Isn't pain whatever the patient says it is???

  1. Hi,
    I'm pretty P.O.'d too.... Am a Hospice nurse with a patient who's had a lifelong hx of neurological pain. Each time I see her she c/o pain "all over", is grimacing, moaning, cries out when moved, etc. when I ask if she needs pain meds she says yes...Requested her order for be increased to 30 gm oxycodone TID (now on 20 gm TID) w/breakthru pain meds PRN. The facility and the NP in charge claim that "she's always been like this - it's just what she says. We don't even ask her about her pain, and she doesn't bring it up so she's fine" Urgggghh!!!! So they never give her any PRN pain meds.:angryfire I've been gradually titrating her up, and it hasn't touched per pain, hence the request for the increase. What on earth happened to "Pain is whatever the patient says it is?" Is that only for patients under a certain age, or does it exclude dementia patients, or what?
    This small battle may be lost for now, however, the war is not close to being over!
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  2. 51 Comments

  3. by   fergus51
    I hope you keep fighting for her. Patients need nurses like you. I can't stand to see pain untreated.
  4. by   leslie :-D
    Quote from momcats3
    Hi,
    I'm pretty P.O.'d too.... Am a Hospice nurse with a patient who's had a lifelong hx of neurological pain. Each time I see her she c/o pain "all over", is grimacing, moaning, cries out when moved, etc. when I ask if she needs pain meds she says yes...Requested her order for be increased to 30 gm oxycodone TID (now on 20 gm TID) w/breakthru pain meds PRN. The facility and the NP in charge claim that "she's always been like this - it's just what she says. We don't even ask her about her pain, and she doesn't bring it up so she's fine" Urgggghh!!!! So they never give her any PRN pain meds.:angryfire I've been gradually titrating her up, and it hasn't touched per pain, hence the request for the increase. What on earth happened to "Pain is whatever the patient says it is?" Is that only for patients under a certain age, or does it exclude dementia patients, or what?
    This small battle may be lost for now, however, the war is not close to being over!
    hi momcat,

    what is your pt.'s dx for her to be in hospice? also, neuro pain is one of the more challenging types to treat. as for mcaffrey's "pain is whatever the pt. says it is", i have mixed feelings about. but since your pt. is clearly exhibiting textbook signs of pain, you are 100% correct in trying to get it controlled. it drives me crazy when nurses write in their notes, " no c/o pain" or "denies pain". that is such a crock for there are so many patients that will indeed deny pain for many different reasons. i would pursue any channels you must to get a scheduled regimen started, and document very clearly all pertinent data. you've done good....thumbs up to you.
  5. by   bellehill
    From one frustrated nurse to another...keep at it!
  6. by   teeituptom
    It is easier to treat pain than it is to find a reason not to treat it, so always treat it.

    Take the path of least resistance Grasshopper
  7. by   fab4fan
    Are you using anything besides opioids to treat the pain? Neuropathic pain usually requires a multi-faceted approach. Is she on any anti-seizure meds? How about anti-depressants?

    As far as what the other nurses said, would they do the same for someone wo has a history of chest pain? (If you don't ask him if he has chest pain, he doesn't say anything about it, so it must not be real.)
  8. by   aimeee
    Quote from fab4fan
    Are you using anything besides opioids to treat the pain? Neuropathic pain usually requires a multi-faceted approach. Is she on any anti-seizure meds? How about anti-depressants?
    My thoughts exactly!

    One of the big frustrations working with facility staff is acheiving consistency in documenting response to the regimen and in actually following a regimen if prn meds are involved. Its difficult to get all staff on all shifts on the same page.
  9. by   cargal
    "..Requested her order for be increased to 30 gm oxycodone TID (now on 20 gm TID) w/breakthru pain meds PRN. " I'm thinking you mean oxycontin 30 mg for continued long acting relief? What are you using for breakthru pain? An addition of elavil or neurontin would probably help. I suffered with "all over fibromyalgia like pain" and elavil worked wonders.
    I empathize with you, as a Hospice nurse I certainly have had my fights with MD's. I have found some success with asking for Kadian, or switching to MScontin as some people respond better to one or the other for some reason.
    I had a pt on 300 mg MS contin BID and 2-3 cc roxanol q 1-2 hours for breakthru, taking it pretty much on time w/a. He walked around and went out and had to be discharged from the program d/t improved status (after I left the job, I heard). I would have tried methadone to improve his lifestyle, and kept him on the program for pain med adjustment, if I could have.He also took ibuprofen and elavil.
    Good luck and keep us posted! PS, since Kadian is 24 hour coverage, you don;t have to depend on other shifts to medicate. I also think that working with the pt gives some relief, maybe the placebo effect, or the fact that they are validated.
  10. by   RAMROD MITTEN
    Treatment of Neuropathic pain usually requires a polypharmacy approach.
    First and foremost, the patient needs to be trying Tegretol. IMHO, it's the BEST agent for neuropathic pain. If pain centers at just one spot, a Lidoderm patch may be helpful, but I really doubt it's usefulness.
    Methadone would be a wonderful treatment option for this patient. 10mg TID would, I suspect, make a HUGE difference in their QOL. Dilaudid 2mg PO q4PRN would also be my choice for BTP.

