Dying, unresponsive patient and assessing pain

[tsm007]

Ugh, I hate this first year of nursing. I really wish I had a mentor, but for now AN is it.

Okay, onto my question. I was taking care of a hospice patient that was actively dying, unresponsive and had been NPO for 8-9 days. He had an order for Roxanol q 2hrs prn for pain. The nurse before me said she had been giving it every 2 hours for pain because he had some moaning and that his respirations were 4 and she expected him to die my shift. She recommended just giving him the Roxanol q 2 hrs. So I gave him Roxanol right when I came on shift due to her reports of moaning and pain and saying he was due for another dose. I talked to the family, did my assessment. Respirations were now 10. Every time I walked down the hall I sort of poked my head in to check on him. Two am went in to see how he was doing because I was going to give him another dose, but he wasn't moaning and didn't seem to be in pain that I could tell. The daughter was sleeping at bedside so I just kind of left them be. I repeated the same thing checking on him throughout and at 4 am he still didn't seem to be moaning and I couldn't really see anything that indicated he was in pain so I talked to the daughter who was now awake. I explained to her that I had checked on him at 2am and 3am and they were both sleeping and he didn't really seem to be in pain at that time so I let him be for now. I told her I could give him another dose if she'd like, but he wasn't showing any signs of pain. She said she kind of thought the same thing that he wasn't moaning like he was earlier and didn't seem like he was pain and honestly I think she was just looking for me to reassure her that he wasn't in pain.

Now, I am sitting here feeling bad because truth be told I am not 100% sure if I made the right decision. I sort of felt like the previous shift might have been trying to hasten death by giving it q2 hr instead of q2 hr prn, but I don't know. I wasn't there to assess him then. I don't feel like I was "holding" medication from him. It was ordered prn. Of course, at the same time I am not very good at assessing pain in unresponsive people yet. He didn't seem restless. He wasn't moaning. Can some of you give me some ideas on what things to look for to determine pain in unresponsive people? Do you think I made the right call on this? This is nursing judgement stuff is hard.

[NurseQT]

You did the right thing.. When assessing for nonverbal signs of pain look at their face.. Are they grimacing or have a calm/peaceful look. Look for restlessness, anxiety, or agitation. And check their respirations, are they uneven, labored, ect? If the patient is resting quietly I don't give them a PRN dose of pain meds unless the CNAs are planning on repositioning and providing cares.

Don't ever hesitate to call the hospice nurse if you have questions or concerns, this is their specialty and will most likely be able to offer you words of advice, suggestions, and reassurance.

[calivianya, BSN, RN]

I really like the CPOT scale for patients that can't tell you what the heck is going on.

It works like this:

[tsm007]

I really like the CPOT scale for patients that can't tell you what the heck is going on.

It works like this:

That is an awesome reference. Thank you.

[smoinat]

You made the right call. PRN is as needed, hospice is very difficult, if you can sleep with clear conscience that's what counts.

[AmyRN303, BSN, RN]

we use CPOT often for patients who cannot report pain...we have one score set for intubated patients and one for non-intubated patients. (Now I see it posted above!) Very helpful. Essentially what you did there!

[ktwlpn, LPN]

We schedule comfort meds around the clock and prn for breakthrough sypmtoms for actively dying patients.the physical process of the body shutting down may be uncomfortable iself.mottling,cyanosis,irregular respirations all seem capable of causing discomfort