[nurse kratchet]

here's my problem. i have a res. which i'm pretty sure has bone ca. a month and a half ago this women [an old RN i might add.] was up excersizing doing leg lifts at the rails in the hallway everyday knew what day her b-12 shot was due etc.. took tylenol q day and on the bad rainy days ultram. now all of a sudden she's c/o R flank pain dx uti. hospitalized 3x's and always came back with the same dx. hospital couldn't run tests d/t her pain came back inconclusive[bone scan] she has lost 30 lbs. thus far and continues to lose weekly. drinks all of her supp. when she downs her pain medication. i have never seen nothing like it she sceams out in excrutiating pain most of the time and when she does she is just jumping all over the place. now i know your going to say kidney stones but none were found. her color is so grey and her eyes are even bulging from the pain. recently had a ct and was seen by neurology suggested a mri. i hope the md agrees because he said no to a emg when asked per pt for another bone scan. have no dx for hospice and today i had the don call him for same he said no because then he could not hospitalize her????? all this women is on is ultam 50 q4 and tylenol. all i want is something to make her comfortable!!!!! can't call medical dir. he's it!! any suggestions because i can't see her like this much longer .

[Sleepyeyes]

Persistance is the key here because the severity and intractibility of the pain are the clues that the Patient has a pain problem that is not being addressed.

Some Dr's tend to focus on the source of the pain. Other Dr's (string 'em up!) focus on the rationality of the pain--that is, they judge whether the patient's condition is a likely pain source and Rx accordingly.

Both are wrong. They do not address the problem because they are not seeing the pain as the problem.

Emphasize to Dr. that regardless of the source of the pain, and regardless of whether he believes her, the patient has certainly got a lot of pain that her usual med is not covering and that she needs something more until the source of the pain is dx'd, if nothing else because the staff can't handle her ADL's without causing her to go through the roof. Let him know that it is (sigh) your job to phone him or on-call whenever Pt. c/o "severe, intractable pain" or exhibits s/s of "severe intractable pain" such as "grimacing, immobility, irritability, refusal of care, crying, depression" and that according to the nurse's notes, this patient's pain began X days ago, and can't we get her something on a prn basis?

Read to him from the nurse's notes. Make sure he knows there are a lot of nurse's notes on this problem and his previous responses have been documented.

If he refuses increase or change in meds, ask why not. Chart the conversation and "no new orders" and why. Confirm with him, "OK so I will just document for the 4th time this week, no new orders, because I do have to document on this, as you know."

Continue to chart patient pain, responses to passive pain control teaching, and MD response qs or prn.

Repeat prn

Keep calling doc with the same litany. REMAIN CALM AT ALL TIMES. This will give him the impression that you don't care if you have to call him 30 times a day, you will. Direct any behaviors that interfere with getting the pt. her pain meds (cursing, name-calling) back to the original problem. (After you get the Rx, have a chat about that, but not before. )

But the main prob here is to persist on behalf of the patient. This isn't a popularity contest, this is patient advocacy.

(I've done this happen so often in LTC, it makes me wish for a book called "CYA Clinical Procedures Made Easy" because the family/patient could sue the NH and win if her pain issue is not adequately addressed.)

Good luck, and let us know what happens, please?

[aus nurse]

So well said sleepyeyes. What excellent advice and I can not add anything that you have not covered.

Exactly what I was thinking when I read this post. The problem here is that this resident does not have adequate analgesia.
The issue of a diagnosis for the pain should then be secondary.

Keep advocating for your resident nurse krachet..thank goodness for nurses who care.

[nurse kratchet]

res.doing much better today.because she was finnally medicated continuosly throughout previos shifts.oh and i forgot she has a duragesic 50mcg which doesn't help. and quinine sulfate260mg the goofy nurse on 11-7 though gave the quinine out of compliance it's q 12 and she gave it last night @0100 when it was just given @2100 md was supposed to come and see her today but never showed he did order sed rat ,hemogram u/a and an aa titerwhich im unfamiliar with if someone can get me some info on that i'd appreciate it. she really made me feel good though at the end of the shift when wanted pain meds and wouldn't let any nurse give it to her but me it makes me feel good because now i know that she realizes i.d do anything to help her. and as far as the charting goes it's there! but i have to keep after the RN sup to get after the doc and alot of the times i get i called him and he doesn't want anything else.so thats why i had to go to management but i will continue to be my res advocate till the she passes PEACFULLY! thank you for just being there and helping me with this .

[rachyrach]

sleepyeyes is right, persistance is the key. You seem to be your pt. only advocate right now. Keep driving people nuts until you get someone to listen to you. Good luck to you and your pt.

[oramar]

Have things changed that much in 2 years? When I worked medsure/telemetry not to long ago hospice patients were sometimes admitted for sever, intractible pain. That was an acceptable admission diagnosis back then.

[nurse kratchet]

well i finally found the source of res pain ,spinal stenosis,degenerative discs with fragments located in the spinal canal,osteomylitis.res on duragesic 125mg and also had a spinal block. doing much better now! thanks for all your concern!

[sunnygirl272]

Originally posted by oramar
Have things changed that much in 2 years? When I worked medsure/telemetry not to long ago hospice patients were sometimes admitted for sever, intractible pain. That was an acceptable admission diagnosis back then.

unfortunately, pain control is no longer a reimburseable diagnosis...a kind doc will fudge one. even when the real one is pain control. home-based hospices will have pt admitted sometimes for respite, but this is usually to a nursing home with whom they have a contract.

[shygirl]

Get duragesic patches and a prn morphine order.

[hpyrn]

I just finished a 8 hour pharmacy inservice at the hospice center that I work at. Duragesic patches are expensive,do not give ongoing pain relief, take 12 hours to work and 12 hours to stop working. We use alot of mso4 SL and are starting to have tremendous results with methadone. Docs are kind of resistant to this but they have to be reminded sometimes that there are other drugs out there besides duragesic and oxycotin. Good Luck!