to be in your shoes.
  5. Visit  DelightNP profile page
    0
    Am I the only one that doesn't think this is appropriate? Are you providing the only skilled nursing care he is receiving, with no experience in wound care, debridement, infection control, or adequate pain management? That is not kosher at all.

    And Lortabs are ridiculous for that sort of pain. IMO, Lortabs are useless all around. I'd definitely prescribe something stronger.
  6. Visit  renerian profile page
    0
    This has happened to me twice in my life. Once the insurance company that my grandmother and dad had (both deceased) found out I was a nurse and the primary caregiver they would not cover wound care. Many lay people do dressings. In home health I had taught probably hundreds of non skilled people how to do dressings. Way of the world with short stays and most insurance companies we work with at my job pay for 1 to 2 visits for a nurse to teach a family member how to do something-that is it. Seldom have I had approved repeated visits but I sure hope some companies pay for it.

    renerian
  7. Visit  DelightNP profile page
    0
    I'm sure it can be done, I'm just not sure its the best thing, especially for a child with partial thickness burns.

    But then, I'm really rather conservative.
  8. Visit  z's playa profile page
    0
    I'm going to be HUGE on pain management when I graduate. If the pt is still screaming, the pain is not under control. No other way to interpret it. I would get the doc to explore new and stronger options for sure!
    Can't stand it when doctors tell you that the meds already ordered SHOULD be enough.

    Happy Holidays!
  9. Visit  nekhismom profile page
    0
    Thanks everyone for your responses. I am one who believes that pain is what the pt. says it is, and if they are screaming, they NEED MORE MEDS!! PERIOD!! I have no wound care experience, but the dr. flat out refused to get a home health nurse or aid or any kind of in home assistance for my brother, so my mom asked me to take care of the wounds. I questioned him about pain relief, even asked for morphine (can you tell I'm used to a hospital? ) and he said he just wanted to increase the lortab from 5 mg to 7.5 mg. :angryfire

    My poor little bro, his burn is becoming more painful every day, and he just SCREAMS in pain with his dressing changes, even with lortab and 400-600 mg of motrin.

    One more thing, shouldn't the debridement be sterile d/t the increased risk of infection? If so, the dr. never once told my mom that would care should be sterile. We learned in school that burn care should be sterile, but I know things don't always work the same way in the real world.

    Thanks again for everyone's support and answers. I wish my little brother had some of you all for nurses/NP's! Then he would have proper pain relief!
  10. Visit  nekhismom profile page
    0
    Originally posted by DelightNP
    Am I the only one that doesn't think this is appropriate? Are you providing the only skilled nursing care he is receiving, with no experience in wound care, debridement, infection control, or adequate pain management? That is not kosher at all.

    And Lortabs are ridiculous for that sort of pain. IMO, Lortabs are useless all around. I'd definitely prescribe something stronger.
    I think it's totally inappropriate, too, especially since I don't have burn care experience. I've never even been on a burn care unit! We didn't have one in my area, they were all shipped out. My brother was burned at night, so he did not go to a burn unit, so he NEVER received any skilled nursing care other than what little I can do. That makes me REALLY nervous. I agree that Lortabs are pretty useless, at least in my experience. THey certainly don't help him! Do you have any suggestions as to what I should ask his Dr for specifically? He seems really keen on the Lortab.

    Thanks!
  11. Visit  renerian profile page
    0
    Is the doc ordering the care a FP/IM/Pediatrician? Maybe he needs to see a burn specialist and I am sure that doc will sign for home health. Would your insurance cover it? You can always call your insurance company and find out if they work with a case management company and start there. Sometimes, alot of the times actually, you have to know how to work the system. People do it all the time. Start calling. You can always call the burn doc and get them to call in something stronger. I am sure they would.

    renerian
  12. Visit  nekhismom profile page
    0
    Originally posted by renerian
    Is the doc ordering the care a FP/IM/Pediatrician? Maybe he needs to see a burn specialist and I am sure that doc will sign for home health. Would your insurance cover it? You can always call your insurance company and find out if they work with a case management company and start there. Sometimes, alot of the times actually, you have to know how to work the system. People do it all the time. Start calling. You can always call the burn doc and get them to call in something stronger. I am sure they would.

    renerian
    The doctor is a general surgeon, as there are no "burn" doctors in the area, and he did not feel the need to refer my brother to someone further away or to contact home health. I asked, I was denied. I specifically asked for stronger meds than Lortab, but the dr. said "I think 7.5 mg of Lortab should be just fine for this." Even though the kid was screaming as he cleaned the burns. :angryfire

    I think I will call the Dr. yet again and BEG for stronger meds, and I will also call the insurance co. to see if they do have case mgt. Thanks, renerian!
  13. Visit  BarbPick profile page
    0
    Part of Oncology is pain control. The best drug I can see is a once daily dose of Roxonol. Liquid Ms, perfectly titrated to Mg/KG by a Pediatrician.
  14. Visit  Dave ARNP profile page
    0
    My thinking is to go with a shorter acting drug which would get him through the procedure, but wouldn't have him zonked the rest of the day. If his pain isn't a constant issue, then this could work.

    Depending on what he weighed, you could try Actiq. It's a transmucosal form of Fentanyl which would have a pretty rapid onset. My holdback on this drug is that it starts it's dosing range at 200mcg and (as I said, depending on his weight) could readily send him on the road to CS, or deeper into sleep.

    If we can't get the fentanyl dose low enough to do the trick, I would suggest Dilaudid LIQ. While MS LIQ would also do the trick here, Dilaudid would be a little better punch for severe pain I am sure he is having. This has a nice quick onset, and if given correctly shouldn't be too sedating.

    As far as an all day control medication you're pretty much stuck with either Oxycontin or MS Contin (or another time release MS). Avinza is really good, but again the lowest dose is going to be too much. I think you're going to be looking at doing OxyIR 4/5 times a day and schedule it to where he can have a constant dose.

    Finally, on Lortab. I do ALOT of pain management and I REALLY like Lortab. BUT... It is almost useless alone. Minor issues will be covered by it, but for anything severe at all, you're going to need stronger. However, when needing a PRN in combination with Methadone (AND Methadone would be GREAT in this case, but I've just never seen it used in kids) or MS Contin... you get GREAT results.

    Sorry I couldn't be more help. I don't a huge amount of PEDS pain management. My knowledge mainly applies to adults

    Dave


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