Sickle Cell Crisis and pain management?

  1. 4 I work on a busy med-surg floor and recently have taken care of several patients aged 28-37 with sickle cell crisis. When I receive report from other nurses on these patients, it is always the same story - they say they are drug seekers and that they bring the crisis on themselves by getting dehydrated on purpose to make their retic count increase so they can come to the hospital and get drugs. Most of these patients are on lots of pain meds (sometimes a PCA plus breakthrough meds, sometimes PO plus dilaudid IV Q2h) and when I assess they appear to truly be in pain. I am a new nurse (5 months) and want to know your thoughts on sickle cell crisis. I tend to medicate them as much as they want (within order guidelines and if they appear in pain - I don't medicate them if they are sleeping etc, but if they call for meds and rate their pain above a 5 and it is time I will give them the meds). The night nurses get mad at me because then the patient is used to me giving them consistent pain meds and the night nurses tell me to make the patient wait for longer intervals.

    I read up on sickle cell crisis and it seems like the pain would be crippling. Any insight on this? I desperately want to be a patient advocate yet at the same time I don't want to be a sucker/enabler for drug seekers. I don't see why a person would bring it on themselves?

    Thank you!
  2. Visit  Lola77 profile page

    About Lola77

    From 'Tampa, FL'; 37 Years Old; Joined Feb '09; Posts: 104; Likes: 218.

    11 Comments so far...

  3. Visit  kfarinato profile page
    7
    I think you are doing the right thing. As nurses in general we are not supposed to judge pain. It is what the patient says it is. Medicate within the orders and let the other nurse's comments roll off your back.

    Patients in sickle cell crisis also need fluids, so staying on top of that is a good thing too.
    Zookeeper3, leslie :-D, SharonH, RN, and 4 others like this.
  4. Visit  General E. Speaking, RN profile page
    2
    We currently have two patients on our floor in sickle cell crisis. I, too, find that they are immediately "labeled" drug seeker. You know they must have a tolerence to narcotics because of repeated admissions. This is afterall an expected outcome of longterm narcotic use. I am sure that some of those that come in are somewhat seeking but this is not my place to judge. I saw one of our patients had a lab test that determined what percentage of cells were "sickled". I think I am correct. His was 22%. Now I am not familair with what percentage causes more pain, etc... however, it still comes down to pain is what the patinet says it is. I will try and manage their pain. Anticipate there needs and if they are not over sedated and it is time, I will medicate.

    It is a difficult patient to care for. You did just fine.
    Last edit by General E. Speaking, RN on Mar 25, '10 : Reason: afterthought
    SharonH, RN and MinnieMomRN like this.
  5. Visit  PurpleLVN profile page
    5
    I'm usually a very calm, rational nurse but I've got to speak out!!! Although I do not have Sickle Cell, I do have several young relatives that SUFFER from the disease. This is a very painful disease and unless you've experienced or have actually seen a crisis, then a person will NEVER understand the extreme pain and anguish these patients go through.
    I'm sorry but this idea of questioning if these patients are "drug seekers" really p's me off. Purposefully dehydrating yourself-get real. There's even debate regarding just how much water an individual needs anyway.
    OP, you are correct in not "judging". I know it can be difficult assessing and treating "pain" in all types of pt's. I think you're doing a great job!!!
    Zookeeper3, leslie :-D, SharonH, RN, and 2 others like this.
  6. Visit  General E. Speaking, RN profile page
    1
    Quote from PurpleLVN
    I'm sorry but this idea of questioning if these patients are "drug seekers" really p's me off.
    I hope your comments were not directed at me. When I said some may be drug seekers in my post, I meant it in a general term as with any admission for any diagnosis with any patient. I, too, despise the reporting off to other nurses about their suspicions. When I hear in report that "they watch the clock and ask for pain meds on the dot" my response is "wow, they really must need their medication then because they are in pain".

