Comfort Care

The physician usually orders a dosage to begin with. You can increase the dosage every 30 - 60 minutes to get the desired effect of pain control that your patient needs. Possibly more often at the beginning, then back off once patient is more comfortable. I usually only go up 1-2 cc/h each time. It depends on the patient. Check your policy at your facility.

HTH

general guidelines are increase for respirations above 30 and signs of pain, asking for more pain meds, grimacing, restless behavior, anxious behavior, yelling, abusive behavior without being stimulated. I reassess every 5 minutes with a morphine drip as it takes a short time to be effective when IV,then increase as needed. If I see no change I go up again, if I see a small change I reasses in a few minutes then go up again if still in discomfort. I usually go up in 5mg increments each time I assess a behavior of need. Comfort measures means to me, not uncomfortable but not necessarily unconscious. The difficult issue here is personal ethics, are we actually helping or hindering the inevidible death of this patient. I believe in Death with Dignity, that allows a person to die in the manner they are comfortable with. If a patient says just let me sleep, I do that, if I am asked to talk to them I do that too. Just call the supervisor and tell them that your patient needs constant attendance during this time of near death and has requested it. Please send some help for a while until family or someone else, clergy etc can relieve me.

I am a nursing student and yesterday when I was in my clincal rotation through the coronary care unit I had my first patient who was on comfort measures only. I was wondering how do you observe pain in a patient who is almost in an unconscious state. The nurse that I was shadowing used two techniques, one is to push on the nail bed to see if there is a pain response or to push on a nerve right below the eye brow. I would like to know what other techniques you might use to ensure that the patient is not in pain although they are unresponsive.

JB, what you mention seems to be more of a neuro assessment of whether or not the patient is able to respond to pain. When dealing with comfort care, it seems to me borderline unethical to cause pain during an assessment.

When I have a patient on "comfort care", I use several assessments. The first is how the patient reacts during cares and turns. Moans, cries, or grimaces are all indications for increased medication. Vitals are a second assessment (increased heart rate, BP, or respirations), however "normal" vitals do not contraindicate medicating for pain. Families are a good source as well. Sure, we sometimes get annoyed by them, and they sometimes over-react, but they generally have a good idea when a family member is in pain and might need more medication.

Let's not forget complimentary therapies as well. Backrubs, fans, and gentle conversation might help. I find light aromatherapy very effective (the scent of benzoin is very calming). Music therapy can help too (be sure to ask what the patient likes to listen to -- don't assume!) All of these things can help ease pain. Not that you want to abandon the medication, but complimentary therapies may allow you to use less medication to maintain the same amount of analgesia.