Are we adequately treating pain?

nyapa, RN · Nov 16, 2007

I think we do undertreat pain. And it is often based on prejudice. I cared for a man with ca of the bowel last week, newly diagnosed. He was in pain, but never complained unless you actually asked him. He just sat in his corner quietly. Now he refused chemo and radiotherapy because he has had family die of ca, and he has seen the effects of treatment.

The team would not give adequate pain relief, in fact we had to fight to get pain relief for him. Why? Because he was an IV drug user. He never showed any signs of withdrawal while he was in hospital, he never left the ward, and he had few visitors. They let him go home with two days of modified release medication, after which he had nothing.

He told me, interestingly, that at one stage he mentioned having therapy, Suddenly the teams attitude changed..."how are you feeling" "do you need pain relief" etc etc. He changed his mind again - his prerogative, and they treated him like dirt - again.

I hung my head in shame watching this. We all advocated plus, plus, for this man.

Hellllllo Nurse, BSN, RN · Nov 16, 2007

I know we are undertreating pain.

As a sufferer of chronic back pain which sometimes turns very acute, as well as debilitating migraines, I have been denied tx for pain and treated as a "seeker" a number of times.

mom4josh · Nov 16, 2007

One of our hospitalists is notorious for piss-poor amounts of pain meds, especially for cancer pain (I work oncology/medical floor). We had an 80-something woman with cancer for whom he wrote for 0.5 mg Morphine q4h prn. Practically needed an insulin syringe to measure!

Unfortunately, he usually isn't the one we have to wake at 2am for more pain meds.

Thankfully, our oncologist orders completely adequate doses (5-10 MS, 4-8 Dilaudid). He's who I want on MY case!

Hellllllo Nurse, BSN, RN · Nov 16, 2007

When I worked hospice, our standing orders included MS up to 20mg q 1 hr without having to call a doc.:pumpiron:

Sabby_NC · Nov 16, 2007

Good thread. No we do not.

Pain is what the patient tells us it is. My goodness me if my patient rates pain that is unacceptable to them well then it is unacceptable to me. Titrate Titrate and titrate.

I am relieved that we have standing orders and comfort kits that have opioids in them that we can activate and use in a pain crisis.

Personally I believe for my patients that opioid rotation works so much better for them. Tolerance is built up quickly in patients with acute pain.

I saw the show you are talking about and I cringed.

This is the 21st century and there are a lot of great pain medications out there. Let's use them

Anagray, BSN · Nov 16, 2007

not where I work. the first thing a person gets is pain relief if they have pain (and sometimes even when they do not). I can not tell you how many people I deal with who are seeking Hydromorphone. I feel very bad for them and most of the time I feel like there is no other way but to give them what they want.

Blee O'Myacin, BSN, RN · Nov 16, 2007

I just watched an episode of Trauma Life in the ER and Code Blue on Discovery health and observed two different cases.
#1 Was a young boy (prob 6 or so) with an almost full amputation of his left arm, midline humerous area due to a boating accident. It was pretty heart wrenching hearing this boy cry and tell his dad that its hurts so bad. He was given 2 of morphine pre-hospital and additional on arrival.
#2 Was a ~35 y/o female involved in an MVA with a femur fracture of her left leg. This lady was in some extreme pain and was very voval about it. The Chief Surgical Resident was pretty pompass in my opinion and finally ordered 2 mg of morphine, just prior to them putting her into a traction splint. Needless to say, she screemed the entire time. Why?
Now, I understand the argument of of masking pain, but how can we let our patients writhe pain??? Research has shown that we under treat pain. Does anyone else have any experiences or thoughts to share?

2mg of morphine is like spitting into the wind. Pain is a huge issue in the ER where I work - there are some docs who treat it well and some that are more hesitant.

My feeling on this is that it is part of my job to take issue with the undertreatment of pain for my patient. If this comes up, I document the dose not working, the request (and then denial) for additional pain medication.

Pain is what the patient says it is - and a person in pain would be "seeking" pain meds if they are in the ER. So why not just treat? (I'm not talking about the addicts just in for a fix, but even addicts get sick and break bones - and then it is inappropriate not to treat their pain with an inadequate dose of meds).

