[michelle126]

Have a pt with neck ca with mets to brain. Major pain issues that I think we are under medicating. Since he is NPO all meds are IV push, transdermal, GTube or SL. Right now he is somewhat confined to the nursing home because of the need for frequent IV push prns.
We've been upping his Diluadid and he is now at 10mg every hr and prob takes it at least 16 times a day, MS IR 80 mg at least 10 times a day and of course the 400 of Fentanly. I think we can be managing his pain with a pca or drip better. Do any of these meds reach a max where they are no longer effective? Trying to get a pain referal or at least an onocologist who might have a better treatment plan.

Any input?

[Griff1950]

Opiods have no ceiling dose.

[Griff1950]

Question re: Fentanyl patch? I assume you are changing the patch at the recommended 72 hr. intervals? If so, is there an association of this time period with breakthrough pain? There are some new studies of Fentanyl transdermal dosing that suggest a 48 hour interval works better than increasing dosage amounts.

[zooparade]

Sounds like u definately need a pain management referral for this pt. Problems come in when we use multiple opiods to cover pain. Also the fact that this pt. is experiencing so much brealthrough pain that he needs 16 extra doses of Dilaudid and 10 extra doses of MSIR. Is the pt. on any adjunt meds for other types of pain? ie ativan, elavil, NSAIDS, etc? That would be my first question. Then, why are we allowing this pt. to suffer through having to ask for pain meds 26 times a day. Although it is true that opoids have no ceiling, this just sounds like bad pain mgt.

[KarenGeorgeBSRN]

Good Morning!

Based on respirations, speak to the physician about decreasing the time of Duragesic patch change. An inverse relationship is noted; many on hospice care are cachetic and lack SQ fat; Fentanyl must be absorbed into fat and tiny blood vessels to then distribute to the body and eventually the brain. It takes a good six hours if the patch is properly placed (try the flank area or waist not bony area), and this might be a true help for this client.

48 hours may do wonders!

Thanks,

Karen G.