chronic pain patients: pain in the behind to care for

[Tadpole]

Hello,

Just came here to blow some steam off. I just put in a three day stretch with a chronic pain patient assigned to me that was a royal pain in the behind to take care of. This patient was on our floor for a ORIF of her knee. She also had a hx of fibermyalgia and was on all kinds of pain meds and narcs and junk to keep her zoned out most of the time. I tried my best for the three days I had her as my patient to take very good care of her and meet her needs, but for the most time she was very rude and nasty to me. It did not matter what I did, I could never do enough nor could I do it right.

Here is the question I would like to put out there: Why do these docs keep ordering all of these highly addictive substances for these folks? I know that when I go see my doc he is very conservative about pain killers and does not want folks to become addicted to them. He will give you something for pain, but he won't keep ordering it over and over again for you. He also looks for alternative medicines to give to you that will do the same thing but are not addictive.

Another question to throw out there: Why are most chronic pain patients "nasty" to deal with? They always have "attitudes" with the nursing staff. Most are downright rude to everyone who takes care of them. Many do not know the words "thank you" and are very demanding and critical of your care to them.

Sorry if I sound like I am not compassionate. I really am. I just came here because this is a safe place to sound off about these issues. If anyone out there has some answers, please, please post them.

I just want to understand better why these people act the way they do. Thanks.

[rehab nurse]

to the poster who asked about my not having disability...

i tried to apply for long and short term disability, but i was denied due to my lupus. i was denied for additional life insurance too.

and my ex has his own small business and hides his little bit of money. i can't get anything from him.

my money has now been exhausted, and i have no more assets. it's scary how one illness on top of another wiped me out. my 401k, my house, everything is gone. the next month is going to be rough. i don't know what i'll do.

back on topic,

i absolutely believe, like P_RN, that only pain management docs should manage pain in the hospital. especially for those who are on narcotics long-term at home. regular docs are afraid to order the high doses these patients need. maybe some of it is because they are not up-to-date on new practice, but i know more of it is because they are scared of DEA and other discipline.

i wear a medic alert bracelet that's linked to my medical records for in case of emergency. i pray if i am ever in a trauma or find myself in a hospital and unable to speak for myself, that someone finds it and treats my pain appropriately. that's my worst fear.

this cancer is just ravaging through my body and wasting away the little strength i had left. i am afraid to see what life will be like when i am in my 50's or 60's if i am like this now.

thanks everybody for this thread. it is nice to discuss these things and learn from each other. i only wish this entitlement society we live in could learn to respect all nurses and other health care providers. it is scary reading about the increasing assaults on HCP's and nurses.

[EmmaG, RN]

This is what we try to get ordered but by the time we get our residents trained, a new group rotates in and it's back to square one. :trout: Cancer pain is never going away. These people wake up in excruciating pain or are afraid to fall asleep so their meds don't wear off. I can't tell you how many nights I've spent playing catch-up. [/quote']

You bring up a couple of good points. Getting pain under control is a hell of a lot more difficult to do than keeping it controlled. Many patients (no matter what their pain issues are, acute or chronic or a combination thereof) anticipate pain and that often results in the behaviours we see described here. There will always be "drug seekers" who only want the rush; those aren't the ones I'm referring to here. I think the problem is that all these people get lumped in together and judged as a group, when there are distinct differences in how to handle them and their pain. And those with chronic pain (or even those have repeated bouts of acute pain) know that they are viewed with suspicion, and that in itself makes them defensive, which can lead to demanding and rude behaviour.

If I have a patient with pain issues, I try to determine what exacerbates the pain and keep one step ahead of it. I'll offer pain meds when time, rather than waiting for the patient to call for them. Once they know that you're willing to work with them rather than against them in this respect, it establishes a sense of trust and oftentimes I've found that they are calmer and easier to deal with.

