Pain management in LTC

[bluegeegoo2]

I have a 82 y/o female pt who suffers from severe, chronic back pain. She is also suffering from dementia. Long story short, we've tried several different approaches for pain relief, but none seem to work. We had her on Duragesic patches, but they really increased her confusion. (She's up ad-lib, but VERY unsteady. I had her activity status changed to up c asst, but management jumped all over me because "we don't have the staff to watch her like that"). Anyway, called the MD and rec'd an order for oxycontin 20mg BID. Her pain was well controlled, but she was snowed for the first few days. We held the Klonopin she was getting TID, and she was starting to come around. The problem? Her husband is c/o her being "sleepy" all of the time, and wants her more alert. The other nurse on my unit agreed and has had her Oxy d/c'd. Now, the poor lady is alert all right, but combative d/t her pain level. You can just look at her and see the pain she is enduring. But, so long as she's alert, right? I feel like more time should have been allowed to see if she adjusted, as well as d/c the routine Klonopin and Ambien, and make them prn. Probably wouldn't have hurt to drop the Oxy to 10mg BID and work from there. But, this other nurse is putting her alertness above her pain control, where as I would rather her start out a little sleepy and at least be controlled, then adjust from there. Am I wrong? What else can I do? I am "trumped" on most of my calls on this unit, but will be going back to my old unit in a few weeks. I truly care about this ladys' wellbeing, as my Mom has endured years of chronic back pain and have seen first hand how horrible it can be. If you know of better ways to control pain without knocking her out, please let me know!

[leslie :-D]

Leslie, thanks for the clarification. I agree that sometimes our creativity (both in house and in the field) can be an incredible help in taking care of our pts.

As I said, I hope that my comments don't in any way look like aspersions cast on your skill, knowledge, good sense, etc. You clearly know your stuff and are generous in sharing your knowledge :redpinkhe

aw, no offense taken at all, miriam.

yrs ago, i was much more open about my hospice experiences, until one day, a nurse asked me if i posted on an's.

i asked her why, and she talked about a thread where she felt she knew of the pt i was talking about.

i almost died, and of course, denied it to the hilt.

since that day, i won't even elaborate on seemingly benign incidents, fearing identification of a person, place, event.

if i didn't have to be so careful, the stories i could tell....

hoo boy.

leslie

[CapeCodMermaid, RN]

We can all learn from each other's experiences remembering that each practice setting is different, the regs are different, the patients are different, and our skills and comfort levels are different. That's why we all love this forum.

[marachne]

We can all learn from each other's experiences remembering that each practice setting is different, the regs are different, the patients are different, and our skills and comfort levels are different. That's why we all love this forum.

I agree, and am enjoying this forum greatly. The only thing I'd add is that practice also changes...albeit slowly. It's discouraging to think that it takes an average of 10 years for new data to move from research to practice. As I said before, it's hard to keep up with all the new literature, so providing each other with information regarding innovations in practice is another bonus.

[Furwillfly]

I think hospice care is very different than treating chronic pain. I think if one is dying and a durgesic patch is cut.......fine. They probably need the dose delivered immediately, as they probably won't be there in 3 days anyhow.

I'm not going to go back and forth with more experienced nurses here, we are all here to learn from each other, young and younger and old and older. We all know there is a reality and the 'right' way. But I do believe if one of my fellow nurses found me cutting a patch in half and putting on a patient with chronic pain, they would turn my *** in to state.

That's my 2 cents.....

[noc4senuf]

Our facility is involved in a "resident centered pain control" grant from the state. We are one of 21 facilities that have been working on our grant and all the paperwork/training/education involved since April. All depts will be trained on being able to notice and report pain that they see in our residents.

Each resident will be screened on admission with a "cognitively able" or "not cognitively able" screen. Dependent on the results, they will then be assessed thoroughly. These will also be utilized qrtrly and prn. We are excited to get this rolling and onboard. Starting in October, we will see the monies start coming in from the state for the next year.

[bluegeegoo2, LPN]

Our facility is involved in a "resident centered pain control" grant from the state. We are one of 21 facilities that have been working on our grant and all the paperwork/training/education involved since April. All depts will be trained on being able to notice and report pain that they see in our residents.

Each resident will be screened on admission with a "cognitively able" or "not cognitively able" screen. Dependent on the results, they will then be assessed thoroughly. These will also be utilized qrtrly and prn. We are excited to get this rolling and onboard. Starting in October, we will see the monies start coming in from the state for the next year.

How would one go about getting a grant like that? I live in Indiana, and don't know if such a thing exists, but it would be GREAT to have better training at spotting pain. It took me a few WEEKS to figure out that one of my res was in pain. She could not verbalize her pain adequately, and I failed to see it in a timely manner. I finally did figure it out and she is now properly treated, but if I had had better training, she would not have had to suffer for weeks before rec'ing better pain control.

