How much pain medicine is too much?

  1. 0 I am a PCT at a hospital and i just got home from work and experienced a situation that I would like the opinion of outside parties on. A patient has been in our care for several days for pain control of a type I chiari malformation. The pt has orders for 2mg dilaudid q2 which she receives constantly (literally 24mg in a days time) as her pain is always a 10/10, etc. I mean the kind of pt that will set a timer on their phone to go off every two hours so that they may ask for pain meds. Essentially this pt has not slept for the three days she has been with us because she is always, always asking for (and receiving) dilaudid day and night.

    Her vitals are fine every time they are checked (which, by our policy, is 30 min after every admin of dilaudid; pt also kept on continuous pulse ox) but is clearly "high" off the meds. Slurred speech, stumbling gait, can hardly keep her eyes open, cant recall her last med time. what really drove me to write all of this, however, was what happened this past evening. The pt wandered out of her room topless (no gown, no shirt, no bra) and just in pants looking for the RN.

    Upon discovery she was immediately helped back to her room and attempted to be reoriented. I believe (but am not 100% sure) the nurse then held her next dose of dilaudid. at the next scheduled time the RN definitely administered it. The way this case has been handled does not seem right to me at all.

    It seems we are clearly encouraging what appears to be drug abuse and not considering any other options nor treating current problems properly. Please advice and opinions, because as a future nurse, I would not be simply following the others and continuing to give the drug to please the pt. Thank you!
    Last edit by Joe V on Jun 6, '12 : Reason: spacing
  2. Visit  jlwerley profile page

    About jlwerley

    From 'Chicago area'; 26 Years Old; Joined Nov '09; Posts: 14; Likes: 5.

    35 Comments so far...

  3. Visit  Been there,done that profile page
    12
    Yep... we've stoned the patient. As long as her vitals are ok and there is a DOCTOR'S order, we will continue to stone the patient.
    If the nurse were to approach the DOCTOR that ORDERED the narcotic.... he would bite her head off. The doctor is well aware of the situation. The acute care setting is rarely the time to address addiction issues.
    I have been somewhat successful by consulting the pain control service and getting a different team involved.

    If they came into the hospital with an addiction, we aren't going to change it in the few days we are working with them.
    MedChica, beckster_01, paddler, and 9 others like this.
  4. Visit  classicdame profile page
    14
    If you will look at the studies done on chronic pain you will know that vital signs do NOT indicate pain. Acute pain, maybe. But the body compensates for chronic situations and vital signs are not significant. If the patient is not sleeping I suspect she is in pain. I personally would rather be stoned then be in pain. This patient needs a pain specialist consult, not interruptions in her care. We tend to have negative connotations about people on pain meds and try to "fix" their non-existent drug abuse. Could be the poor lady needs the meds
    MedChica, liveyourlife747, chare, and 11 others like this.
  5. Visit  not.done.yet profile page
    16
    Even if she has an addiction problem, I am not going to solve it in a 12 hour shift. I am, however, going to believe that Chiari malformation is extremely painful and that I need to adequately treat that pain. That may mean slurred speech. I'll be watching vital signs for respiratory depression and oversedation, but I will also be trying to find the balance of medications to achieve adequate pain relief without those symptoms. It is a balancing act and takes time to find. Often I don't have time to find it in one shift. Not treating her pain is not an option. Undertreating her pain is not desirable. Withholding pain medication because I suspect she has a tolerance or addiction problem? Cannot, will not, could not do it. Unconscionable.
    liveyourlife747, chare, beckster_01, and 13 others like this.
  6. Visit  netglow profile page
    7
    I'll add to all the above in that some people go goofy on narcs no matter what the dose...
    Tzs1981rn, WeepingAngel, GrnTea, and 4 others like this.
  7. Visit  Epic_RN profile page
    6
    Quote from not.done.yet
    Even if she has an addiction problem, I am not going to solve it in a 12 hour shift. I am, however, going to believe that Chiari malformation is extremely painful and that I need to adequately treat that pain. That may mean slurred speech. I'll be watching vital signs for respiratory depression and oversedation, but I will also be trying to find the balance of medications to achieve adequate pain relief without those symptoms. It is a balancing act and takes time to find. Often I don't have time to find it in one shift. Not treating her pain is not an option. Undertreating her pain is not desirable. Withholding pain medication because I suspect she has a tolerance or addiction problem? Cannot, will not, could not do it. Unconscionable.
    This, this and this. Could not have said it better. Pain is pain, regardless of what our personal opinions are of the pt's pain control regimen. Would rather be snowed out of my mind than feel that severity of pain. I've cared for post op chiari pts and the relief they've expressed in the reduction of their pain level has been enormous....
  8. Visit  caliotter3 profile page
    2
    I agree that an acute care admission is not the time to address addiction unless the doctor takes it upon him/herself to do so. Addicted persons are allowed to describe their 'pain' as they see fit, just as are non-addicted persons. However, I would be very careful to assess anyone receiving their maximum prescribed medications and keep the assigned nurse apprised.
    MedChica and Hygiene Queen like this.
  9. Visit  KelRN215 profile page
    9
    A Chiari decompression is an extremely painful surgery. When I worked inpatient neurosurgery, our Chiaris would be on either morphine or decadron q 2 hr as well as valium q 6 hr. In a Chiari decompression, they cut through all the muscles in the neck. It is painful and patients need to be medicated. Is this patient on a PCA or getting doses q 2 hr? Sounds like she should be on a PCA. And I don't think that just because a patient is asking for the meds- which the doctor ordered at an appropriate dose- for legitimate pain makes her an addict or a seeker. I always medicated my Chiaris for the first 24-48 hours around the clock whether they asked or not. Once you get behind on pain control for those patients, it can take a while to catch up.
    MedChica, OCNRN63, azhiker96, and 6 others like this.
  10. Visit  leslie :-D profile page
    8
    not knowing specifically what her order is, it sounds it needs to be amended to an opioid that is longer acting and/or, increased.
    if pt is missing sleep to ensure she gets her next dose, something is off and needs attention.
    as a nurse, i would definitely consult with the dr., as no one wants to see disturbed sleep patterns.