    We have actually started a new Pain Mgmt team with nurses and doctors at my hospital. I am excited to see what we can accomplish with this group and to try and put a stop to the preconceived notions and judgments regarding pain management.
    PurpleLVN likes this.
  7. Visit  Kooky Korky profile page
    5
    Many moons ago, I cared for Johnny, a repeat patient in our ER, who had sickle cell anemia. If Johnny was faking, I'm the man in the moon. And I am not the man in the moon.

    This poor guy was in so much pain, crying, holding himself stiffly since it hurt to move. And his parents suffered right along with him. It tore my heart out.

    I really would like to kick the behinds of those smug idiots who call themselves nurses where you work, lola77.

    Next time someone tells you that a patient is drug-seeking, ask them how they know that the pt is faking or induced the pain intentionally. Just a simple "how do you know that?". Of course, they'll give you an idiotic answer. Just take care of the patients, try to inform and teach your hateful coworkers, and try hard not to be as mad at them as I am. May they develop some painful disease, that no one can diagnose, that lasts much longer than anyone thinks it should, and have no one believe they're really suffering.

    General, when I had surgery, I watched the clock, too. And asked for my pain med about 30 minutes before I thought I'd get it. Why? I knew it would take time for the nurse to find the narc keys, answer a couple of lights along the way, grab the narc, run up and down the long hallways, and finally give it to me. One jerk of a nurse told me that I could not have anything other than what was ordered, even though I had developed an extremely serious complication. Of course, the surgeon didn't think to increase my pain med. I told the nurse to please call him, she refused, I had to get DON involved, as I was really in agony.
    Last edit by Kooky Korky on Mar 25, '10
  8. Visit  PurpleLVN profile page
    1
    Quote from General E. Speaking, RN
    I hope your comments were not directed at me. When I said some may be drug seekers in my post, I meant it in a general term as with any admission for any diagnosis with any patient. I, too, despise the reporting off to other nurses about their suspicions. When I hear in report that "they watch the clock and ask for pain meds on the dot" my response is "wow, they really must need their medication then because they are in pain".

    We have actually started a new Pain Mgmt team with nurses and doctors at my hospital. I am excited to see what we can accomplish with this group and to try and put a stop to the preconceived notions and judgments regarding pain management.
    I'm sorry General E. Speaking-not directed at you, OP or anyone other poster!! I saw a thread a few weeks ago where the OP was venting about Sickle Cell patients "faking" their pain and I regretably did not address that OP at that time. I was so angry that I didn't want to say something out of anger. No worries!!

    I actually think your facility should be commended for the Pain Mgmt team!! Wish you the best of luck!!
  9. Visit  meadow85 profile page
    1
    I'm with you. Pain is subjective. If the patient says he/she is pain then you have to assume he/she is in pain. If you felt they were drug-seeking then I would bring it up with the physician.
    Last edit by meadow85 on Mar 25, '10
    SharonH, RN likes this.
  10. Visit  SharonH, RN profile page
    2
    The nurses you work with are jerks. The idea that someone would deliberately subject themselves to the crippling pain of a SCC just to score some Dilaudid is so offensive , it is difficulty to respond civilly. As I wrote in the other thread, it seems that no other group with chronic illness is treated with as much suspicion as those with SCC except for known drug addicts. Do not let yourself become contaminated by those vipers. Continue to medicate your patients in a timely and compassionate matter and distance yourself from those who would attempt to cloud your mission to help restore your patients back to their normal state of health. You will never become a great nurse if you follow their lead, trust me.
  11. Visit  Bklyn_RN profile page
    0
    An inconvenient truth is that there are sicklers who have become addicted to highly addictive narcotics (read the drug info insert for dilaudid etc). Also a sickle cell crisis can be as painful as narcotic withdrawal symptoms. I do not know if they would intentionally dehydrate themselves. However as JCAHO mandates, patients reports of pain are to be given the highest priority. So as long as there was a valid order...
  12. Visit  General E. Speaking, RN profile page
    0
    Quote from Bklyn_RN
    An inconvenient truth is that there are sicklers who have become addicted to highly addictive narcotics (read the drug info insert for dilaudid etc). Also a sickle cell crisis can be as painful as narcotic withdrawal symptoms. I do not know if they would intentionally dehydrate themselves. However as JCAHO mandates, patients reports of pain are to be given the highest priority. So as long as there was a valid order...
    I often wonder after getting Dilaudid 3mg IV Q2 hrs for x amount of days then suddenly being taken off it, how it affects you. We try and decrease the amounts to wean. I don't recall anyone going home on any kind of maintenance narcotics. After the crisis is over the pain should cease? Correct? It has to be difficult because it is withdrawing...
  13. Visit  NRSKarenRN profile page
    5
    Please remember that in sickle cell disease, acute crises involve vaso-occlusive pain episodes often with tissue ischemia occurring.


