Published Jun 7, 2013
NC29mom, ASN, LPN, RN
320 Posts
I have a hospice patient, admitted with ES Cardiac, and co-morbity of Gastroparesis. I am having a nigtmare of a time trying to get his ABD pain managed. Attempted to resort to using a Morphine PCA, but his wife backed out at the last minute, so now we are back to using PO meds. I have tried to educate myself on the disease, but there's just not a lot of information out there....especially related to pain management. So, I am turning to you....
Currently, he is receiving MS Contin ER 30mg PO Q8H, Morphine Sulfate IR 30mg PO Q4H PRN breakthrough pain (receiving ATC), and Roxanol 20mg/mL 1mL Q2H PRN breakthrough pain (receives almost Q2H ATC). Lorazepam 2mg PO Q4H PRN agitation, Reglan 5mg PO Q6H ATC, Phenergan 25mg PO Q6H PRN nausea (given ATC), Compazine 10mg Q6H ATC, and Zofran 4mg Q4H PRN nausea.
Now, I realize the morphine doses aren't very high. However, I just started working with this particular patient 2 weeks ago (another nurse was managing). Since I started working with him, the ER and IR doses have been increased from 15mg to 30mg. There's a long way to go with increasing the doses; however, there's been no significant change since increasing them over the past week. My patient still rates pain 10/10. The pain is not constant. He will be fine, then suddenly be in a pain crisis. He rarely eats ANYTHING. His blood sugars stay around 100-200, mainly because his caregiver gives Prednisone 5mg Qday. He has almost constant nausea, with intermittent dry heaving. Stools are white, and he is jaundiced, making me believe his liver is involved somehow. This is exactly why I wanted to convert to a PCA, because in my experience, any patient with liver issues/cancer, tend to do soooo much better when medication administered any route BUT oral. We use subcutaneous route for our PCA's (continuous infusion). Plus, he has a hard time keeping pills down with the n/v.
Please ask me any questions. I am begging for help! This man has absolutely no quality of life, and it's really bothering me. I know we have him for ES Cardiac, but our goal is symptom managment, regardless of the underlying cause.
thanks in advance for any input!!!
MomRN0913
1,131 Posts
I had a patient with end stage kidney disease who happened to have unexplained gastroperesis. She always, always, always was in pain. Eventually it was so what controlled with a duragesic patch and prn Roxanol and Ativan OP. this was in the home setting.
Perhaps your patient is simply not absorbing and if they won't take the IV route or sub q route you can try the patch and morphing via suppository.
I had a patient with end stage kidney disease who happened to have unexplained gastroperesis. She always, always, always was in pain. Eventually it was so what controlled with a duragesic patch and prn Roxanol and Ativan OP. this was in the home setting.Perhaps your patient is simply not absorbing and if they won't take the IV route or sub q route you can try the patch and morphing via suppository.
Got to love autocorrect. Morphine supp. Doh.
We tried a fentanyl patch.....wife ripped off bc she thought it was causing chest palpitations. ...she's bad for administering meds how she feels appropriate. ..its nothing for her to crush the morphine ER, even though weve told her not to. Shes definitely part of the problem.
Haven't tried morphine rectally; however, we give tabs PR all the time if cant swallow. Another issue is diarrhea. ....it comes and goes and usually comes during his pain crises, making that route difficult too.
I guess i was hoping there was a "magical" medication combo which would eliminate having a crisis.....
I was wondering if methadone would be a better choice....but then again hes still gonna need something for breakthrough. ..
Thanks for your suggestions! !
lovinlife11
138 Posts
Do u have continuous care available? Maybe someone to find out what works for him and educate the wife a bit? I like the idea of subcutaneous pca for pain too, maybe better absorption for him, it's too bad the wife is not on board. Let us know how it works out!
GoalsInTransition
96 Posts
Often, just switching narcs (even at equianalgesic doses) can produce better results. Is either Oxy or Dilaudid an option, even for breakthrough coverage?
I have had good luck giving Ativan 1-2 mg and Zofran 8mg ATC for patients with various gastric symptoms (q 4-6 h); both have the added benefit of mild sedation (AKA "relaxation").
I agree with you, though, in that the 30 of MS Contin (though increased significantly from the initial dose) is not nearly what the patient needs right now... Time to step it up-- lets hope your ordering provider is on board. Also, we give Roxanol q 1 hour PRN.
Good luck-- and let us know what works!
leslie :-D
11,191 Posts
seriously, i suspect the opioids are worsening his symptoms, as they further delay gastric emptying, delay gi motility, and can/do induce increased pain, n& v.
we've used erythromycin with decent/improved results...
along with neurontin and/or ultram and/or nortriptyline.
these meds were initiated after dc'ing the narcs and pts reported improved effect.
need to avoid or minimize anything narcotic and anticholinergic, as they appear to do more damage than good.
IF he needs to stay on narcs, i would try methadone as it is the only narc i know that responds favorably to neuro pain (which the gut is rich with neural networks)...
and PREVENT CONSTIPATION...which always, always, always worsens any situation.
i hope you are being aggressive with bowel mgmt.
gastroparesis IS a tough one.
if all his symptoms are refractory, perhaps ketamine may be the way to go...
but you need to be inpatient with experienced staff to administer.
wishing him and his family, comfort and resolution.
leslie
Im desperate for some help with managing a patient's pain/nausea symptoms. This is an ES cardiac hospice patient, but has zero quality of life r/t gastroparesis.
What do you do for your patient's to avoid a pain crisis? What do you do in the event of a crisis? My pt currently taking: MS Contin ER 30mg Q8H, Morphine sulfate IR 30mg Q4H PRN (getting ATC), Roxanol 20mg.QH prn (getting ATC), ativan 2mg Q4h atc, zofran 8mg Q6h atc, compazine 10mg q4h prn (receiving atc) phenergan 25mg.q6h atc, reglan 10mg QID, prednisone 5mg qday.
Any help, suggestions would be greatly appreciated. My pt is completely miserable. ....he really needs help!!
JustBeachyNurse, LPN
13,957 Posts
Duplicate threads merged.
mcnincha
2 Posts
I agree with previous post related to use of methadone...our medical director recently went to a conference where the use of low dose methadone tid or qid depending on pt and history proved more effective than doses increased to higher doses bid..kytril is also a wonderful antiemtic but is costly. If provider is resistant to methadone than suggest sq or iv diluiadid pca which is much more less likely to increase nausea with vomiting but will of course cause constipation...I hope this helps. Methadone if used correctly is a wonderful medication. I truly hope your pt recieves relief and you co tinue to care for your pts so deeply!!
Ps...for pain crisis he would really benefit from iv or some type line to give iv push dilauidid with max dose of 4 mg q hr and of course if you have pca pump clinician bolus can be given untill comfort achieved if titrate till effective order in place as can increase in basal rate and demand dose and time if order to titrate to effect....also it has been my experience that reglan is less than beneficial in our hospice pt population with side effects far outweighing benefits...just my experience and opinion..
Thanks so much for the awesome information. I am going to talk to our medical director about switching to methadone. And, possibly add neurontin. I am scared to stop all narcotics, as he is getting >500mg of morphine Q24H now.
Unfortunatly, we don't use IV routes in the home. We can do SQ PCA infusions, but the wife backed out at the last moment saying, "Lets wait until it gets really bad before we switch (like it could get any worse)". Right now, I am stuck with the PO/PR/topical routes of administration.
I have printed some information regarding diet compliance I plan on reviewing with the spouse. Hopefully, this will help also.
thanks so much for everyone's information. I will keep everyone updated. Hopefully my patient is headed toward more good days.