help my res. is in severe pain!

  1. here's my problem. i have a res. which i'm pretty sure has bone ca. a month and a half ago this women [an old RN i might add.] was up excersizing doing leg lifts at the rails in the hallway everyday knew what day her b-12 shot was due etc.. took tylenol q day and on the bad rainy days ultram. now all of a sudden she's c/o R flank pain dx uti. hospitalized 3x's and always came back with the same dx. hospital couldn't run tests d/t her pain came back inconclusive[bone scan] she has lost 30 lbs. thus far and continues to lose weekly. drinks all of her supp. when she downs her pain medication. i have never seen nothing like it she sceams out in excrutiating pain most of the time and when she does she is just jumping all over the place. now i know your going to say kidney stones but none were found. her color is so grey and her eyes are even bulging from the pain. recently had a ct and was seen by neurology suggested a mri. i hope the md agrees because he said no to a emg when asked per pt for another bone scan. have no dx for hospice and today i had the don call him for same he said no because then he could not hospitalize her????? all this women is on is ultam 50 q4 and tylenol. all i want is something to make her comfortable!!!!! can't call medical dir. he's it!! any suggestions because i can't see her like this much longer .
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  2. 16 Comments

  3. by   Sleepyeyes
    Persistance is the key here because the severity and intractibility of the pain are the clues that the Patient has a pain problem that is not being addressed.

    Some Dr's tend to focus on the source of the pain. Other Dr's (string 'em up!) focus on the rationality of the pain--that is, they judge whether the patient's condition is a likely pain source and Rx accordingly.

    Both are wrong. They do not address the problem because they are not seeing the pain as the problem.

    Emphasize to Dr. that regardless of the source of the pain, and regardless of whether he believes her, the patient has certainly got a lot of pain that her usual med is not covering and that she needs something more until the source of the pain is dx'd, if nothing else because the staff can't handle her ADL's without causing her to go through the roof. Let him know that it is (sigh) your job to phone him or on-call whenever Pt. c/o "severe, intractable pain" or exhibits s/s of "severe intractable pain" such as "grimacing, immobility, irritability, refusal of care, crying, depression" and that according to the nurse's notes, this patient's pain began X days ago, and can't we get her something on a prn basis?

    Read to him from the nurse's notes. Make sure he knows there are a lot of nurse's notes on this problem and his previous responses have been documented.

    If he refuses increase or change in meds, ask why not. Chart the conversation and "no new orders" and why. Confirm with him, "OK so I will just document for the 4th time this week, no new orders, because I do have to document on this, as you know."

    Continue to chart patient pain, responses to passive pain control teaching, and MD response qs or prn.

    Repeat prn

    Keep calling doc with the same litany. REMAIN CALM AT ALL TIMES. This will give him the impression that you don't care if you have to call him 30 times a day, you will. Direct any behaviors that interfere with getting the pt. her pain meds (cursing, name-calling) back to the original problem. (After you get the Rx, have a chat about that, but not before. )

    But the main prob here is to persist on behalf of the patient. This isn't a popularity contest, this is patient advocacy.

    (I've done this happen so often in LTC, it makes me wish for a book called "CYA Clinical Procedures Made Easy" because the family/patient could sue the NH and win if her pain issue is not adequately addressed.)

    Good luck, and let us know what happens, please?
  4. by   aus nurse
    So well said sleepyeyes. What excellent advice and I can not add anything that you have not covered.

    Exactly what I was thinking when I read this post. The problem here is that this resident does not have adequate analgesia.
    The issue of a diagnosis for the pain should then be secondary.

    Keep advocating for your resident nurse krachet..thank goodness for nurses who care.
  5. by   nurse kratchet
    res.doing much better today.because she was finnally medicated continuosly throughout previos shifts.oh and i forgot she has a duragesic 50mcg which doesn't help. and quinine sulfate260mg the goofy nurse on 11-7 though gave the quinine out of compliance it's q 12 and she gave it last night @0100 when it was just given @2100 md was supposed to come and see her today but never showed he did order sed rat ,hemogram u/a and an aa titerwhich im unfamiliar with if someone can get me some info on that i'd appreciate it. she really made me feel good though at the end of the shift when wanted pain meds and wouldn't let any nurse give it to her but me it makes me feel good because now i know that she realizes i.d do anything to help her. and as far as the charting goes it's there! but i have to keep after the RN sup to get after the doc and alot of the times i get i called him and he doesn't want anything else.so thats why i had to go to management but i will continue to be my res advocate till the she passes PEACFULLY! thank you for just being there and helping me with this .
  6. by   rachyrach
    sleepyeyes is right, persistance is the key. You seem to be your pt. only advocate right now. Keep driving people nuts until you get someone to listen to you. Good luck to you and your pt.
  7. by   oramar
    Have things changed that much in 2 years? When I worked medsure/telemetry not to long ago hospice patients were sometimes admitted for sever, intractible pain. That was an acceptable admission diagnosis back then.
  8. by   nurse kratchet
    well i finally found the source of res pain ,spinal stenosis,degenerative discs with fragments located in the spinal canal,osteomylitis.res on duragesic 125mg and also had a spinal block. doing much better now! thanks for all your concern!
  9. by   sunnygirl272
    Originally posted by oramar
    Have things changed that much in 2 years? When I worked medsure/telemetry not to long ago hospice patients were sometimes admitted for sever, intractible pain. That was an acceptable admission diagnosis back then.
    unfortunately, pain control is no longer a reimburseable diagnosis...a kind doc will fudge one. even when the real one is pain control. home-based hospices will have pt admitted sometimes for respite, but this is usually to a nursing home with whom they have a contract.
  10. by   shygirl
    Get duragesic patches and a prn morphine order.
  11. by   hpyrn
    I just finished a 8 hour pharmacy inservice at the hospice center that I work at. Duragesic patches are expensive,do not give ongoing pain relief, take 12 hours to work and 12 hours to stop working. We use alot of mso4 SL and are starting to have tremendous results with methadone. Docs are kind of resistant to this but they have to be reminded sometimes that there are other drugs out there besides duragesic and oxycotin. Good Luck!
  12. by   tex
    One suggestion, remember if your patient is thin, duragesic patches are not your answer. Your patient has to have some body fat. Placing a patch on someone that is clearly boney is a waste of medication. I am from the school, that you do not have to stick your patient with one needle to provide relief from pain. Depending on where you live. You need a pharmacy that does compound mixing. I even had a pharmacy that would deliver to the area hospital's if the hospital wasn't able to compound. If your patient can swallow, morphine release is in 200 mg doses, and my patients have taken up to 5 qd with morphine concentrate for breakthrough sL. Dilaudid is wonderful in SL form also. You can compound it with how many mg per gtt. But I learned any time you administer over 4 gtts at a time, thrush or soreness of the mouth can present itself. Another wonderful drug for your lung, respiratory illness's. Is to get morphine in vial to adminster it along with your other respiratory medications via their neub. The trick is to make sure that the morphine is preservative free. It will not interfer with your other morphine that is intended for pain. What it does is relax the muscles in the lungs and allows your patient to breathe easier. Good luck Tex
  13. by   aimeee
    Tex--you can get Dilaudid compounded as an SL liquid? I've never heard of this. Did a private or hospital pharmacy compound this for you?
  14. by   tex
    Yes you can get it compounded, matter of fact you can get flavors. A pharmacy in Niagaria Falls did it for me. It is so many mg per gtt. I live in NC now and I can get it here also. You need to find also a pharmacy that has the ability to make suckers that are for pain, nausea all in one. Ususally the patient can suck this sucker for around a min or so. It is a beautiful thing Tex

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