This is so hard to watch, and for the family too. Some LTC facilities are very opposed to controlling it because of the sedative effect the meds can have. I almost think I'd rather have physical pain!
Patient is on ativan 1mg Q4, valium 2.5 TID, no relief so far. Have you had a patient like this? What helped? Resperidal? Haldol? Add Xanax to the already antianxiety meds on board???
We are using soothing music, volunteers to come hold her hand etc...
I have had good luck with seroquel, trazadone, or haloperidol/risperidol. These can all cause some sedation, so we just start really low doses. Sometimes I have found that by the time someone is on increasing doses of strong long-acting narcotics, lortab is not effective in breakthrough pain. I hope this helps, but it can be a battle with facility staff, especially giving prns.
Specializes in BNAT instructor, ICU, Hospice,triage.
I hate to say it but we are not making any headway here. She is worse today but the ativan if it is having a paradoxical effect is probably still in her system. Fentanyl patch is at 100 mcg/hr, patient still states she has abdominal and headache pain. Started risperdal last week, increased it yesterday to 1mg BID. She is off of the ativan and valium and we started Xanax. I'm fearful that I may not have been aggressive enough and should have started her on haldol instead but was trying to keep the LTC facility happy.
Is she impacted or having urinary retention? Fentanyl is hard because you don't really know for sure how much they're absorbing. Would you consider converting her to something else or adding something for breakthrough?
That reminds me- it is fairly unusual but I have seen restlessness related to fentanyl. This has happened to me twice and both pts did well when the narcs were changed. I ditto methadone- it is a great drug. However- when you start methadone remember that someone with a previous narcotic use actually needs a LOWER starting dose of methadone. It is a very strange drug...
Specializes in BNAT instructor, ICU, Hospice,triage.
We just upped to Risperdal today to 2mg BID. She is still frantic but she does have episodes where she will sleep now. The doctor wanted to up the Risperdal first before starting the Haldol. This facility doesn't have experience with methadone. Would you still go that route? Her daughter actually said the other day that she thought the fentanyl may be causing it too. Patient is still on the fentanyl.
Specializes in psych, addictions, hospice, education.
Now that she's off the Ativan and Valium, i hope she's getting a dose of Xanax that will prevent withdrawal. If not, her continued restlessness could be withdrawal. Benzos can't just be stopped or cut down alot all at once.
Fentanyl patch seems like a strange way of pain control for someone nearing end of life in Hospice . I would definately look at switching this in case this is causing the problem. I wonder if a PCA pump would be more appropriate. That way, you can at least monitor how many demand doses and attempts your patient makes and will give you a better understanding of where the pain level is. You mention abdo pain, is there any bleeding that could be going on?
I recently had a patient with terrible agitation, worst I have experienced, We tried Haldol, Ativan, Phenobarb, opiods and finally we had some results with Prochlorperazine (compazine). Does your patient have a history of any Dementia? If so as another poster mentioned you could have a paradoxical effect, Benzo's sometimes make symptoms worse.
Make sure she has no unfinished business. sometimes if there is some emotional turmoil and unresolved issues, this can cause terrible agitation. Also, has anyone asked her if she is frightened? Does she have any unanswered questions about dying? Sometimes it is helpful to ask members of the family, particularly those that are close to the patient, to stay with them, including overnight, when sometimes these symptoms are heightened. Check with the patient first though. Ask her, "would it help if you daughter/son etc stayed with you for some company"
I feel for you, it is just a terrible symptom to see and can make us as nurses feel very helpless when we cannot alleviate it.
I definately think a more appropriate analgesia regimen is needed here, especially if you have ruled out urinary retention and constipation.
Would love an update on how you little lady is doing.
I recently had a patient with terrible agitation, worst I have experienced, We tried Haldol, Ativan, Phenobarb, opiods and finally we had some results with Prochlorperazine (compazine). Does your patient have a history of any Dementia? If so as another poster mentioned you could have a paradoxical effect, Benzo's sometimes make symptoms worse.
i too, have observed favorable results from compazine, on a few acutely anxious pts.
that, and thorazine we use pretty often...for agitation, anxiety, nausea/vomiting.
sometimes the old drugs are the mainstays of treatment.
. I would definately look at switching this in case this is causing the problem. I wonder if a PCA pump would be more appropriate. That way, you can at least monitor how many demand doses and attempts your patient makes and will give you a better understanding of where the pain level is. You mention abdo pain, is there any bleeding that could be going on?
ErinS, BSN, RN
347 Posts
I have had good luck with seroquel, trazadone, or haloperidol/risperidol. These can all cause some sedation, so we just start really low doses. Sometimes I have found that by the time someone is on increasing doses of strong long-acting narcotics, lortab is not effective in breakthrough pain. I hope this helps, but it can be a battle with facility staff, especially giving prns.