Just recently had a patient who was constantly calling for meds, requesting they be given round the clock even though they were ordered as prn. He didn't appear to be in pain, and when I questioned him, he admitted that he wasn't but rather was concerned that he wouldn't have enough "on board" when PT came in the morning to put him through his paces. We had a long talk, and I told him we could have PT call us ahead of time and we'd premedicate him prior to his sessions. He was satisfied with that and it worked for him. It had been the anticipation of how badly it was going to hurt to move and walk that had him laying awake all night watching the clock.

[leslie :-D]

Once they know that you're willing to work with them rather than against them in this respect, it establishes a sense of trust and oftentimes I've found that they are calmer and easier to deal with.

i second this!

a little 1:1 goes a long way in understanding your pt's behaviors.

once they feel vindicated, outcomes are usually much more desirable for nurse and pt.

leslie

[deeDawntee, RN]

What NEEDS to be done is for these patients to be seen and pain managed by a pain specialist who has total control over their first hours to days of hospitalization. My place had and entire anesthesia pain service.......surgeons and attendings could not write for or change narcotics. Only the pain service 24/7 could.

That is brilliant!! How can we get that instituted nationwide? Some of the stories on this post make me want to weep, from both sides of the stethoscope.

In many ways the nurse is as powerless as the patient. We both can be brutalized by the system.

What can we do...

[CHATSDALE]

constant, unrelenting pain will make a person cranky

we once had this young girl with sickle cell and i know that this is a painful crisis, her parents felt so guilty about passing this on that you had to weep for them but with all the understanding it was still a difficult shift

pain can cease to be a symptom and become disorder in itself

[deeDawntee, RN]

constant, unrelenting pain will make a person cranky

we once had this young girl with sickle cell and i know that this is a painful crisis, her parents felt so guilty about passing this on that you had to weep for them but with all the understanding it was still a difficult shift

pain can cease to be a symptom and become disorder in itself

Excellent point. Why isn't it seen as such?

[purple1953reading]

I think one of the main problems with uncontrolled pain is that we have gone from staying in the hospital a week or so to having surgery, and going home that day, or at the most, in 2 days. Therefore, the PCA or injectable or IV meds are dc'd the next am, and oral meds started, and then the next day, sent home. The surgeries don't hurt any less than they did a few years ago, we just don't medicate like we did. everything is headed to the MINIMUM. I know that the first OS I had, was free with oral meds, just see him monthly, but in the hospital, and post op he never ordered an increased dose for the narcotic toleraant patient. To order a narcotic patient the same dose as somebody who takes only tylenol is absolutely ridiculous. A friend with failed back surgery, was denied her normal meds because she had a 1 mg MS PCA. HOW IGNORANT!! There is differenec between addiction and tolerance, at least , in definition, but both are tolerant, and will suffer Withdrawal.

PLease be a patient advocate for your patients in pain. Why this is so mis managed is because drs. are afraid.

[EmmaG, RN]

Another good point.

We had an end-stage cancer patient who required continuous morphine at over 400 mg/hr. She would still awaken and was aware of her surroundings, but finally her pain was controlled. A pulled nurse found out about this and turned our doc into the hospital ethics committee for "physician assisted suicide"

Luckily, our doc won out.

Docs (and nurses) who are afraid of liability (criminal and otherwise), insurance companies that declare patients are discharged ASAP, hospitals that follow a customer service model as if they were a five-star hotel instead of a healthcare facility, a demanding public with just enough knowledge to be dangerous... no wonder we get caught in the middle, and these patients suffer as a result.

I agree that the best way to go would be a hospital pain management service that can assure everyone is treated individually according to their needs, rather than with a one-size-fits-all mentality. That would solve many of these problems; patients who truly do have chronic pain issues would get the level of care they deserve, and those who are simply "drug seeking" would soon learn their crap won't fly.

[EmmaG, RN]

constant, unrelenting pain will make a person cranky

we once had this young girl with sickle cell and i know that this is a painful crisis, her parents felt so guilty about passing this on that you had to weep for them but with all the understanding it was still a difficult shift

pain can cease to be a symptom and become disorder in itself

How sad, and how unnecessary. Pain simply perpetuates the crisis. LOTS of fluids, O2 and round the clock pain meds will often stop a crisis in its tracks; I have a real problem with docs who only order 'prn' pain meds for patients with sickle cell. This is one instance where you really DO have to keep ahead of the game, work to get it under control then medicate to prevent the pain from returning, and I've seen too many nurses unwilling to do this.

