Pain management approach

Specialties Emergency

Published

Looking for some input.

In my ER, they stress pain control big time. We are supposed to do all we can to manage someone's pain adequately. My question, though, is how do you chart on a patient whose pain has not been controlled, but the MD won't give additional orders. Of course I am chatting that I have spoke to the provider and no new orders were given, but what do I chart for my hourly rounds where I'm supposed to reassess pain? Do I chart every hour that the patient is in pain and the MD is aware? Doesn't this look like I'm not doing enough, like maybe I should be going further? And what about those patients that tell you they are in pain, but look very comfortable? I know that a patients iOS is what they report it to be, but when it comes to charting, I never really know what to write! It's tricky, because I don't want to chart that they are in pain every hour, but let it look like I'm not doing anything......but when the doc says no to any mess, I'm stuck. What do you chart in a situation like this?

any input would be great. Thanks!

Specializes in Emergency Dept. Trauma. Pediatrics.

You chart something like: Patient rates their pain an 8. Doctor Who notified, no new orders at this time. Will continue to monitor.

You can offer some none pharmacological interventions and chart that you did that. But outside of notifying the doctor and charting you did, there isn't anything that's going to fall on you regarding more meds. You can ask again when the patient asks again.

In cases where the patient continues to ask for meds and the doc refuses, I make the doc go in and explain or talk to the patient to tell them they aren't getting anymore pain meds and why. I will chart the doctor notified the patient of no more pain medication at this time.

3 ways to chart this:

  • Pt in room stating pain is 8/10. Notified ER MD, no orders received.
  • Pt resting in room playing on phone in no apparent distress. Pt states pain is 8/10 and immediately goes back to playing on phone. ER MD notified of pain level, no further orders given.
  • Pt lying in bed, in obvious discomfort, crying, wincing, ect, states pain is 8/10 and getting worse, noted change in V/S to correlate with increase in pain. Notified ER MD of pain and obvious patient discomfort, multiple requests for more pain medications denied at this time, no reason given.

Which sounds like you did what you could? The first is just a statement. The second and third describe what you saw and assessed, as well as the physician being notified and what happened because of that information.

And the big problem is your second sentence "We are supposed to do all we can to manage someone's pain adequately. ". Who determines adequately? The pt, you, the physician? Most patients will not be pain free, not possible in most cases, but that is what they want. I always tell my patients our goal is to not get you pain free, it is to get you more comfortable (not comfortable, more comfortable than they are initially).

I just ask the MD why are we not giving pain meds. They usually have a reason. If so, chart it and tell the patient. Many times there is a valid short term reason why not, but other times, they are just being a jerk for whatever reason. If they are being a jerk, I ask them to go explain to the patient why they are not getting more pain meds.

amzyRN

1,142 Posts

Specializes in ED, Cardiac-step down, tele, med surg.

"MD aware, no new orders". Hospitals are pushing this pain management thing because survey scores are low due to uncontrolled pain. Yet, it's not always possible to control pain completely in every instance. That is an unreasonable expectation. Medication may make the pain more tolerable, but it's not going to always get rid of the pain entirely.

I am so tired of this push to medicate pain to the max. It sucks to have to reverse it if you give too much. You could document that you repositioned the patient, or gave an ice pack, or used distraction, those are nursing interventions that don't need an MD order.

JKL33

6,768 Posts

First things first:

1) As mentioned above, prepare the patient for what to expect. I think this is super important because it is a bit of a comfort to someone in acute pain, and a bit of advanced notice (albeit kindly stated) to someone interested in playing games. I tell everyone that "most times we aren't able to make people pain-free, but I hope to take the edge off and help you get some relief while we investigate what's going on."