    Finally, Elavil Elavil Elavil! Needa start some Elavil!



    -Dave, and yes.... THAT one.
  11. by   CoffeeRTC
    I agree with everyone here, but we are missing another big issue here..what type of facility is this person in? A LTC? Hospice? Treating pain is a big issue in LTC QIs... and is looked at by state inspectors. If the facility is refusing to treat this persons pain, based on the hospice suggestions..maybe these agencies need to be notified. I'm sure this isn't an isolated incident.
  12. by   momcats3
    Hi Everyone,
    Thanks so much for the ideas and words of encouragement. Have looked at Elavil, Neurontin and others as adjuncts and for one reason or another, they didn't work out. I'm going to look into the Tegretol for her...Also talked to our NP who'd done a pain eval. for this patient last fall. We made recommendations then, which the facility/MD agree with, however, they will not agree w/our latest recommendation on increasing the med. And, BTW our NP told me that, at that time, these same nurses laughed, actually laughed, when they heard we were evaluating for pain control. So, am still fighting hard - have a great hospice team behind me, and we WILL get her pain undercontrol. Oh, and by the way, rumor has it that the state will be in there w/in the next 2 weeks. I've been documenting everything....If nothing gets resolved, will take it further.
    :angel2:
  13. by   dhudzinski
    Quote from momcats3
    Hi Everyone,
    Thanks so much for the ideas and words of encouragement. Have looked at Elavil, Neurontin and others as adjuncts and for one reason or another, they didn't work out. I'm going to look into the Tegretol for her...Also talked to our NP who'd done a pain eval. for this patient last fall. We made recommendations then, which the facility/MD agree with, however, they will not agree w/our latest recommendation on increasing the med. And, BTW our NP told me that, at that time, these same nurses laughed, actually laughed, when they heard we were evaluating for pain control. So, am still fighting hard - have a great hospice team behind me, and we WILL get her pain undercontrol. Oh, and by the way, rumor has it that the state will be in there w/in the next 2 weeks. I've been documenting everything....If nothing gets resolved, will take it further.
    :angel2:
    Don't give up! You are on the right track. You have received a lot of great advice. THE biggest thing that needs to be done is a VERY thorough pain assessment. I have found that even the most confused or demented patient can let me know about their pain as long as I am observant and patient with them long enough.

    I have been working on Pain managment for the past 29 years and have been a pain management Nurse specialist for the past 15 yrs. I see RED :angryfire when I encounter individuals whether they be nurses, or physicians or family members who discount a patient's pain complaints. BUT I try to use each incident as a chance to teach about the effects of untreated pain.

    The research is out there that shows that when pain is not treated and is allowed to continue the nervous system changes and nerve endings that normally do not transmit pain are now being recruited to transmit pain messages. Thus the patient's pain grows and they will say I hurt all over and even my skin hurts. and confused patients will become agitated and combative when they are touched and turned.

    I have had personal experience with severe pain that was not believed. I also had a sister who died (at the age of 42) from metastatic colon cancer because she was labeled as a drug seeker, neurotic over anxious female and NEVER really assessed for the pain that she had for three years.

    Compassionate care demands that we treat each person as we would like to be treated if we were in the same circumstances. No one is immune from pain and my continued dream is that one day I will be called to the bedside of one on the "unbelievers" and have the opportunity to teach them about pain treatment, in a compassionate way OF COURSE!
    I could go on and on about pain managment but I will stop here..
    keep us posted! and good luck, you are in my thoughts!
  14. by   NRSKarenRN
    Great replys. Trial and elimination sometimes difficult but worthwhile in the end. Have seen low dose steriods added and beneficial to those with MS.neurological disease.

    Don't forget to assess THE BED patient is in! Too many times mattress is old , patient sacrum / buttucks easily felt w hand underneath mattress. Have seen patients pain relieved with 4# thick eggcrate mattress, low airloss matress, even sheepskin underneath legs. Keep up the good work.

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