    sickle cell disease pain management:
    evidenced-based clinical practice guidelines
    enhance health related quality of life
    http://www.aspmn.org/conference/docu...scd1stpres.pdf


    the vaso-occlusive crisis, or sickle cell crisis, is initiated and sustained by interactions among sickle cells, endothelial cells and plasma constituents.1 vaso-occlusion is responsible for a wide variety of clinical complications of sickle cell disease, including pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.

    a vaso-occlusive crisis is initiated and sustained by the interaction among sickle cells, endothelial cells and plasma constituents. clinical complications include pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.

    acute pain in patients with sickle cell disease is caused by ischemic tissue injury resulting from the occlusion of microvascular beds by sickled erythrocytes during an acute crisis. chronic pain occurs because of the destruction of bones, joints and visceral organs as a result of recurrent crises. the effect of unpredictable recurrences of acute crises on chronic pain creates a unique pain syndrome.2,3

    acute bone pain from microvascular occlusion is a common reason for emergency department visits and hospitalizations in patients with sickle cell disease.4 obstruction of blood flow results in regional hypoxemia and acidosis, creating a recurrent pattern of further sickling, tissue injury and pain. the severe pain is believed to be caused by increased intramedullary pressure, especially within the juxta-articular areas of long bones, secondary to an acute inflammatory response to vascular necrosis of the bone marrow by sickled eythrocytes.5 the pain may also occur because of involvement of the periosteum or periarticular soft tissue of the joints.

    the approach to pain control must include measures to treat acute pain crises, prevent future vaso-occlusive crises and manage the long-term sequelae of chronic pain that can result from multiple recurrent bony infarction.

    [FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]T[FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]he [FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]m[FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]anagement [FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]of [FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]s[FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]ickle [FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]c[FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]ell [FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]d[FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman][FONT=yaaaaa+frutiger-roman]isease
    [FONT=frutiger-bold]tolerance, physical[FONT=agaramond-regular] dependence, addiction,[FONT=agaramond-regular] and pseudoaddiction
    [FONT=agaramond-regular]a major barrier to effective management of
    [FONT=agaramond-regular]sickle cell pain is a lack of understanding of
    [FONT=agaramond-regular]opioid tolerance, physical dependence, and
    [FONT=agaramond-regular]addiction. tolerance and physical dependence
    [FONT=agaramond-regular]are expected pharmacologic consequences of
    [FONT=agaramond-regular]long-term opioid use and should not be confused
    [FONT=agaramond-regular]with addiction.

    [FONT=adobepistd]■ [FONT=frutiger-bold]tolerance [FONT=agaramond-regular]is a physiologic response to the
    [FONT=agaramond-regular]exogenous administration of opioids, and
    [FONT=agaramond-regular]the first sign is decreased duration of medication
    [FONT=agaramond-regular]action. when tolerance develops,
    [FONT=agaramond-regular]larger doses or shorter intervals between
    [FONT=agaramond-regular]doses may be needed to achieve the same
    [FONT=agaramond-regular]analgesic effect.

