Pain management in LTC

leslie :-D · Jun 22, 2008

i've always had good luck w/vicodin w/the elderly.

stronger meds tend to snow them easily.

w/vicodin, they have reported good pain relief w/o feeling 'woozy'.

i'd most likely start w/the 5mgs just to guesstimate amt of pain relief.

but have a feeling pt will require 7.5mg or even 10mg.

i have also cut fentanyl patches in half, w/good results.

best of everything.

leslie

SuesquatchRN, BSN, RN · Jun 22, 2008

Pain in LTC is badly and under-medicated, IMO.

I had a woman return from hosp c an inoperable hip fracture. Tears running down her face. The charge nurse called the NM who said, "Tylenol." I got mad and called the doc who gave her oxycontin, which eased her pain and put her to sleep. In report the next morning the idiot relieving me said, "Oh, we can't have her overly sedated." Why? So she can be alert for her board meeting?

She lasted a week, with her pain meds d/c'ed.

I was accused of "pushing pain meds" for my moaning, DYING residents.

If I ever return to direct patient care it will be hospice.

marachne · Jun 22, 2008

pain is definitely undertx in LTC, esp in the confused. One thing to be aware of is that non-verbal pain can be expressed differently in people with dementia. Get a hold of a copy of the PAINAD - it's a proven tool. Document, document, document. Educate the husband (and your coworkers if necessary). Pain can KILL -- it affects the immune system. Also, often agitation is an expression of pain. I agree, cut the ambian, klonopin and reduce the oxycotin. With older adults the mantara is "start low and go slow." Also, how is her renal function? You want to be careful of metabolites in some of the opiates. oxy isn't bad, fentanyl is better, MS04 is the worst, however it has the advantage of coming in a time release formula so you get better longer coverage. Tylenol as an adjunct can be useful. Sometimes it can be enough on it's own, but with chronic pain, it can be of limited use. Be aware of co-morbidities (liver function?) that can impact your dosing. Good luck. This is the kind of thing that just frustrates the hell out of me.

lovingtheunloved, ASN, RN · Jun 22, 2008

Had a similar problem with one of my ladies. She now gets a lidocaine patch daily to her lower back, and vicodin prn. She very rarely complains of pain anymore, and before she would barely get out of bed she was in so much pain.

leslie :-D · Jun 22, 2008

and as w/any opioids, make sure these pts have something extra added to any current bowel regimens.

constipation makes pain 100x worse.

leslie:twocents:

marachne · Jun 22, 2008

and as w/any opioids, make sure these pts have something extra added to any current bowel regimens.
constipation makes pain 100x worse.
leslie:twocents:

Oh, good reminder. Esp. when I was doing my palliative care fellowship, there were few things that made me crazier than docs ordering scheduled opiates w/o an appropriate bowel regimen -- and I mean senna, not docusate, which is generally useless in this kind of situation.

Constipation can not only make pain worse, but also confusion.

CapeCodMermaid, RN · Jun 22, 2008

I am a crazy person when it comes to pain management (okay some of my staff would say I am just plain crazy!) Pain, especially in the dementia population, is sorely undertreated. Nurses are afraid to medicate; doctors are afraid a well and constantly prescribe medications that are not effective for chronic pain.

Start low and go slow is good advice. In a narcotic virgin, 10mg of MS Contin q 12 hours is a place to start. It would be better to start with 10mg of Oxycontin because it has fewer metabolites which can cause confusion, but Medicaid won't pay for Oxycontin unless you show the MS Contin was ineffective. We usually start patients off with 10 mg q 12hours with OXY IR 5 mg q 4hours for breakthrough. We titrate up from there remembering there is no ceiling for morphine. My problem with ONLY PRNs is that most of these residents can't verbalize pain and not every nurse has the assessment skills needed.

Don't forget about other methods to reduce pain. NSAIDs are effective in some pain given with the narcotics. Heat and cold work for some...positioning, music, distraction therapy.

It's amazing how behaviors diminish when the resident's pain is treated. I've seen patients with horrible behaviors (screaming, throwing food, hitting out) become calm and relaxed after a few doses of pain medication.

Explain to the family and the nurses that the sleepiness when first starting a narcotic medication is usually temporary and a bit of lethargy beats pain any day of the week!

Try establishing a pain committee or appoint a pain champion. Call your local hospice and have inservices on pain control.

And....please don't cut a fentanyl patch in half...the medication will not be delivered properly if the patch is cut. The patch comes in as little as 12.5 mcg so there shouldn't be any reason to cut a patch.

And finally, about constipation I knew an NP who specialized in pain control. She said: "The hand that writes the script for the narcotic pain medication better be the hand that is also writing the order for a bowel medication or it should be THAT hand which has to do the disimpaction when the time comes."

SuesquatchRN, BSN, RN · Jun 22, 2008

My problem with ONLY PRNs is that most of these residents can't verbalize pain and not every nurse has the assessment skills needed.

I've worked with more than one nurse who wouldn't give them.

CapeCodMermaid, RN · Jun 22, 2008

I've worked with more than one nurse who wouldn't give them.

I have a few of those nurses too. I wonder how they would like to have to suffer in silence. I worked with a supposed dementia specialist who said demented people don't feel pain. I asked her if Mrs Jones winced every time she took a step because she thought it was funny...that's a nervous tick she told me. I called the doc and got a standing order for APAP 1000 mg at 8am. Funny after two days of tylenol the 'nervous tick' went away.

I usually ask the docs for standing orders of pain medication with something else for breakthrough PRN. At least that way the patient has a chance of having their pain managed without MY having to be on the unit every minute of every day.

morte, LPN, LVN · Jun 22, 2008

MS contin starts at 15 mg, roughly dose = to 10 of Oxycontin........

marachne · Jun 22, 2008

It's amazing how behaviors diminish when the resident's pain is treated. I've seen patients with horrible behaviors (screaming, throwing food, hitting out) become calm and relaxed after a few doses of pain medication.
.... And finally, about constipation I knew an NP who specialized in pain control. She said: "The hand that writes the script for the narcotic pain medication better be the hand that is also writing the order for a bowel medication or it should be THAT hand which has to do the disimpaction when the time comes."

One of my favorite quotes about "agitation" and dementia: "A person with dementia who is "agitated" is a person with unmet needs." Sometimes (often) it's pain, but it can be other kinds of discomfort and distress. Find the source, correct and much of the times the behavior goes away. I totally agree that pain medication should be scheduled when you have a known condition -- hello, OA doesn't go away with dementia, nor post-surgical pain, or chronic back pain -- scheduling ensures adequate coverage throughout the day and night. And I LOVE the NP quote -- perfect! As I said, it's important to use things that are effective. Adding to someones medication burden isn't useful (i.e. docusate & senna). Also, knowing side effects that can cause other problems, i.e. sorbitol and lactulose cause gas and bloating....as well as realizing that someone with "diarrhea" of the constant, small oozing type may well be impacted! I think only nurses and new parents get so involved in discussions of poop.