    when you become a nurse, you will use your nsg judgment in determining when to give a med or not.
    vitals that are wnl, are indicative that it is ok to give...despite slurring and gait disturbances.
    if your hospital has it, requesting a pain consult would be ideal.

    please try not to judge those you deem as seekers.
    many times, these pts are scared to death of any pain returning, and so, they want their meds to stay ahead of it.
    sounds perfectly reasonable to me.

    if the pt isn't on an antispasmodic, perhaps that can be suggested as a means of improving her outcome.

    bottom line, as a nurse, you need to look at the big picture in supporting your pts needs.
    more often than not, there is nothing black and white about nsg.

    leslie
    MedChica, RockinChick66, OCNRN63, and 5 others like this.
  11. Visit  KelRN215 profile page
    0
    Quote from KelRN215
    A Chiari decompression is an extremely painful surgery. When I worked inpatient neurosurgery, our Chiaris would be on either morphine or decadron q 2 hr as well as valium q 6 hr. In a Chiari decompression, they cut through all the muscles in the neck. It is painful and patients need to be medicated. Is this patient on a PCA or getting doses q 2 hr? Sounds like she should be on a PCA. And I don't think that just because a patient is asking for the meds- which the doctor ordered at an appropriate dose- for legitimate pain makes her an addict or a seeker. I always medicated my Chiaris for the first 24-48 hours around the clock whether they asked or not. Once you get behind on pain control for those patients, it can take a while to catch up.
    Addendum to my previous post... they would be on morphine or DILAUDID q 2hrs. Decadron is obviously not a PRN pain medication though Chiaris do much better when they are on it, IMO.
  12. Visit  jlwerley profile page
    0
    ill add that there was no decompression surgery, nor is she scheduled for one. to me, in my developing nursing judgement, it seems that our version of pain control is inadequate if q2 dilaudid leaves the pt with a continuous 10/10 pain. it seems to me she is in need of a pain specialist or the drs need to consider other treatments for the pain (as in surgery). she also has other pain meds ordered, so why not try toradol or something else for a bit to see how that treats the pain instead of just always giving dilaudid. also, at what point do we decide not to advocate for pts who may be addicted and voice our concern to the dr, who may then order further help for their addiction (psych consults, social work, whatever addiction therapy there is, etc). also, again in my developing nursing judgement, i try to take in the whole picture when i see pts asking for pain meds and describing the pain they have to our nurses. for example, i saw said pt describing her pain as beyond 10 out of 10 and that it was killing her meanwhile she is texting on her phone, eating ice cream etc. when ive seen other pts describe pain like that, they can barely verbalize, doubled over etc. i know you have to take pain at what pts say, but again at what point do you start to advocate for the pt

    these are just ramblings of a tech and student who felt something was off about the situation. thank you all for your responses, they have helped me learn more about dealing with difficult pt scenarios!
  13. Visit  Dixielee profile page
    3
    You didn't mention if this patient was pre op pain management or post op. I had never heard of a Chiari malformation until Last November. My very healthy, marathon running, college professor daughter experienced sudden onset acute headache and visual disturbances after playing soccer. The pain was so severe she couldn't walk without assistance. She immediately went to the ED and a CT showed a huge Chiari malformation. The neurosurgeon said she needed surgery immediately, and so she did.

    She had never taken narcotics and was hesitant to take ibuprofen preop. She also required huge amounts of narcotics after surgery, including a dilaudid PCA pump with additional meds for break through pain. This ordeal gave me a whole new perspective on pain control.

    Her doc had told us that this was a very painful surgery and to prepare for a lot of pain. I know there are a lot of people who live with the pain of the malformation many years before actually requiring surgery. Since her diagnosis, we have researched it a lot and learned so much! I am thankful she was able to present with acute symptoms and have the surgery without having to go through years of misdiagnosis and pain.

    I'm not about to pronounce judgement on whether your patient was getting enough or too much pain med, but I wanted to pass along my daughter's situation as an example.

    I do, however still get mad about the large numbers of repeat patients who come to the ED with back pain, dental pain etc. who appear to be seeking, but there again, it is not my call.
    GrnTea, Fiona59, and Esme12 like this.
  14. Visit  RNsRWe profile page
    4
    Have medicated many patients who I believed were probably there just to get high. This patient, however, does not have a situation that automatically warrants the tag "seeker". She might just need the amount of narcs to kill her pain that also make her a stumbling fool. Keep her safe in her room, monitor her frequently (as is the case in your hospital policy about cont p/ox and vs checks). And give her the drugs as ordered.

    However, if I see that the patient is having decreased respirations or any sign that tells me that giving her the dose of Dilaudid may do her actual harm, I'll call the doctor to see if there's something else I can give her instead, stretch out the time between shots, and get something else ordered for an in-between-Dilaudids dose.

    Wonder why this patient isn't on a PCA, actually? Assuming she isn't so stoned she can't operate the button....?
    MedChica, Aurora77, Anna Flaxis, and 1 other like this.

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