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.
But I think what ERRNTraveler is saying is that most patients don't snuggle up to go to sleep if their pain is high, like a 9/10 or 10/10. If your pain is that high, you are trying to move around and get comfortable, and your mind is focusing only on relief. And I think that when a patient is so sedated, whether on pain medication or anti-anxiety medications or whatever, if they are responsive to only painful stimuli, it may not be in their best interest to be further medicated. Especially in those who are opioid-naive, further medication may cause respiratory depression.
ERRNTraveler, if I'm wrong in my thinking of what you said, please correct me.
my heart goes out to all those who live in pain every day. i can't imagine how draining and disheartening it must be.
one poster mentioned a 24/7 pain service that manages all narcotic orders- what a beautiful idea! our pain services is not in house after hours- telephone consult only. and they are not involved frequently enough by the primary team. no one wants to deal with the pain issue until it is a crisis at 3AM and getting an epidural takes an act of congress.
in my current job the resistance to pain control for the pt is coming from the attendings. one surgeon in particular, who will not allow his patients to be medicated for pain or anxiety, he has the 2 mg morphine IV q 2-4 hours d/c on the AM of POD #1. HELLOOO... these are post open heart patients, 3 chest tubes and you want them OOB! it is so personally hard to see patients in pain, try to manage it non-pharmacologically, call repeatedly and just run into the "we don't want to over-medicate" wall
it's so bad, i think even at my relatively young age, if i was told i had to have CABG to save my life, i would think twice because it is mideval torture what they put these patients through. education of our older physicians on pain control is sorely needed
I am beyond tired, but I hope I this clarifies the point I was trying to make...
I mentioned the same thing twice because clearly, you & some others are not understanding my point. I NEVER said that if a pt. is sleeping, they couldn't be in any pain, only that if they would not wake up when spoken to or touched, and would only respond to painful stimulation, then they are overly sedated and should NOT be given any more narcotic pain medication.
I disagree. I am not speaking in absolutes, while it appears that you may be doing so. I said that not every patient who needs a sternal rub (or your painful stimulus of choice) to awaken is necessarily over-sedated. Clearly, some are. But not all.
YES, they are overly sedated. If the only way to wake a pt. up is through painful stimulation, continuing to give them sedating medications such as narcotics can cause respiratory issues. If you don't consider this to be over-sedated, then what DO you consider to be overly sedated??? Would you continue to give narcotics to a patient who was only responding to painful stimulation???
That depends on the patient.
I have, and I no doubt will again. In your response, you edited out an important point I was trying to make: Being awake is not a criteria for being in pain. Elevated pulse, respirations, and BP, sweating/flushing/tearing, restlessness, facial expressions and tension, muscle tension, etc., can all point to pain in a patient who is nonverbal or unconscious.
Do you not believe that someone who is unconscious can feel pain? If they respond to painful stimuli, the answer should be obvious.
The problem I see in dealing with pain issues is the 'one-size-fits-all' attitude. I believe it should be approached on an individual basis.
How, then, do you wake someone up who will not respond to any other stimulus??? If not a sternal rub, SOME form of painful stimulation must be used when verbal or other tactile stimulation fails to produce a response...
Why would you feel you must elicit a response? If a patient is stable, but unconscious or otherwise unresponsive to verbal/tactile stimuli, why cause them even more pain just to see if they respond?
Over the years, I've worked primarily in oncology, but have cared for patients with all sorts of pain issues. You don't treat those who are narcotic dependent/tolerant the same as you would those who are narcotic naive. You don't treat chronic pain patients who are narcotic dependent and in acute pain the same was you would those who are suffering from intractable chronic pain.
I suppose the problem I have with your statements above is that you appear to be painting all with the same broad brush. No, not every patient who "needs" painful stimuli to respond is over-sedated, and it certainly isn't a reason to withhold pain medication in those instances.
I agree with you. I would not medicate that patient. Nurses should not blindly medicate a patient with narcotics just because they ask....we must use good sound judgement and assess the patient first.
I am beyond tired, but I hope I this clarifies the point I was trying to make...
I disagree. I am not speaking in absolutes, while it appears that you may be doing so. I said that not every patient who needs a sternal rub (or your painful stimulus of choice) to awaken is necessarily over-sedated. Clearly, some are. But not all.
That depends on the patient.
I have, and I no doubt will again. In your response, you edited out an important point I was trying to make: Being awake is not a criteria for being in pain. Elevated pulse, respirations, and BP, sweating/flushing/tearing, restlessness, facial expressions and tension, muscle tension, etc., can all point to pain in a patient who is nonverbal or unconscious.
Do you not believe that someone who is unconscious can feel pain? If they respond to painful stimuli, the answer should be obvious.
The problem I see in dealing with pain issues is the 'one-size-fits-all' attitude. I believe it should be approached on an individual basis.
Why would you feel you must elicit a response? If a patient is stable, but unconscious or otherwise unresponsive to verbal/tactile stimuli, why cause them even more pain just to see if they respond?
Over the years, I've worked primarily in oncology, but have cared for patients with all sorts of pain issues. You don't treat those who are narcotic dependent/tolerant the same as you would those who are narcotic naive. You don't treat chronic pain patients who are narcotic dependent and in acute pain the same was you would those who are suffering from intractable chronic pain.
I suppose the problem I have with your statements above is that you appear to be painting all with the same broad brush. No, not every patient who "needs" painful stimuli to respond is over-sedated, and it certainly isn't a reason to withhold pain medication in those instances.
