pain control

[zelda]

In our facility we have several nurses and med aides who are not educated enough on pain control in the elderly. If pain medications are not written on a routine schedule, they usually are not given, either because pain is not identified, or because it is just forgotten. I am a strong advocate and feel that our elderly are undermedicated for pain. I frequently used the prn order written by the physicain and using the parameters given, set up times on the medex so pain meds would be given routinely. Usually the order from the physician was for every 4 hours prn and I set them up on BID doses. As we all know, physicians also undermedicate for pain and it is difficult to get a routine order sometimes! During our last annual survey I was criticized heavily and was even said to be prescribing medications under a nurses license by a state inspector. I no longer do this and now we are again having difficulties with adequate pain control. Was I actually prescribing medications? Would like any responses on this and also would like any advice available on how others are managing pain with our elderly population.

[JillR]

When I do rounds one of the things I ask my patients is are you comfortable? If not I ask them what I can do to help. I will try repsitioning first, then tylenol and then if these don't work I will call for a stronger pain medication. I always find out what works for the patient best and go from there. Many people have chronic pain that may not be treated because they have lived with it so long that they don't think there is anything that can be done. Even if this is not the reason they are in the hospital for that reason, I still address it because I feel that people heal better if the can rest well.

Many people don't like to call their discomfort "pain" so I will ask "do you hurt anywhere?" . I noticed that putting the question in different word sometimes brings out the truth.

I hear in report many times that the patient never complained of pain but many patients won't bring it up unless the question is asked directly.

If you are dispencing medication without an order then that is beyond the scope of practice for a RN. We have standing orders for tylenol and must call for other analgesics.

If you fell that pain is not being addressed consistantly you could develope a pain flow sheet and protocol for pain management. Try requesting an inservice at the facility you work.

[belinda]

Pain management is a very important topic of conversation. You are right. We do under treat pain. In your facility, are pain assessments being completed on a regular basis? It sounds as if there needs to be a good policy and procedure in place with regard to pain management. At my facility, we do a pain assessment on admission and then quarterly thereafter or with any changes. If someone falls, we do a pain assessment. And dependent upon the pain assessment, we make changes to their plan of care as needed. whenever, pain managemnt is changed, we do another assessment to make sure the pain med is effective. Hope this helps a little. Have your pharmacy come and do a pain management inservice!!

[leslie :-D]

I need clarification.... what did you mean when you said you'd set up the q4h prns with a bid schedule? Anyway, I too, work in a ltc facility and I find that Tylenol works great for chronic conditions. Also Neurontin. But when it comes for the controlled narcs,i.e., morphine, oxycontin, I get ex-tremely frustrated when my collegues seldom administer the prns. There is such a fear and knowledge deficit, and I don't know why. Depending on the acuity of the pain, I have found myself either begging an MD for duragesic (for pts. in their final days/weeks and for ca pts.). Also, we contract with hospice, and sometimes the nurses feel it's o.k. to give the morphine if hospice suggests it. But no matter what, don't stop advocating for these people. Many will deny pain for that's just what many of these elderly were conditioned to do...live with the pain, to be stoic. It's up to us to assess and document any variations from their baseline. I hope this helped somewhat.

[Jeannette_5]

The fact that you scheduled the pain medication on a scheduled basis (bid) satisfies me that you are genuinely concerned and with every right. But, in your case what I tend to do is tell the oncoming nurse how often this patient had to be medicated and explain to her how the patient responds when you have medicated him or her (i.e appeared more comfortable etc..). I always ask my patients about the presence of pain, encourage them to notify me and more importantly, tell them that there is medication for pain available, the type and how often they can have it. It is amazing how often the pain medication is requested after they are aware of these things. Also, there are visible signs that a person is pain (not to mention their vitals -- the blood pressure tends to zoom when there is pain). On a final note, do not rewrite a PRN order for a scheduled one without the physicians authorization. If you feel that the patient needs around the clock pain medication, explain your observations to the MD and then ask the MD to rewrite the order for something that can be given ATC. Hope this helps!

