Dealing With the Patient in Pain

[mbrnstudent]

A question for anyone...

I'm a nursing student in my last semester of my RN program, and I'm still trying to perfect my communication with, sometimes difficult, patients. In a clinical situation, I was helping care for a patient in pain. Already on a PCA pump with morphine, the patient continued to report their pain level at 8 and up. The patient was also already receiving medication for nausea, but continued to ask for something or surely be sick. I tried explaining that we had already given all we could at the time. No more pain medication or anti-emetics could be given...and I was at a loss for words while this patient continued to report severe discomfort. I even tried repositioning, relaxation, distraction, anything.....Any thoughts on how best to manage pain such as this? How to communicate to someone that nothing else can be done for the time being?

[FLArn]

If the patient is reporting a pain level of 8/10 the doctor needs to be contacted for an order to increase the pain meds. and also more anti-emetics. Sometimes it is necessary to alternate 2 or more meds, such as zofran q8 alt. w/ compazine q 8 hr so something is given q 4 hr. It is actually dependent on the patient's diagnosis, post-op appendectomy would be medicated much differently from a terminal colon CA.

[Virgo_RN, BSN, RN]

If the morphine PCA isn't cutting it, the med could be changed to hydromorphone. A different antiemetic may be more effective as well.

[Tait, MSN, RN]

There is a phenomenon about morphine, and I have seen in action, where a patient actually reports higher pain with morphine.

I would have assured the patient that I would call the MD, and if they wouldn't do anything I would attempt to at least get a pain management consult with anesthesia.

Tait

[PostOpPrincess, BSN, RN]

I agree with all of the above posters. Also, if you have a chronic pain patient, perhaps you should ascertain that the Pain Control Team/Pain Doctor is involved?

I deal with post-op pain a lot--but there is a difference in dealing with post-op versus cancer or versus nerve pain, etc.,

In post-op pain, 8/10 is not acceptable.......as for the other situations, best to consult an expert in those areas....

[JomoNurse]

Sometimes you have to ask yourself if the patient has a drug problem and is just chasing a high. Some drug addicted patients will say they have a 10/10 pain any time they are conscious. If the patient has a confirmed diagnoses that causes pain, then by all means a new medicine needs to be tried out and/or the dose needs to be changed.

[FLArn]

Addicted patients' reports of pain can NOT be discounted as simply "med seeking" ; these patients will have developed a higher drug tolerance and may truly need more med to achieve acceptable pain management. The first priority MUST be acceptable pain control. Then we can address the issue of addiction. Esp. in post-op patients and in terminal patients is addiction really an issue?

[rn/writer, RN]

I have a husband and a daughter who do NOT get adequate relief from morphine. If they require a PCA, they need dilaudid. I have post c-section patients who do NOT get relief from their Dilaudid PCA and need morphine. Some of my patients actually do better on an oral narcotic and we d/c the PCA altogether.

If I can't find a way for my patient to have a manageable pain level (or n/v control), you'd better bet I'll be calling the resident to ask for other alternatives.

Keep in mind, too, that people with severe chronic pain problems or intractable CA or bone pain may be accustomed to enormous amounts of pain meds. What would knock most of us on our backsides barely makes a dent for them. They suffer greatly at the hands of docs and nurses who are afraid of narcotics and do not understand their proper use for this kind of patient.

Calling in the pain team, if one is available, is an excellent idea. Even if it takes a while to find the proper meds, there has to be some comfort for the patient in knowing their needs are being taken seriously and that we care enough to keep trying.

[Virgo_RN, BSN, RN]

Yes, some people do have an incredibly high tolerance to pain meds. I remember once a patient who went through three Dilaudid PCA syringes in one 8hr shift, and still their pain was out of control. The doctor would not order anything more, and said that she had counseled the patient prior to surgery that the pain would be difficult to control safely.

I've also had a few patients that were so sedated that they were snoring while sitting up in the chair talking to me, or their RR was

Fortunately, these situations have not been the norm, but they do happen.

[RNperdiem, RN]

From a nursing point of view, you have done all you can.

If all those interventions are not enough to keep the patient's pain under control, then it is time for the doctor to be called.

[rachelgeorgina]

MD and/or pain team needs to review.

[AnnieNHRN]

I agree with a lot of the previous posters. One thing I have noticed, especially with post-op ortho pts, is that Percocet ends up giving better pain relief than a Morphine PCA. I see a lot of nausea with Morphine too. Heavier guns don't always mean better pain relief.