    [FONT=adobepistd]■ [FONT=frutiger-bold]physical dependence [FONT=agaramond-regular]also is a physiologic
    [FONT=agaramond-regular]response to the exogenous administration
    [FONT=agaramond-regular]of opioids. it requires no treatment unless
    [FONT=agaramond-regular]withdrawal symptoms—such as dysphoria,
    [FONT=agaramond-regular]nasal congestion, diarrhea, nausea, vomiting,
    [FONT=agaramond-regular]sweating, and seizures—occur or are
    [FONT=agaramond-regular]anticipated. the risk varies among individuals,
    [FONT=agaramond-regular]but when opioids are given for more
    [FONT=agaramond-regular]than 5 to 7 days, doses definitely should
    [FONT=agaramond-regular]be tapered to avoid physiologic symptoms
    [FONT=agaramond-regular]of withdrawal.
    [FONT=agaramond-regular]genetic, psychologic, and social roots. the
    [FONT=agaramond-regular]use of opioids for acute pain relief is not
    [FONT=agaramond-regular]addiction, regardless of the dose or duration
    [FONT=agaramond-regular]of time opioids are taken. patients
    [FONT=agaramond-regular]with scd do not appear to be more likely
    [FONT=agaramond-regular]than others to develop addiction. the
    [FONT=agaramond-regular]denial of opioids to patients with scd
    [FONT=agaramond-regular]due to fear of addiction is unwarranted
    [FONT=agaramond-regular]and can lead to inadequate treatment,

    [FONT=frutiger-bold]pseudoaddiction [FONT=agaramond-regular](16) applies to patients
    [FONT=agaramond-regular]who receive inadequate doses of opioids
    [FONT=agaramond-regular]whose doses are not tapered, and therefore
    [FONT=agaramond-regular]they develop characteristics that resemble
    [FONT=agaramond-regular]opioid addiction.
    [FONT=agaramond-regular]understandably, some patients whose pain is
    [FONT=agaramond-regular]managed poorly will try to persuade medical
    [FONT=agaramond-regular]staff to give them more analgesic, engage in
    [FONT=agaramond-regular]clock-watching, and request specific medications
    [FONT=agaramond-regular]or dosages. staff often regard this as
    [FONT=agaramond-regular]manipulative or demanding behavior. patients
    [FONT=agaramond-regular]with scd often are quite knowledgeable
    [FONT=agaramond-regular]about the medications they take for their condition
    [FONT=agaramond-regular]and the doses that have worked in the
    [FONT=agaramond-regular]past. requests for these specific medications
    [FONT=agaramond-regular]and doses should not be interpreted as indications
    [FONT=agaramond-regular]of drug-seeking behavior. in addition,
    [FONT=agaramond-regular]patients who have had frequent painful
    [FONT=agaramond-regular]episodes often behave in ways learned from
    [FONT=agaramond-regular]prior experiences. a patient, for example, who
    [FONT=agaramond-regular]believes that a medication will not be given
    [FONT=agaramond-regular]unless he or she appears to be in severe pain
    [FONT=agaramond-regular]may lie quietly when alone but begin to
    [FONT=agaramond-regular]writhe and moan when a nurse or physician
    [FONT=agaramond-regular]enters the room. pseudoaddiction or clockwatching
    [FONT=agaramond-regular]behavior usually can be resolved by
    [FONT=agaramond-regular]effective communication with the patient to
    [FONT=agaramond-regular]ensure accurate assessment and by adequate
    [FONT=agaramond-regular]opioid doses.
    [FONT=agaramond-regular]as in the general population, some persons
    [FONT=agaramond-regular]with scd will use illicit drugs, such as
    [FONT=agaramond-regular]cocaine. patients who have problems with
    [FONT=agaramond-regular]substance abuse require individual treatment
    [FONT=agaramond-regular]to provide competent and humane management
    [FONT=agaramond-regular]of their pain.
    [FONT=agaramond-regular]http://www.nhlbi.nih.gov/health/prof/blood/sickle/sc_mngt.pdf


    [FONT=agaramond-regular]
    Last edit by NRSKarenRN on Jun 21, '14
    SharonH, RN, Bklyn_RN, PurpleLVN, and 2 others like this.


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