[marachne]

If I can make a recomendation, there is a wonderful new series called "How To Try This" which grew out of the "Try This" series. Among the nice things about the HTTT series is that they were developed by expert geriatric nurses, and they have videos as well as written information.

The most recent addition is the pain assessment model and includes the PAIN-AD, the psychometrically tested pain assessment too for cognitively impaired individuals.

[noc4senuf]

We looked at many different QIO's of several states and settled on those of WI and TX. We also have a Medical Director on board who specializes in pain, and a pharmacist. Our group submitted a grant proposal to the dept of health which will run for one year. ABout the same time it starts, we are able to begin working on a second year.

We will be paid monthly on a per bed basis. The total for our facility alone is about

140K. We have also put into place how reaching our goals will be achieved.

[CapeCodMermaid, RN]

From the manufacturer of the Duragesic/Fentanyl patch:

DURAGESIC patches are intended for transdermal use (on intact skin) only. Do not use a DURAGESIC patch if the seal is broken or the patch is cut, damaged, or changed in any way. Using a patch that is cut, damaged, or changed in any way can expose the patient or caregiver to the contents of the patch, which can result in an overdose of fentanyl that may be fatal.

Regardless what a pharmacist or MD told you, you would not be covered if something happened to the patient because you cut the patch.

[rehabhereIcome]

LAST HOURS questions....

When a patient is in there last hours and prn doses of Morphine/dilaudid etc are ordered....and the patient no longer able to verbalize the need for BT pain control...how do you decide to give pain meds? I have based it on facial grimacing or moans with repositioning but would like others input or a reference/literature that I might turn too. Also...we use scopolamine for end of life fluid build up in the lungs....I had a nurse go on and on about how Lasix is the best and I have asked MANY nurses I work with and they say that is not the case and it is not the typical med we use at our facility....why/when would lasix be the best option? One more thing....unless there are secretions sitting up way high in or nearly in the mouth I DONOT see the benefit of suctioning a PT and have not...am I wrong?

Thanks......

[marachne]

LAST HOURS questions....

When a patient is in there last hours and prn doses of Morphine/dilaudid etc are ordered....and the patient no longer able to verbalize the need for BT pain control...how do you decide to give pain meds? I have based it on facial grimacing or moans with repositioning but would like others input or a reference/literature that I might turn too. Also...we use scopolamine for end of life fluid build up in the lungs....I had a nurse go on and on about how Lasix is the best and I have asked MANY nurses I work with and they say that is not the case and it is not the typical med we use at our facility....why/when would lasix be the best option? One more thing....unless there are secretions sitting up way high in or nearly in the mouth I DONOT see the benefit of suctioning a PT and have not...am I wrong?

Thanks......

First some resources: Hopefully, this is an attachment Nonverbal pain assessment.pdf if it isn't and it's a link, well it's some info from the American Society for Pain Management Nursing about pain assessment in the non-verbal person. Also http://tinyurl.com/7ck6gb takes you to the "how to try this" page which has videos for different tools, including the "PAIN AD" which is specifically for people w/dementia, but seems applicable across the board. This: http://tinyurl.com/7bm6ec is a link to one of EPERC's Fast Facts again about assessing pain in non-verbal persons. I highly recommend all the Fast Facts for EOL questions.

As to the issue of scopolamine (or atropine or glycopyrrolate) they are all routinely used. I have never heard of using Lasix, and I would strongly suggest it not be used as is is a completely different mechanism and much more likely to be harmful than useful. http://tinyurl.com/84tgrk is another Fast Fact that has both pharm and non-pharm suggestions -- one of the things to keep in mind is that the secretions are distrubing to others, but there seems to be little evidence that it is distressing to the patient.

I try to avoid suctioning, unless, as you say, it can be reached by a Yaunker tip. I would never do deep suctioning. Even the oral suctioning is often more something for the pt's family (at this stage we are often treating the family as much as the pt.)

Finally, while you said "in their last hours" but we don't always know when that time is exactly -- and are often fooled. If someone is on high dose opiates, even if they are not eating, you need a bowel regimine. The GI tract is still sloughing dead tissue, and stool can build up in the vault, which can be very discomforting.

Also, if someone is having a lot of myoclnis, they may have neurotoxicity from the opiates -- the paradoxical aspect of this is that the opiate is actually making the person more sensitized to pain. If that's the case, you should lower the dose and switch to another opioid.

Hope that helps.

Nonverbal pain assessment.pdf

[MedicalLPN, LPN]

Marachne is right, the PAIN-AD scale is a wonderful tool to use when assessing pain, it saddens me so much to see how pain is under treated in almost every setting. It seems many nurses and physicians don't believe in palliative care and feel that it's acceptable for patients to suffer. Nothing gets me angrier than a nurse or physician saying something along the lines of "Well, if he can't talk then he's not in pain." Even had an oncologist tell me that once...