Blee

NurseNature · Nov 16, 2007

This undermedication of pain has actually been one of the biggest shocks for me in clinical settings. In school we are constantly taught about around the clock pain control and treating pain before it starts and so on and so forth. Then we get to clinicals... and it just makes me cringe. Most of the nurses don't even give pain meds that ARE on standing orders unless they feel the pt is in extreme pain. Pediatrics have been the only exception thus far.

I recently had a close family friend pass away from CA and he was literally screaming in pain the last week of his life. He refused visitors b/c he was in so much pain. I just couldn't help but think he was receivng inadequate care. From my understanding a dying pt should not be in pain. I know I have a lot to learn, but I hope I will be able to give comfort to the pt and family in knowing they/their loved one is not writhing in pain.

KulRN · Nov 16, 2007

and what about those patients who suffer from SICKLE CELL CRISIS???? In the hospital where I work at, we do see a lot of these patients suffering from sickle cell crisis and are frequent flyers. They come in almost lethargic due to unbearable pain, joints swelling, hypoapneic and showing signs of dehydration. I have seen a lot of nurses and even Docs just shrug their shoulders because they think these patients only comes to the hospital "to get their drugs" and even heard a comment saying "these people knows how to work the system in order to get free drugs". I don't exactly know how these patients feels when they're on crisis but I can't imagine the pain they're going through ( just by reading literature about sickle cell). I, personally don't judge these people right away...I look at the whole picture, their symptoms and labs. I know that majority of the point of care of these patients needs to begin from them. They need to be EDUCATED. I don't deny my patients their pain meds when they tell me that they're in pain....of course the only time I "hold off" is I see that they look too sedated and if their blood pressure calls for their meds to be held off. I mean we can see amongst them who's faking or who's sincere. Docs needs to be notified and sometimes educated as well...as we NURSES are the primary care taker of these patients and we spend a whole lot of time with them to know if something needs attention....WE ALL NEED TO THINK OUTSIDE THE BOX and not to judge too quick! :nono:

discobunni · Nov 16, 2007

Hmph! HECK NO!!! For example: (among others) A very close friend of mine on her way to her last day of clinical as a student nurse about a week ago got into an MVA. She was transported, and checked out by "fellow nurses" HAHAHAHAHA in the ER. Her foot was blue and broken in 4 places, she just had an ORIF yesterday. She told them how much pain she was in, they brought her two tylenol. When they began to set her foot, she is asking for pain relief in which the nurse went "heeheehee" and walked out of the room.:angryfire

Talk about wanting to punch somebody in the face!! :devil: And the crazy thing was, they KNEW she was an SN (so obviously was educated about pain management), and they deliberately didn't give her anything!:madface:

Aside from that...I DON'T CARE if someone is a drug user, or tests positive for drugs. If they are in a situation where they are OBVIOUSLY in pain, then I'm giving it as long as I can get an order and it is safe to do so. Furthermore...another problem is they don't seem to look at the person's tolerance to drugs, someone who is a drug user probably needs a higher dose for adequate pain control.

purple1953reading · Nov 16, 2007

Not only are people undermedicated, they are not properly medicated. Years ago, almost every patient had orders written for fever, pain, and pain not controlled by the first choice of drugs , i.e., Tylenol #3 , two tabs q 3-4 hours, prn pain, If not controlled by T3, may give Demerol 50 mg IM q4hrs prn. In addition, EVERY patient needs to be medicated for that acute pain due to trauma, that is not part of their chronic pain. Also, many meds don't work for some patients like they do others. Morphine, for example,has no effect on me. I found this out after a TKR, and was told the PCA was all I HAD. Most patients prefer Percocet or a oxycodone based med, then Codeine, or hydrocodone. We all know it is now the most abused drug, but , in addition to controlling pain, that drug also has an UPPER effect, where the patient FEELS BETTER, in additon to pain control that does not come with Vicodin. I prefer Vicodin, as I don't like the out of control feeling. BUT NO MATTER we MUST not let our patients lay there and cry and scream in pain. IT IS RIDICULOUS, and why should they be in a hospital, if it is not to be helped. I believe that as the advocate, we do everyting we can for our patients, but unless medical staff cooperates, we are often at a loss. Too many drs. are now afraid to prescribe adequate pain meds. IT is funny how if a dr has experienced the same type pain he is treating, the difference in the amount of pain control he offers his patients.