[deeDawntee, RN]

I would to extend my sincere thanks to everyone who has posted on this thread. This has been extremely enlightening for me. I have a complete different point of view of pain management now. It has been a "painful" process to see where the system has really let the patients down and the nurses as well.

:thankya:

I'm going to do some investigating at my facility about this issue and see if there is any policies that can be changed or implemented that might make a difference. I feel I have to at least try to do something.

[katfishLPN]

I am a chronic pain patient, and it hurt to read your post. I know you may not intend to generalize, but it hurt to read the title of this post. I know you are not talking about me personally, but patients like yours ruin for those of us who are legit pain patients.

I am a cancer patient, so that has increased my pain, but let me tell you that I was started on narcotics 3 years ago for intractable back pain. I'm not going into all my problems, but let me tell you that my surgeon referred me to pain management, and he told me nothing will ever help me. So did 3 other surgeons.

I did the PT, the exercises, the heat and the injections, etc. Then I worked my way up the pain med ladder. And, for those of you who freak out, let me tell you I don't practice anymore. I don't want any PM's telling me I'm an impaired nurse like I did last time I responded to a post about chronic pain patients.

CP patients like myself are usually (at least in my area) sent to a pain management specialist, who is usually and anesthesiologist for any type of chronic, intractable pain that doesn't respond to conservative measures. I waited 6 years to go on any meds, and I waited too long. I am young too. I'm just 30 years old. Anyway, I am on these meds because they are the only thing that has proven to give me any quality of life, and therefore, my doctors think they are appropriate. I can barely walk, not without a cane at least. But these meds at least give me a pain level of 4 most of the time and they allow me to care for my children, my home, etc. I can get out of bed and for the most part, do what I want. If I didn't have these meds, I would not be here today, I know that for certain. If you've ever had pain so bad you couldn't walk, take care of your own ADL's, and it lasted for weeks on end, you would feel like I do. Now with my cancer, the pain is worse.

I am sorry for the way your patient treated you. But please know, we are not all like that!!! Some patients are appropriate to be prescribed long term opiates, but those are not every pain patient. It has to be weighed between doctor and patient, and has many factors to consider. In this area, no primary docs prescribe anything more than a short course of C-III narcotics. If a patient doesn't respond, they are sent to pain management, and they start the long road of PT, injections, surgeries, etc. It's not just a "here, you have back pain, so here's your 80 mg Oxycontin. Come back in a month, ok?". I know I can't speak for your area, or even all patients, but I just want you to know that not every pain patient is like that!!! I am not!!! I am a very compliant patient, and my doctors respect me for that. I may be a minority, but I know a lot of people who are in constant pain and they wouldn't be able to function without some type of pain meds.

I know I am rambling here. I hope this is not coming across as condescending, or rude, because that is not my intention, honestly!!! I just wanted to give you a reason that patients are prescribed opiates long-term, and also tell you that I am sorry you were treated horribly by this woman.

I should also say, that pain does horrible things to your mind, especially when it's not adequately treated. You can get very irritable, anxious and depressed. Chronic pain especially depletes the chemicals in the brain and causes depression, that's been proven time and time again. So, a lot of pain patients have psych issues hand in hand with the pain, and that may be why your patient had such a bad attitude towards you?? I'm purely speculating here.

Anyway, I want to thank you for being a compassionate nurse. And again I am sorry for the way you were treated. I just had to reply to you and give you my story.

I am sorry for your pain but glad it is managed!! No matter how! Thank you for your post. I feel the same way. Very disappointed in the generalization.

[katfishLPN]

I think a good pain seminar would be appropriate, to help with some of the misconceptions. Just because you sleep doesn't mean you're not in pain by the way.