Pain managment for the old old population with Alzheimer's and expressive aphasiia

tpnurse95 · Apr 16, 2016

During my last clinical, I had an especially complicated patient that I believe was being under treated for pain. However, are some patients to old for opioid use?

90 year old African American male with a contracture of his right leg. It crossed over his left leg and was fixed at about a 30 degree angle. Uncrossing his legs seemed physically impossible. Unstagable pressure ulcers on his right hip, sacrum, and right heel. Urinary catheter and colostomy bag. Urinary output is dark, amber color. No output in colostomy for 2 days, but bowel sounds were normoactive . Hypertension, hypokalemia, Alzheimer's, and was recently admitted for acute UTI. He has expressive aphasia and is very confused and uncooperative. Suspected bacteremia. Eats about 1/4 to 1/2 of meals, puree diet. Suspected abuse, PSTD, or neglect. Although his wife and son and came to visit him every morning to feed him, he screamed out when anyone touched him. He screams very loudly "please don't hurt me, please don't kill me!" He screams when you touch the stethoscope to his chest, take his bp, and especially if you try to move him he grabs on to the bed rails and we had to pry his fingers apart just to turn him to assess his wounds. If you just talk to him or feed him he is very sweet, tells the nurses thank you and he loves us. Very appreciative. He is on a bets blocker, calcium channel blocker, antidepressent, anticonvuslant, vitamin D, 81 mg aspirin. Xanxax and NSAID PRN. Vitals BP 119/53, HR 74, R: 18, T 97.6, O2 100%

So my question is, why isn't he on any other pain medications? Is it because his diastolic his so low or his old age? He literally screams so loudly the whole floor could hear, it made basic care very difficult. What intervention's would you suggest?

amoLucia · Apr 19, 2016

He has a PRN. Is it being given with regularity? A pain management technique is that pain med be given PRIOR to painful care activities.

But really, it sounds like this pt should be receiving SOMETHING around-the-clock. Be his advocate and get him something. PLEASE.

Perhaps he qualifies for hospice?

CoffeeRTC, BSN, RN · Apr 19, 2016

Was he living at home? Psych evaluation? For anxiety? The elderly definitely can take pain meds. Is he getting an antibiotic? Stool softner? You mentioned no colostomy output, what about that? Is he dehydrated too? Therapy needs to look at him for positioning / comfort.

tpnurse95 · Apr 19, 2016

According to his MAR, his PRN medications had not been given during the night shift. I agree, it should have been given around the clock. He was receiving Normal Saline IV fluids, but his oral intake of fluids was not very adequate.

He slept all day except for when we provided care, but often screamed out in his sleep.

No stool softener ordered either, but there was no evidence of a bowel obstruction. I was thinking the lack of output was from lack of mobility and inadequate food intake.

He was receiving an antibiotic, I forgot to mention that before.

He was living at home with his wife who is 80 years old and his son.

Hospice would probably be a good idea, but I didn't see anything that suggest he is going to pass anytime soon, just that he was in bad condition from inadequate care at home.

A consult with therapy would have been a good idea as well for positioning. It was difficult to decide how to lay him with his contractured leg and multiple pressure wounds.

I'm not sure if he will still be on my floor when I go back this Friday, but I plan on being an advocate for him if someone else has not already done so. I just want to know what I could have done differently or what I can do next time to help him, because no one (except my instructor and I) was giving him proper care and assessment because of the screaming and him being uncooperative.

amoLucia · Apr 19, 2016

His pain med should be ordered as to be given AROUND-THE-CLOCK, like 6a - 2p - 10p, for continuous pain mgt. Not just as a prn to be given at the nurse's discretion (obviously the nurse's discretion is that he didn't need it on 11-7 - I don't see it!?)

With all that is wrong with your pt, I think he'll most likely qualify for hospice. The usual time window with hospice is that death is expected within 6 months - do you think that he'll LAST beyond 6 months with all his problems? Hospice will be good with pain mgt.

I'm guessing that this pt is in the hospital??? Don't know his admission date so I'll give the facility the benefit of the doubt and figure they haven't treated him long enough to come up with a comprehensive treatment plan. I just pray that he won't fall into that pile of 'disposable' geriatric pts. If he were in my past LTC facilities, we'd have been all over him like 'white on rice' to start addressing his problems.

Our top 2 nursing concerns would have been pain and safety - safety and pain.

tpnurse95 · Apr 19, 2016

Thank you for your input. It's possible that they were still coming up with his treatment plan. I'm not sure that he will last that long, but I hope they have come up with a solution by now.

Tenebrae, BSN, RN · Apr 23, 2016

First of all, going on those things alone you have suggested I would be seeking to get him on some regular analgesia. If taking oral meds is a problem something like a topical pain patch perhaps. I would also be advocating for something to deal with the anxiety and agitation.

I work in a secure dementia facility.

I will happily medicate when its due. One of the concerns I have with this specific patient group is that it could be easy to get into the trap of over medicating and using medication as a form of chemical restraint which our facility does not allow. Also, its sometimes if someone is verbally and physically agitated, and unable to state whats going on for them, it can become a guessing game of whether they are agitated because of whats going on in their head or are they agitated because they are in pain? which is why ongoing assessment of their condition following administration of any medication is so important

I've also noticed among some nurses that there is a tendency to accept noise/agitation with dementia patients as 'just of their dementia". As nurses we have an obligation to advocate for all our patients, IMO we have a special responsibility to ensure that those who dont have a voice still get their needs met.

jdub6 · Apr 27, 2016

I absolutely agree that nurses need to assess for pain and advocate for these pts. I find that in many cases like the one in the OP, where the family either provides or is involved in care, that families can be resistant. They may have seen these behaviors develop so gradually that they just accept it as "the way he is." Same with the physical issues, they likely came on gradually and when they started it is possible the pt could speak and denied pain, thus the family really doesn't see what you do.

Also, some people, particularly older people like this pts wife, have been told by family or even by docs or nurses that "they start the morphine and then you die" or "that will cause constipation/ stop his breathing/ cause addiction" or "he shouldn't take them because he has xyz and opioids are known to cause complications" (and if you consult Dr google about any narcotic and many chronic conditions you will find warnings "do not use of any history of breathing problems like asthma or copd" or "people with this condition should not take opiates").

It can be very difficult to convince someone to put these beliefs aside for their loved one. Many times it is a gradual process of long term education and slowly changing the med regimen. Absolutely agree hospice if this pt is terminal or home health if not could be helpful in this process. If the family notices that suddenly Dad is much more quiet while in the hospital you may see this as comfort but they may see it as killing him or sedating him for staff convenience as they are used to his baseline behaviors.