2) Re-eval - also choose words carefully. "The pain medication I gave you should be kicking in, what number would you say your pain is down to now/are you starting to get a little relief?" We often have a pain med order with PRN option that can be dosed 1-2 additional times. If, clinically, the patient doesn't appear much improved and reports little change in pain, I will proceed with the PRN meds in addition to whatever comfort care I can do to try to help. OTOH, if it looks like we're heading down the awful game-playing road (you know the signs, I'm not going to write them out for the community at-large to pick apart...), I will say, "I'm sorry to hear that the Dilaudid didn't change anything at all...usually it starts to take the edge off the pain at least a little bit. Let's talk to the doctor and see if there's anything else we can try since the narcotics didn't help as much as I'd hoped". Inform provider. It should go without saying...all communication must be calm/neutral, compassionate.

As far as how to document these things. With careful evaluation of the pain, giving the meds, providing non-pharmacologic interventions, and communication techniques like those I mentioned, more often than not there is a reduction in pain that I can show/document using the 0-10 scale. If someone's in acute severe pain, usually I'm at the bedside doing other things and re-dosing pain med until the patient is more comfortable (both observed and reported). Then I document the improved pain level.

On the other end of the spectrum. Every once in awhile I do the 'no new orders' thing, but I'm kind of going away from it unless the situation really calls for it. Malingering does not require me to make the chart read as if the provider did something wrong. I'd rather document clinical observations and be done with it. I'm from the pre-EMR era, and I still find some of our old phrasing accurate and thus useful. So, if after 2 shots of Dilaudid the pain report is 10+, I chart "10" and attach a comment like these:

-Relaxed on stretcher w/ HOB elevated, using personal electronics/talking with visitors at bedside. VSS. No acute distress observed at this time. Awaiting lab results. Will continue to monitor. Requests snack - given.

-Resting w/ eyes closed, left lateral recumbent. Reps even/sonorous. Reports no improvement in pain when awakened by writer. Physician notified. Pt informed of plan to continue period of observation and hold on additional meds for now. Additional warm blanket given.

- Laughing/animated conversations with visitors at bedside, no acute distress noted at this time. Requests additional pain medication. Physician notified and states plan to re-evaluate after CT report received. Pt updated on plan. Denies any other needs at this time.

Yes, these are wordy compared to current norms, but fill in your own patient's situation and can you see how you can convey the situation without sounding judgmental?

Lastly, if pain relief interventions truly are not working, I ask the physician to come and re-eval.

2) Re-eval - also choose words carefully. "The pain medication I gave you should be kicking in, what number would you say your pain is down to now/are you starting to get a little relief?" We often have a pain med order with PRN option that can be dosed 1-2 additional times. If, clinically, the patient doesn't appear much improved and reports little change in pain, I will proceed with the PRN meds in addition to whatever comfort care I can do to try to help. OTOH, if it looks like we're heading down the awful game-playing road (you know the signs, I'm not going to write them out for the community at-large to pick apart...), I will say, "I'm sorry to hear that the Dilaudid didn't change anything at all...usually it starts to take the edge off the pain at least a little bit. Let's talk to the doctor and see if there's anything else we can try since the narcotics didn't help as much as I'd hoped". Inform provider. It should go without saying...all communication must be calm/neutral, compassionate.

We very, very rarely get PRN orders in our ED, and if we do have them it's likely because the pt is a behavioral med pt awaiting placement, or it's a pt with admit orders and they're awaiting a bed assigment. We SOMETIMES get an order to repeat a dose x1 prn but that's usually for zofran. I will say though that I feel very fortunate to have very responsive docs, who if you have a request, they will either provide orders for pain meds or give you a reason why they're not going to, and if the patient is, shall we say difficult, they will go and explain to them why they are not ordering either initial pain meds or more (unless the crap is hitting the fan with another patient).

Guest219794

2,453 Posts

I think a large part of it your actual assessment of the PTs pain. Not the number chosen. If you believe the PT is in pain and should be treated, you should advocate, and document that you did so. Personally, I don't advocate for a PT based on a 1-10 scale. I find it an occasionally useful tool that is way overused.

I also think we make things worse when we re-assess knowing there will be no more narcotics.

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