My eyes may be closed but I'm in pain - page 2
by nkochrn 4,456 Views | 15 Comments
I just awoke and opened my eyes for only a split second to barely be able to make out the face of my recovery nurse. I feel so weak and powerless right now, the anesthesia must not have worn off yet. She just asked me if I want... Read More
- 0Nov 8, '12 by CapeCodMermaidAlways better to err on the side of giving the pain med. Sometimes people in excruciating pain are dozing because they are exhausted.
I don't show pain on my face and have a high tolerance to most kinds of pain, but I get cellulitis every so often and am in agony. Luckily I have a fabulous doctor who writes for what I say works and the nurses for whatever reason don't argue if I tell them I need 2 percocet every 4 hours the the first 16 hours and then PRN.
- 2Nov 9, '12 by Perpetual StudentMy mindset is to look for reasons to not give pain meds, not reasons to give them. Those reasons are rather exceptional--completely unresponsive, denies pain completely (even then I'll give something PO before transferring the patient and continue to reassess), respiratory rate less than 8 or otherwise completely inadequate such as with sleep apnea, maybe BP if it's really lousy but I'd just treat the pain then correct the BP most times. Otherwise, I consider it my job to give as much relief as possible without unduly compromising safety.
I'd rather have a patient that's too sleepy than one that hurts too much. I can always let 'em wake up a touch prior to transfer if necessary.
Some folks fail to consider how often the patient may be drowsy due to drugs such as benzos, antihistamines, or even lingering gas if it's shortly after arriving in the PACU, etc. yet have uncontrolled pain. As mentioned, you can look at the heart rate, but don't forget that it's just one piece of the puzzle. You might not see much of a bump in the beta-blocked patient, nor will the tachycardic patient necessarily be hurting. Also, in chronic pain there generally isn't much change in heart rate.
- 3Nov 9, '12 by *LadyJane*Some patients may be trying to practice self-hypnosis, or trying to escape into a painless part of their mind. I have done this when a patient, post surgery. A nurse came up, put her hand on my forearm without saying anything, to see if I was awake, I opened my eyes and looked at her, so she asked me how I was doing. I said, a lot of pain! She was puzzled because I was so still. (I was so still, because I was trying not to breathe because it hurt so bad to breathe), and was excruciating to move in the slightest, so I was perfectly still.
She would have thought I was resting quietly, except she put her hand on my arm, and asked me. Thank god she did. She called the doc, and got the PCA order turned up. God bless her!
- 0Nov 9, '12 by wannabecnlThank you for this post! It is a good reminder for anyone, but as a newbie in the PACU, I'm especially grateful for the guidance. Yesterday I had a patient who was a good example of how there are closed eyes and then there are closed eyes, if you know what I mean. This lady came out looking drowsy; she was arousable, but otherwise never opened her eyes. She wasn't wrinkling her forehead or making any noise, but she did look stressed somehow. Her pain went from 4 to 5; I gave 2 of morphine to see if we could reverse that trend. The pain went to a 7. 4 more of morphine, and then her face (eyes still closed) changed completely. No more stress in her eyes when she looked at me, no more edge to the set of her mouth. We got her pain down to a 2 or 3. It went back up again after an hour, but by then she was on a PCA pump, which I think will work great for her.
Anyway, the differences in her features between her two expressions were subtle, but taken all together, the change was remarkable. It had almost nothing to do with sleep or eyes being closed. Most of my patients in pain don't fall asleep, but the exceptions need pain control, too. Thanks again for this reminder.
BTW, I'm finding facial expression to be more helpful than pain score for some patients; this woman's 4 looked a lot worse than other people's 6 or 7, and at 7 I was expecting her to say 10! This is why I advocate the use of comfort goals--asking the patient what number they'd like to try to get to, knowing that 0 is not always possible. There's some really good literature out there, and it's in the ASPAN pain management guidelines. But I digress...
- 0Nov 10, '12 by echoRNC711[QUOTE=Perpetual Student;7023963]My mindset is to look for reasons to not give pain meds, not reasons to give them. Those reasons are rather exceptional--completely unresponsive, denies pain completely (even then I'll give something PO before transferring the patient and continue to reassess), respiratory rate less than 8 or otherwise completely inadequate such as with sleep apnea, maybe BP if it's really lousy but I'd just treat the pain then correct the BP most times
Respiratory rate of 8??? Is that a typo? Am I misreading this...you would give pain meds to someone with RR of 9?
- 0Nov 10, '12 by Perpetual StudentYeah, I would assuming they're complaining of significant pain or showing signs thereof. I'd give a smaller dose (perhaps 25 mcg of fentanyl) at increased intervals (10-15 minutes) until the patient reported relief or became too sedated. I would also be sure to give meds like ketorolac or acetaminophen. I'd coach in deep breathing to ensure adequate ventilation, of course. And would let the patient recover and be breathing adequately without coaching prior to transfer. To be clear, the quoted statement was with the immediate post-operative patient in mind who is still sedated due to agents other than opiods and who is being closely cared for in the PACU.
Sometimes these patients end up with a protracted PACU stay, but I believe that's better than just saying "tough luck buddy" and shipping them to the floor with uncontrolled pain. I would certainly agree that in other contexts it would probably (but not always) be inappropriate to administer opiods to someone whose respiratory rate is 9.