holding the pain med

[frustratedRN]

i dont understand why some docs (and nurses) do this. in fact i would love to understand and am thinking about conducting my own survey.

i have had countless patinets with MASSIVE decubiti whos wounds need suctioning and packed. sometimes there is pain med ordered and sometimes not. sometimes when the pain med is ordered the nurse doesnt give it.

ive heard the story that these dont really hurt because there are fewer nerve endings under the skin but some of these stage IV and even II look painful to me.

mostly these are patients who are non verbal. they still give non verbal signals...flinching, moaning, pulling away....but the surgeons who debride these wounds, right in the beds, dont seem to care.

i ran into a room with a syringe of morphine for a patient like this and the surgeon wouldnt let me give it.

she had no allergies, she had recieved it before, and her respirations and sat levels were good.

i still dont understand why i couldnt give it. he said....she doesnt need it....bullshit.

i assisted the most immature and nastiest surgeon ive met thus far insert a chest tube the other night.

the pt was 51 years old and an md himself.

i gave him 1 mg versed...no sedation.

i gave him 1 more mg versed....barely touched him. thats when the surgeon began to cut.

this poor guy was screaming and begging for more medication. i asked the doc if i could give it and he wouldnt answer me. i guess it had to be his idea. i didnt care whose idea it was so long as the pt got it.

finally he let me give one more.

this pt told him before the procedure he had a low tolerance for pain and a high tolerance for pain meds. and this was a doc who had a plueral effusion. he would very sparingly take percocet only when the pain got intense.

so why was this not given when i had the syringe right there filled?

when that doc started cutting and the pt started screaming i just held his hand tightly. i felt that cut too. it was terrible.

i tried to engage that doc (pt) in a conversation about freud just to divert his attention. and that worked for a while.

so here again...like so many countless times...a patient was in a great deal of excruciating pain for seemingly no reason. (he was on a constant pulse ox and his sats were good, especially for a plural effusion)

when i have to perform a complicated dressing change or some other procedure which is sure to cause pain i GET an order for meds.

then i find that other nurses do the dressing changes and dont medicate the patient. too time consuming to get the narcs i guess.

i think this is so cruel.

[tobias fonge]

Any doctor who is not sensitive to the pain of their pts might be burned out. They are a scandal to a profession to which they may not belong. How can we ignore a screaming pt's pain especially during dsg changes or chest tube insertion? That is why we nurses have to be patient advocates. The doctors might hate us for that but that is why we are there. Some body have to stand up for these poor patients who are not having effective pain management. Are we surprised when because of poor pain management, they progress from acute to chronic pain and they come all the time to get relief when we could have managed them effectively the first time?

In a situation where we have problems getting the doctor's attention to address these problems, we can forward these complaints to the higher ups all the way to the medical director. It may not do anything but at least we will know we tried.

I am back in school and they tell us a pt is in pain when they say they are. Don't they tell the doctors these things? To be fair, there are some exceptions out there who do effective pain management.

[ADN 2002]

I had a patient the other day that had separation of the symphysis pubis as a result of childbirth. The pt was a really sweet, Spanish speaking lady in a LOT of pain (if somebody breaks your pelvis, you have pain, right?) I came in (I am a student) to take care of this pt and the family needed an English speaking person to talk to somebody on the phone, so I took the phone and it was the pt's sister wanting to know why the pt had not had anything but Tylenol #3 since the birth of the baby (she was about 24 hrs postpartum). I told the sister and the pt and family that was present -- very limited English between the three of them -- that I would check and see what was ordered for the pt. I was not shocked to see prn orders for Percocet and Demerol, neither of which had been given. What's more, the pt is not breastfeeding, so it doesn't really matter what they give her at this point b/c it won't hurt the baby. They just hadn't given her anything, I suppose b/c she could not ask specifically for a stronger med - but the look of pain on her face was at least a 7 or 8 out of 10.

I rounded up the pt's primary nurse and got her a dose of Percocet - and it made a world of difference. Needless to say, the pt and family really took a liking to me...

It's scary, though how pain goes unmanaged. I myself was on the wrong end of the stethoscope this past June when I had my gall bladder out. They wheeled me out of the PACU as I was coming to and I started screaming in pain. When I got up to the floor, my nurse saw how I was acting and how uncharacteristic it was of me to be behaving that way and immediately checked my orders for pain meds. A couple minutes later, she brought me 25 of Demerol, which by the time the drug started working, I was much better and starting to drift off again. After I got out of the hospital, just out of curiosity, I got my records and found I had only been given 25 of Demerol in the PACU - I could have safely been given more, given my documented RR and overall status at the time.

Even though I wasn't insensitive before, I have found myself to be more sensitive to the pain needs of patients (whether they need ice, heat, meds, whatever) since this experience. I think that many health care workers need to experience something like that to let them know that pain really is what the patient percieves it to be.

[Ted]

Our small community hospital is about to be visited by JCAHO next year. The administration's main focus has been implementing effective assessment and management of pain for all patients who enter our happy little doors. The nurses and doctors are getting tons of inservices on the subject. (Unfortunately, we're getting bombarded with tons more paper work . . . but that's another topic for another discussion thread.)

I've always believed strongly in providing effective pain management. When I worked in hematology/oncology, I've seen a number of patients die extremely uncomfortably despite everyone's best efforts to control the metastatic pain. At least the physicians and nurses of that particular unit tried to control the pain through gallons of morphine and dilaudid gtts and other medications, pain management consults, warm packs, diversional activities, etc . . . At least we tried!

It pisses me off when physicians and nurses don't or won't even try . . . for any reason.

I don't want to "preach to the choir" as I read other people's frustrations surrounding ineffective pain management.

Anyhow, since my hospital is bombarding us with tons of last minute inservices regarding pain management (and other JCAHO issues like restraints, etc), I thought I'd share some "inservice misery" about pain management "ala JCAHO":

http://www.jcaho.org/news/pain_kit_2001/index.html

http://www.jcaho.org/standard/pm.html

I actually read the articles . . . :)

Cheers,

Ted Fiebke