Rate Your Pain
The control of pain could be one of the most subjective and complex assessments that a nurse has to complete. JHACO has put the patient's right to have their pain controlled on the forefront of nursing assessments. What is a nurse to do with all that subjective information?
There's all sorts of pain. There's physical, emotional or a combination of both (and probably a lot more descriptive words that can be used). The most difficult part of pain for a nurse is to put aside some of their own thoughts, and focus on patients as a whole.
Pain control is complex. So one doesn't have to go it alone. Yes, there are "drug seeker, push it fast, give me more" kinds of patients. Those are the patients who need a few more disciplines involved than a nurse with a vial. And one should not hesitate to use them, especially when it becomes apparent that your interventions are not working.
So how does a nurse do all this with a "straight face"? Like a number of things in nursing, a nurse needs to have the ability to leave out judgement. Which is difficult when on the one hand we have to educate patients on care, on the other do it without a tone that suggests distaste.
We need to remember that for the patient the pain is real. And the loss of control real. And there is real fear. This is the patient's perception, for some their reality. If pain has the ability to raise one's RR, one's blood pressure, would it also make sense that it is a real symptom that requires intervention?
I have noticed that, especially in a rehab setting, that there's a huge push for pre-medicating. For a patient to receive a prn prior to the pain "getting out of control". Using key words like "out of control" can backfire. Then you have a patient that is fearful, edgy and in constant anticipation for the other shoe to drop. And that does nothing to help a patient advance in function.
Then you have the "well, patient x was chatting and laughing and rated the pain at a 10. SERIOUSLY????". Again, needs more disciplines involved than you can provide, however, don't be so quick to judge pain on what the patient is doing just to not feel the anxiety that uncontrolled pain or perceived and/or real withdrawal can give.
Take the personality out of the equation, and follow the orders for control of pain. If you are thinking that multiple mg of dilaudid pushed every hour is excessive, then you need to speak to the MD about the plan.
Some patients do not realize there's viable options. There are patients who do realize there's viable options but choose not to take them. It is when we take the judgement out of the equation, do what we can to give a patient access to services that they may or may not take us up on, then can we be mindful of a paients needs.
Such as those in acute pain are mindful of the need to not let the pain get "too bad", chronic pain suffers are intimately aware of this idea, and both need to be medicated per order when indicated. If a patient is over-medicated, a nurse needs to respond to that. And if a patient is under-medicated the same holds true.
JHACO is very clear on the needs of a patient and the right of a patient to receive control of pain. This is when a personal judgement needs to be pushed to the side, and a nursing process be put into play. We should never be in a position to assume that all patients at the end of the day want to be medicated into oblivion, nor every patient who experiences pain and asks to be medicated are seeking some sort of high. We are not feeding addicitons. An addict is an addict. We are contolling pain.Last edit by Joe V on Jun 12, '13
Jun 12, '13As I always like to say...I am not the DEA. One can never be sure if a person is a drug seeker. I was in the emergency room one time with serious GI issues, hurting, crying and the doctor took my MOTHER outside of the room and asked if I was a drug addict. My mom went off on the doctor and low and behold..my CT scan came back with a seriously inflamed colon. After that positive CT scan they were VERY quick to medicate me...it's too bad they didn't listen to me from the start because as we all know in the ED it takes a while to get the ball rolling...drinking the contrast(which was a serious struggle), letting the contrast set it, get taken to the CT scanner, get the CT results read and well you get the picture...by the time the doctor came back with the positive CT scan and to apologize the pain had skyrocketed.
Making an assumption about a patient can be a dangerous and PAINFUL thing to the patient. Unless the patient has blatant visible track marks, I will not give medicating a patient a second thought. Some nurses I work with act like they have a quota on how many drug seekers they can spot...I don't. I treat everyone the same and if I find out later in the day that someone I gave 2mgs of dilaudid to is a drug addict..well what can you do? The doctor ordered the medication..and well at least they got their medication in a sterile environment(that said...I am NOT a drug dealer in anyway, I just stopped getting worked up about the seekers and swindlers a long time ago..not worth the aggravation)...not to mention an addict can have a TBI or a bowel obstruction anyway...
When it comes down to it..if the doctors orders pain medicine I give it...like I said and the motto I learned to live by over the years..I am not the DEA nor am I part of the SNU team(SNU=Street Narcotics Unit..I also have a criminology degree). I don't work in the ED anymore anyway(did a long time ago) the people I take care of have identifiable injuries/recovering from surgeries anyway.Jun 12, '13JHACO is very clear on the needs of a patient and the right of a patient to receive control of pain -Well, every one should know that this type of approach was lobbied by Big Pharma. The result is: 5 millions of Americans are addicted to pain meds and the first dose was obtained legally, was prescribed by a doctor.Last edit by Steve123 on Jun 12, '13Jun 12, '13By the way, second great depression is coming. This time the nation is depended too much on Big Pharma. What all those drug seekers will do when they lose access to their prescription meds such as narcotics, antidepressants and all other garbage like that? If I was a novelist I would write a futuristic novel about a nation which lose its access to medications after decades of mass dependency. Leave pain meds along, it seems that the nation would have great trouble to move bowels after long history of abusing laxatives.Jun 12, '13Quote from Steve123Do you have evidence to back up those assertions? I have never read that "Big Pharma" lobbied for patients to have pain control, resulting in 5 million Americans becoming addicted.JHACO is very clear on the needs of a patient and the right of a patient to receive control of pain -Well, every one should know that this type of approach was lobbied by Big Pharma. The result is: 5 millions of Americans are addicted to pain meds and the first dose was obtained legally, was prescribed by a doctor.Jun 12, '13Quote from Steve123Maybe not exactly what you're talking about but in Aldous Huxley's novel Brave New World the government likes everyone strung out on a drug called SOMA. Easier to control the masses.If I was a novelist I would write a futuristic novel about a nation which lose its access to medications after decades of mass dependency.Jun 12, '13Pain is what the patient says it is in my book UNTIL he or she sets the alarm on the cell phone to wake him/her up all during the night for the PRN medication intervals OR when they ask if they can get it again before I'm even done pushing the current dose. A couple of nights ago, I had a patient that I truly WANTED to keep medicating because that poor fellow practically broke every bone in his body during a MVC between his bike and an SUV. But I couldn't legally do it as often as he requested and he had LOTS of things on board including a PCA. Bless his heart, I came straight out and told him that he needed to try to 'grin and bare it' sometimes because he was already told that he was going to be discharge in a day or so and that he would NOT be taking the IV stuff home with him. Once he realized he was going to be in trouble without an alternate method of coping with the pain, he made significant progress, that night anyway, with the use of distractions and relaxation, as best he could.