[Nancy1]

Pain is a very individualized subject. Many people do not want to use the prns too much, but if you are not using what the MD gave you you are not caring for the pt. I tell my nurses, if Mrs. Smith seems to be in so much pain, try giving her the prn tylenol bid as a trial. If it works, call the MD and ask for a t.o. for this. Now this works in our LTC facility because the doctors and I have discussed this and it is in our policy, just as holding a medication for 2 days is.

The nurse is the one who is able to assess the pt. The MDs come in for scheduled visits.

For what it is worth, that's my 2 cents worth. NA

[cargal]

I am back in long term care again and training to be charge. Our full time charge left , but I am part time. We have a resident that hollars every time she is touched or moved. She in non verbal all the rest of the time, and does not talk, but she will answer questions with the shake or nod of her head. She nods in reply to my questioning of her in pain and nodded affirmative when I asked her if she wanted me to ask the MD to order something stronger than the tylenol she has ordered. The doc is so full of himself and seems to think of himself of our benefactor of his knowledge (lack of pain control) and replied "you have to ask if her pain is worse than a year ago, and she was always a yeller and you may want to get earplugs for the 15 minutes it takes for her am care and moving." I tried to be diplomatic and ask if it wasn't possible that some people have a lower threshold of pain, and he did address this then he dismissed me. I need to do more for my resident , but I'm not sure how to proceed with such an @!*%#!@. Since I am new, I feel I must tread lightly. Her roommate has had Leggs Perth Disease since she was a young girl, and it hurts for her to go on the shower chair, she cries and swears and suffers, but they take her against her will! She has another doctor that I haven't met yet, but I have already been warned that he won't give her anything stronger than her darvocet. We have been sited for the state for not addressing pain, but what can you do with these doctors?

[Fgr8Out]

Two words to all of you looking into ways to address/treat your patients pain...."Margo McCaffery." I heard her speak a month ago and I find her way of addressing nursings concerns to be extremely helpful.

I work with a couple of nurses who still have misconceptions regarding pain control. One of the ways I deal with this is, in report, to tell them how the patients pain was controlled on my shift, and my suggestions on when to medicate them next to aid in their continued control. No, they don't always listen, but if I do this often enough, the message comes out loud and clear on my expectations. When I'm questioned, I use that opportunity to explain pain management and quote my findings, using research based facts.

Good luck! :)

[ComicRN]

In my state (New York) the state surveyors are looking critically during our annual surveys at how pain is being addressed. We can now get deficiencies if a resident's pain control has not been addressed adequately.

I think a lot of nurses are afraid they will "over medicate" an elderly person and I think a lot of elderly people see pain meds as a sign of weakness. It is up to us, as nurses, to assure these folks that these meds will help them with their pain, which will in turn help them with their activitieds of daily living, etc.

I think another area that needs to be addressed is pain control for the dying in the LTC setting. Luckily, I work with doctors an nurse practitioners who are not afraid to help the dying patients with their pain control. Again, it is up to the resident's nurse to be an advocate and to convey to the MD/NP (whoever!) how much pain the resident is having.

[aimeee, BSN, RN]

Bravo to those of you who are concerned with pain control and acting as patient advocates! When there is a lack of follow through on pain control by staff I have found that scheduling the pain assessment and putting it in the MAR is very helpful. This puts the spotlight on the issue and very quickly highlites any patterns. Around the clock pain calls for around the clock schedule.

Rather than ask your pharmacy to do a pain inservice, I would recommend you ask your local hospice. The pharmacists are often very good at knowing about the meds, but may not have the expertise in the assessment techniques you need to use.

As for the Dr. who refuses to prescribe anything stronger...the pain assessment data in the MAR will give you the documented ammo to back up your request. If he still refuses, the recourse is your medical director.

Darvocet! Bah! Barely more effective than Tylenol and yet high potential for poor tolerance. Most patients in LTC would be better served by a different med.

[cargal]

Aimee,

Thanks for the tip, but the arrogant MD is the medical director. He is so freakin full of himself. But anyway, thanks for the support, will stay on it!

[kids]

Originally posted by Fgr8Out

Two words to all of you looking into ways to address/treat your patients pain...."Margo McCaffery." ...

She is a Goddess.

We were DRILLED in her knowledge in Nursing school.