I see a difference here, Oncology patients versus Fibromyalgia. Big difference in how they are viewed.
Wonder how we went around and around and we all wound up saying the same thing.
LOL
How true.
I see a difference here, Oncology patients versus Fibromyalgia. Big difference in how they are viewed.
Well, that was my point--- you have to approach each one individually. There are oncology patients I've cared for who I would have considered to be over-sedated.
I deal with chronic pain patients every day. Yes, some of them can be royal PITAs, but the majority of our patients deal, day in and day out, with pain that would bring most of us to our knees, and they are usually as pleasant and friendly as any other patient.
What we need to recognise is that there is a distinct difference between addiction and dependance.
Addiction is a pathology, where the person repeatedly returns to the same agent, despite clear negative results. For example; getting high on whatever, finding yourself puking your toenails in a ditch and blacking out, only to wake up and knock over a 7-11 on your way back to your dealer to get more drugs and do it all again.
Dependance is a physiological reaction of the body to a chemical agent such as insulin, beta blockers or opioids(narcotic is a legal not a medical term). The body becomes chemically dependant on that agent to provide something the body itself cannot provide, ie: controlled blood sugar, controlled blood pressure, controlled pain.
The current focus regarding narcotics is aimed at discovering, thwarting and punishing the criminal element, (perhaps 10% of the whole, )both the physicians who are knowingly and illegally prescribing opioids and to those using and abusing them. This is an excellent goal, and should be vigorously pursued, by law enforcement.
Sadly, this admirable goal in recent years has been twisted and warped so much that many physicians are afraid or reluctant to prescribe pain meds to the vast majority of honest, legitimate patients who struggle not only with thier ongoing debilitating painful pathologies, but the ignorance, judgement and abuse of the very people who are supposed to be helping them.
I'm not saying that we should be pushovers for everyone we come across professionally or personally who says they have chronic pain, but let's at least give everyone an even assesment before we condemn them.
Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.
I have cared for many patients with narcotic addiction or tolerance issues and I am amazed at how few are actually honest about their issues. I have cared for several (some prisoners) who have admitted that they have used narcs in the past and thus have a high tolerance to pain meds. I have cared for a former nurse who had been addicted to oxycontin--a fact he admitted to me. I will go to bat for these people to get them the pain medication that they need. Yes, their tolerance level is much higher and thus they will need more medication to treat their pain than someone else will. I wish everyone was more honest--it would sure make my life easier. I get really tired of feeling like a "pusher" when I am administering IV narcs. Just be honest about your substance history folks!
I have suffered from chronic pain for over 25 years and I've seen the issues from both sides of the fence. I believe that the reason some patients have such terrible attitudes is that they have become used to getting that attitude from their healthcare providers and so they return it in advance as some sort of a defense mechanism. Other times, it is the result of the sheer agony they are in. I know I've been downright nasty as a post op patient and didn't have any recollection of it at all. I've also been in pain in the PACU and been told that I couldn't have more pain meds because the Doc didn't order them. My response was to page the Doc and ask for more. I got told that he wouldn't like that. Well heck, did she think I liked being in pain? I was in the PACU for crying out loud! We were talking about acute, post-op pain.
After having the OR booked for an appendectomy, a CT scan showed 30cm of inflammed terminal ileum which eventually led to my dx of Crohn's. I was working QA and only 4 weeks from a JCAHO survery. I didn't have the luxury of taking time off for further testing or the exploratory lap that was suggested, however, I did desperately need some pain relief. That got me labeled a "Drug Seeker" even with the clear indication of Crohn's Disease.
I've now added Ankylosing Spondylitis to the list of my medical problems and take 40mgs Oxycontin BID. My biggest fear is having an acute problem and not being able to take adequate pain control. As mentioned in so many previous posts, inpatients are often medicated at levels below their at home levels. They are dealing with some of their chronic pain, all of the acute pain and possibly even withdrawl. How could that make for a good attitude?
Recent oral surgery left me in agony. The dentist recommended that I take some Advil for the pain. Ummmm. I have IBD. I cannot tolerate NSAIDS and what good is 400mgs of ibuprofen going to do when I normally take the Oxycontin? I need my Pain Mgmt Doc to handle a little tooth problem because my Dentist is too scared.
I think the lines of tolerance, dependance and addiction have become too blurred for people to see past and the people suffering in the end are the patients. Education for everyone involved, including the patients is sorely lacking. The fact that I take more than enough meds to knock you out does not mean that I am over medicated, addicted, or no longer in pain. I will never be pain free and only hope to manage the pain well enough to allow me some sort of normal life. My diseases have already cost me my carreer, I will not allow them to make me bed-bound.
Recent oral surgery left me in agony. The dentist recommended that I take some Advil for the pain. Ummmm. I have IBD. I cannot tolerate NSAIDS and what good is 400mgs of ibuprofen going to do when I normally take the Oxycontin?
what's ibd?
ibuprofen could work for the post-dental pain as it does for most inflammatory disorders.
i administer potent narcotics all the time, but still give motrin for inflammation.
and you stated that you were in agony after your oral surgery...if you normally take 80 mg of oxycontin daily and it didn't help w/the agony, was the dentist supposed to prescribe an increased dose?
i'm truly trying to understand your expectations...
ERRNTraveler, RN
672 Posts
Yes, that is exactly what I meant..