When we talked later that morning, he actually thought we would make him pain free before he went home, the poor soul. I told him that it would be MONTHS before he was pain free and that he would most likely have returned to work BEFORE his pain was completely gone.
Education and alternative methods do work for those who are receptive to it. Im not one to want to hurt in any way, either, but I don't think running to grab the Dilaudid as soon as the call light comes on is the answer either. As nurses, we surely must realize that these folks take this stuff every two hours ATC for days and sometimes a week or more and then are suddenly discharged home with no 'dry period'. When they come back within the week, (after exhausting the narcotic RX), I dare say that they ARE addicted. If the doctor readmits them within a couple of days of discharge, the question needs to directed to them as to ""why did you let him go in the first place if you feels he needs to be admitted today?"
There needs to be a protocol to include detoxification for these people who have been heavily medicated for an extended period of time before they are allowed to go home. It is so sad to see otherwise 'clean' individuals turn into addicts because they came to us to 'fix' them. Our job is not complete if we can't send them home, at least sometimes, better than how they came to us.Jun 12, '13Do you have evidence to back up those assertions? I have never read that "Big Pharma" lobbied for patients to have pain control, resulting in 5 million Americans becoming addicted.
Of course, they will tell you about it at continues education class, you will not read about it in nursing text books but if you google "pain medication addiction" you will find a lot of information about it. You will find facts from honest doctors and Big Pharma whistle blowers.Jun 12, '13I think as a whole, we have been conditioned to believe we should be pain-free. Narcotic pain medications are intended to control pain, not eliminate it. There are many situations where complete relief is impossible, such as the scenario LYNDAA posted. Pain cannot be eliminated unless the source is eliminated.
However, we have to remember that managing pain is conducive to the healing process. PT would be horribly painful to many of my rehab patients, and they would be reluctant to continue without pain control - who wouldn't? But some expect to be completely out of pain at all times, even though they just had a surgeon open them up, fiddle around with their guts and staple them back together.
The medical director at the facility where I work is as careful as he can be, trying to not discharge new drug addicts. He tells his patients if their pain is uncontrollable, they will have to stay in facility until it is controllable. Nobody goes home on Dilaudid or straight oxycodone. After having this discussion with the MD, many patients are more receptive to using non-narcotic pain relievers, muscle relaxers, ice, heat and rest. Everybody wants to go home!Jun 12, '13Related comedy: Brian Regan-Hospitals - YouTubeJun 12, '13Quote from Steve123Wow Steve, what's your suggested alternative then? Get rid of all narcotics and leave all those patients writhing in pain? Snatch away all those antidepressants with which many people finally found a control of their lives?...prescription meds such as narcotics, antidepressants and all other garbage like that...
There are devastating effects on healing process if pain is not controlled. I shudder at the thought of patients denied of adequate pain meds on oncology wards or in hospice especially.
On a side note, there is no ceiling effect on opioids. A patient may receive 100mg of Dilaudid a day (an extreme example but possible) and exhibit no side effect. An opioid-naive patient might get knocked out from 0.5mg push. Calling MD should dependent on thorough assessment and history of the patient, not just based on the amount patient receives.Jun 12, '13First of all. I used to struggle with this. How can they say 10/10 and be texting and laughing and joking?!?
It's not our place as healthcare providers to decide what a patient's pain really is. We need to look at our patients as whole people and assess carefully.
I have had opioid addicted patients in my care, and I always get their baseline dose ordered. So what if they take x amount of oxycodone at home? I gave it to the guy, and he was actually comfortable for the first time in days. Other nurses, myself included, shook our heads and said "if I took that much, I'd be dead". Maybe we would, but that gentleman took that much every day and was able to function after an incredibly debilitating injury. Not my place to tell him, no he can't have it, if that's what he needs to function. And yes, FUNCTION, as in, he was not comatose or obtunded or even sleepy or out of it. He was able to make progress towards his discharge goals.Jun 12, '13Quote from tokebiWe had patients who would get that kind of narcotic between their PCA, epidural and PO meds. No joke. Oncology pain is nasty stuff.A patient may receive 100mg of Dilaudid a day (an extreme example but possible) and exhibit no side effect. An opioid-naive patient might get knocked out from 0.5mg push. Calling MD should dependent on thorough assessment and history of the patient, not just based on the amount patient receives.
Must Read Topics