Non-verbal signs of pain - page 3

It always amazes me when I get patients from the hospital who are in horrific pain. I really don't understand. Usually report will include something along the line of "patient is uncooperative with... Read More

  1. Visit  Sparrow23 profile page
    0
    I have a question related to this. For hospice pts with morphine drips, if they become lethargic do you turn it down? Obviously I wouldn't want to decrease their pain meds if they were still in pain, but where do you draw the line in hospice pts between making them comfortable and causing an OD on morphine? In these pts (who were even a day before, A&Ox4 and still with some mobility and who are now lethargic/more confused/decreased respirations etc.) how do you tell the difference between signs of "actively dying" and the effects of pain meds, and how do you handle this? I want to make these pts as comfortable as possible, but I don't want to be responsible for inadvertently speeding up/causing the inevitable either! So much to learn...
  2. Visit  zofran profile page
    0
    Thank you so much for this post.

    I work med surge onc and I can't believe how some nurses ignore prn pain medication! When I call them on it its "They were sleeping," or "she does not like the way dilaudid makes her feel" Wake these people up, assess for pain, and do your job for godness sake!!!!!!! If they don't like dilaudid, give or ask for something else!
  3. Visit  FLArn profile page
    2
    Sparrow,
    The morphine dose is titrated up slowly using the amount of bolus medication needed by the patient over the past 24 hr. plus the patients assessment of their level of relief (i.e. pain was 8-9 on scale of 0-10 is now 2-3) as a guide. When medicated appropriately there is NO danger of an OD. We do not see respiratory depression, we see relief of tachypnea and labored breathing ( resp of 32- 40 and up now at 16-20). Sometimes the dying process accelerates rapidly and you do see a drastic decline overnight or even over the course of a single shift. You keep the patient comfortable using nonverbal cues if they are lethargic, etc. Often the pain meds have made them comfortable enough so they are able to relax and let go, but this is not the same thing as "speeding up the process" Remember, comfort is the primary goal with hospice patients.
    Whispera and ShayRN like this.
  4. Visit  JSlovex2 profile page
    0
    good post. when i was working as a CNA it was part of my job to ask patients to rate their pain. many elderly patients would deny being in pain, but it was obvious to me that they were hurting. i would tell the nurses and get the response, "well, he says he's not hurting." i don't care if they said "zero" and you saw that in the chart -it's obvious they're in pain! go look at the patient, not just their chart! my husband's grandmother is one of those people who doesn't like taking medication and thinks of pain medication as "drugs." she has denied needing pain medicine for years and just last week started moriphine patches. someone with no pain doesn't go from never taking a tylenol straight to needing the patch. she has been in pain for awhile and for whatever reason not wanted to take medicine.

    i've had talks with quite a few older patients who claim they don't need any medication when their body language tells me they do. it's so frustrating when a patient is in obvious pain and rejects medication that you know will give them relief. unfortunately, i think some people don't bother to dig any deeper if the patient says they aren't in pain or that they don't want meds bc for them that means less work.
  5. Visit  ShayRN profile page
    2
    @ Sparrow, I don't know about other hospice programs, but we have been known to turn down drips. Usually when the doc sees a significant drop in the urine output, he is afraid it will build up too fast. Sometimes, it goes right back up when the patient starts screaming out in pain an hour later, sometimes it is ok and the patient has enough in their system to keep them comfortable. I have even seen people wake up when we turn the drips down. So, ofcourse, that is always a concern. Just keep in mind, people who go on drips are the worst of the worst as far as pain managment. I don't just start a drip on someone first thing, we always start low and go slow with Morphine and other narcs. What I see most often is people in excruciating pain, who once the pain is controlled, is better able to communicate with their loved ones. It is always wonderful to hear a family member say they got to talk to their loved one one more time because they were finally comfortable.

    I also want to say, I am not just talking about morphine. How about Advil for arthritic pain? How about a tylenol for crying out loud. It drives me nuts that we don't think twice about popping a pill for a headache, but won't medicate someone who is sick and in bed for days. My back kills me in the morning until I get up and walk, can you imagine lying in a bed for days at a time, with NO pain medication offered? Believe me when I say, you get someone's pain under control, everyones life will be better!
    Whispera and tyvin like this.
  6. Visit  tyvin profile page
    0
    Quote from Sparrow23
    I have a question related to this. For hospice pts with morphine drips, if they become lethargic do you turn it down? Obviously I wouldn't want to decrease their pain meds if they were still in pain, but where do you draw the line in hospice pts between making them comfortable and causing an OD on morphine? In these pts (who were even a day before, A&Ox4 and still with some mobility and who are now lethargic/more confused/decreased respiration's etc.) how do you tell the difference between signs of "actively dying" and the effects of pain meds, and how do you handle this? I want to make these pts as comfortable as possible, but I don't want to be responsible for inadvertently speeding up/causing the inevitable either! So much to learn...
    Shay explained it well and I would like to add that you develop your skill with time. After a certain amount of dealing with helping people pass on you get a sense and know when they are snowed or resting or comfortable etc ... Many people don't want to be all doped up in the end and I assure them we can take the pain away and have them alert as well. Then you have the other group who could care less how groggy they are. And of course there are those that don't have pain at all.

    It is an honor to guide these people and help them on their final journey in life.
  7. Visit  Sparrow23 profile page
    1
    Thank you for those responses Tyvin, ShayRN and FLArn! I don't take care of hospice pts that often and I guess like anything else, it's going to take time for me to develop these skills... Looking back on some of the pts though, I am glad I went with my "instincts" and provided the care that I did. It's always so hard when you are first assigned a hospice pt whose been on the unit for a while and everyone is telling you different things regarding how they were acting previously, etc.
    tyvin likes this.
  8. Visit  bsnanat2 profile page
    0
    I am glad to see this thread and proud to say that, during my orientation recently, my health system spent almost a whole day on pain management. This included mostly new nurses and those new to the health system. They drilled into us pain assessment and made it clear that inpatient care in an acute care facility does not include diagnosing drug dependency and addiction. Not our job and we couldn't cure it anyway. The docs can make referrals to affiliated practices that handle these issues. Our job is to provide appropriate care related to their hospitalization. We were empowered with the ability to report docs and other RN's who were not taking proper steps to adequately manage patient pain. Of course, the problem is that there are nurses who take out their own issues on the patient, whether that be exercising some control over the patient because they have no control in their own life or the influence that drug addiction (whether theirs or a family member's) has had on their life. Either way, check your baggage at the door. The ED still treats appropriately but patients who exhibit drug seeking behavior (over numerous visits) will trigger a psych consult and outside referral and an in-house action plan. Some need true pain management and don't have the resources and some just don't have the money that week for street drugs. The point made was that, as nurses, we must use our training and think and not just go by the written orders and the canned responses we get from patients. Assess the pain level and treat accordingly. If the doc's orders aren't sufficient, request more or something different (give evidence supporting request) and if he doesn't respond, continue to advocate for your patient. Too many of us don't want to develop or exercise clinical judgement.


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