pain management, how do I get better with this?

Nurses General Nursing

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Specializes in hospice, ortho,clinical review.

This is sort of ironic b/c this is actually one my real interests in nursing and I find I know nothing really and don't know where to start.

How do you start to find out what works with what and what you can and can't give together?

I'm learning when they come from post op w/pca's they stay for a night then the next day they're told to give them self 1 last dose while taking say 2 percocets b/c it takes time for that to kick in and they have the immediate release of pain relief from the bolus dose. That makes sense, so I got that part and I understand percocets and tylenol limits and the whole "cets" means acetaminophen.

But last night I had a pt whom everything was giving her N/V I had her the night before when she still had the morphine pump, she managed to talk the doctors into taking it away sooner. The strongest thing she wanted and that worked for her come last light, was 2 extra strength tylenol. Prior to her getting the order changed from 500 to 1000mg of tylenol she had an order for Celebrex. I read up that it's more of a NSAID but she was extremely nervous about taking b/c of the prior N/V that just settled down. (btw she had to take compazine for it to finally work, Zofran did nothing) I didn't push it b/c I wasn't fully aware of the interactions myself, just what was known about the individual drug.

Now at home, on my own research, I see I should have encouraged it more strongly b/c the two work really well together apparantly.

I was able to talk a different pt into taking his Fe even though he originally didn't see the point, b/c I was able to point out how low his H/H was, even though he got an auto transfusion....that I could do, pain management I have no clue where to start to not only be safe but really efficient in helping pts.

Anything you could recommend that I could read up on? Sites that would help? Also, I understand when for example, Neurontin is added b/c I read up on that previously. But I get really stuck on when they start mixing different pain killers...another example was a pt that came up with IV dilaudid and it wasn't cutting it for her so they were trying to give a last IV dose of that while starting her on Percocet! How do you know you can do that within a short time frame?

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You know a lot. You have done great research and your questions are great. Pain management can be all over the place. It is really the "art" of medicine.

First of all have good knowledge of narcan and romazicon (and probably other newer antagonists?) Be comfortable with airway management, bag face mask devices, jaw thrusts.

I have had chronic pain patients come in for minor procedures and have given them, in incremental doses, 1,000 micrograms of fentanyl IV in recovery over a short period of time. These patients are on a lot of pain medicine at home and have a high tolerance. They stay awake (and alive, ha ha), they ambulate to the wheel chair and go home.

You have to trust your gut, trust what the patient is saying, trust what the patient looks like, vital signs, level of consciousness, etc.

Try to relax, narcan works great, ha ha. (I hope you don't reach that point, but if you do!!!!)

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Specializes in ER/ICU/STICU.
Prior to her getting the order changed from 500 to 1000mg of tylenol she had an order for Celebrex. I read up that it's more of a NSAID but she was extremely nervous about taking b/c of the prior N/V that just settled down.

Bottom line is every patient is different and not everything works on everyone. Even though Tylenol is an NSAID, it has no anti-inflammatory effects. Without getting into too much detail, do a search os Cox 1 and Cox 2. Pain management can be very hard because it is very subjective and everyone has different tolerances. Sometimes the only thing you can do is trial and error

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Specializes in Oncology; medical specialty website.

This book has a lot of great information and goes over the basic principles of pain mgmt. I've heard Margo McCaffery speak a couple of times. She's inspiring.

Don't let the fact that the book's ten years old put you off. You'll learn a lot.

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Bottom line is every patient is different and not everything works on everyone. Even though Tylenol is an NSAID, it has no anti-inflammatory effects. Without getting into too much detail, do a search os Cox 1 and Cox 2. Pain management can be very hard because it is very subjective and everyone has different tolerances. Sometimes the only thing you can do is trial and error

Tylenol is not an NSAID.

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Specializes in NICU/Subacute/MDS.
Bottom line is every patient is different and not everything works on everyone. Even though Tylenol is an NSAID, it has no anti-inflammatory effects. Without getting into too much detail, do a search os Cox 1 and Cox 2. Pain management can be very hard because it is very subjective and everyone has different tolerances. Sometimes the only thing you can do is trial and error

Tylenol is not an NSAID. You are correct that is does not have anti-inflammatory effects, hence many people use Tylenol combined with an NSAID (like Ibuprofen) to relieve chronic pain.

Tylenol website

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A great resource for pain management information / guidance is an experienced hospice nurse. During the many years I did hospice nursing I consulted / advised with many non-hospice / non-terminal cases as pain control is truly an art / area of emphasis and expertise in hospice care. Many of the principles can be applied across the spectrum.

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Specializes in Developmental Disabilites,.

Giving alot of pain meds can be scary. The big thing is look at your patient. Is she AOx3, or is she having a hard time keeping her head up? How is their speech and breathing? The general rule of thumb is start low and go slow. You also have to compensate for the amount of pain meds the pt was on at home.

As far as giving IV meds and orals at the same time it helps if you know the half lives of the meds. I try to time it so that the IV med is wearing off just as the oral med is kicking in. With a PCA I let the PT keep the button for half an hour after an oral dose. PO pain meds don't kick in for about 30-45mins. If you give the pill and let them only press the button one more time that leaves a possible 30+ min time frame for uncontrolled pain.

Muscle relaxants are another great tool in pain control. When people are in pain they tend to tense the muscles which causes more pain. So something like valium really helps to relax everything.

When I am playing with pain meds and dosages I keep my pt's on cont pulse ox. Just keep in the back of your mind that Narcan works great.

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Specializes in ER/ICU/STICU.
Tylenol is not an NSAID. You are correct that is does not have anti-inflammatory effects, hence many people use Tylenol combined with an NSAID (like Ibuprofen) to relieve chronic pain.

Tylenol website

My bad you are right, non opioid analgesic

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

Follow a recovery room nurse for about a month.

Pain management is an art.

If you're not careful, you can titrate meds to general anesthesia or undermedicate which is just as bad.

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Specializes in pediatrics, palliative, pain management.
This book has a lot of great information and goes over the basic principles of pain mgmt. I've heard Margo McCaffery speak a couple of times. She's inspiring.

Don't let the fact that the book's ten years old put you off. You'll learn a lot.

Yes, great book! Actually She just wrote a new one that came out this summer. I haven't gotten it yet, but have heard it is very good. "Pain Assessment and Pharmacological Management" Chris Pasero & Margo Mcaffery, 2010.

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Pain management is an art.

If you're not careful, you can titrate meds to general anesthesia or undermedicate which is just as bad.

thanks, jo.

it really is an art, esp since we're trying to get pts in a place where THEY want to be.

one pt will happily live w/mod pain, as long as they remain alert.

others want to be snowed, which is where the true art comes in.

that's when the nurse really needs to assess that pain is gone...even when the pt disagrees.;)

and rr is the least of my concerns...as many folks still suffer w/low resps...and so, you give until pain is gone (in hospice, anyways).

lastly, it seems that nsaids are grossly underutilized w/narcs.

yet their synergistic effects are like no other.

with lots of types of pain, there is indeed, an inflammtory process going on.

and inflammation hurts.

so whether i am giving morphine, dilaudid, fentanyl, i'll always give nsaids with it.

leslie

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