When nurses disagree about pain management...

[flashpoint]

I work in an LTC. Most of our residents are quite young...most of them are under age 70. We have a few residents who have a long history of severe pain and receive narcotics on a regular basis. We have a new nurse who has been there less than a month who doesn't believe that they are in pain and is working to get their mediations reduced. One of the ladies has a long history of abdominal pain to to benign cysts and abcesses...she has had over 20 surgeries, but the cysts and abcesses continue to come back. Apparently, the cysts are back and causing her a great deal of pain. I have no idea if she is really hurting or not. There is no obvious change in vital signs, but she does become diaphoretic, guards her abdomen when she walks, and grimaces. So..since she stated she was getting no pain relief, I talked to her doctor, who increased her pain meds until she can see her surgeon on Monday. The new nurse is really upset that I did this. She told me that she does not believe for a minute that the resident is having that much pain and that when she is distracted by activities that she doesn't request pain meds. She makes the resident wait an 30-60 minutes before giving PRN meds that are due. She also told another nurse that I am just a sucker and that the residents can talk me into anything...she says that she is going to tuirn me in to the state.

I'm not sure what to think about this...I really don't know if this lady is having that much pain or not. She acts like she is having that much pain, but she has a long history of narcotic use (abuse?) and is probably a good actresss. She is not sedated, gets very poor sleep, walks with a steady gait...I just don't know. I am starting to question whether I should be giving the meds or not...I am concerned that I am just feeding an addiction rather than trying to treat her pain...I am concerned that I may be putting my license in jeopardy. I would hope that if I were out of line in giving meds when residents say they are in pain, that someone would have said something to me by now, but maybe it just takes a new set of eyes to see that I am messing up.

My manger is really no help...I've asked her point blank whether I am overmedicating the residents and I've never gotten an answer...she just says things like, "If you have an order, you should be OK."

[Antikigirl, ASN, RN]

OH btw, on pain being pain...yes and no. If you have someone that is not able to make medical choices for themselves they are not in the right state of mind also to make pain assessments. So going only by word of mouth is incorrect. Go by symptoms too! Read that body folks...don't automatically say NO they aren't because they are sleeping..watch them as they sleep..are they twitching, do they look exausted from pain and passed out? Lots to consider!

Body language for me is key to pain..when I am in pain (which I have a high tolenance to and don't like meds myself)...my left ankle moves alot! Don't know why..but if that sucker gets moving...it will increase to the leg and eventually me clawing like I am trying to leave my body with skin and such behind! (when I am at a 10...it is serious...I loose my mind at 8!).

Some stoic people also show pain...showing expressions is a key to a stoic pt, twitch, blinking, not being able to sit in one position for more than a few minutes! Even post stroke pts show signs!

Learn your pt, learn their 'tells' (like in poker! You can tell)...and try to help..that is all we can do!

But to automatically assume a patient is in pain because they say so...naaaa...I don't go by that alone. I mean...would I assess someones cardiac condition by them saying only "I don't have chest pain"...NO! So pain is no different..you just have to be a bit more open to signs!

Also there are cultural stereotypes for pain as well...watch for those! Some maternal women don't want themselves to be seen as weak and unable to care for their loved ones and will hide it no matter how it hurts. Some men would rather walk that admit they have a broken hip! Watch for that too..it is all part of the story! Heck, even people with low tolerence will seem like they are in pain all the darn time and say such, but there is a point where pain relief is hazzardous...so you have to be careful!

I will typically have a small convo on pain with pts..see what their history is...best way to tell if something is wrong...see the way it has been so far for them! AND I discuss a pain plan WITH the pt doing comprimise for best results always having them know that I can add or subtact as they need! That takes care of some of the anxiety..which is a large part of the pain path!

[fultzymom]

OH btw, on pain being pain...yes and no. If you have someone that is not able to make medical choices for themselves they are not in the right state of mind also to make pain assessments. So going only by word of mouth is incorrect. Go by symptoms too! Read that body folks...don't automatically say NO they aren't because they are sleeping..watch them as they sleep..are they twitching, do they look exausted from pain and passed out? Lots to consider!

Body language for me is key to pain..when I am in pain (which I have a high tolenance to and don't like meds myself)...my left ankle moves alot! Don't know why..but if that sucker gets moving...it will increase to the leg and eventually me clawing like I am trying to leave my body with skin and such behind! (when I am at a 10...it is serious...I loose my mind at 8!).

Some stoic people also show pain...showing expressions is a key to a stoic pt, twitch, blinking, not being able to sit in one position for more than a few minutes! Even post stroke pts show signs!

Learn your pt, learn their 'tells' (like in poker! You can tell)...and try to help..that is all we can do!

But to automatically assume a patient is in pain because they say so...naaaa...I don't go by that alone. I mean...would I assess someones cardiac condition by them saying only "I don't have chest pain"...NO! So pain is no different..you just have to be a bit more open to signs!

Also there are cultural stereotypes for pain as well...watch for those! Some maternal women don't want themselves to be seen as weak and unable to care for their loved ones and will hide it no matter how it hurts. Some men would rather walk that admit they have a broken hip! Watch for that too..it is all part of the story! Heck, even people with low tolerence will seem like they are in pain all the darn time and say such, but there is a point where pain relief is hazzardous...so you have to be careful!

I will typically have a small convo on pain with pts..see what their history is...best way to tell if something is wrong...see the way it has been so far for them! AND I discuss a pain plan WITH the pt doing comprimise for best results always having them know that I can add or subtact as they need! That takes care of some of the anxiety..which is a large part of the pain path!

This is true but you still can not refuse to give a patient pain meds just because you think they are not really in pain. That nurse should not be trying to get meds changed just because she thinks the patient is not really hurting. I have a high pain tolerence so I do not necessarily act like someone who does not. I do not yell, scream, ect or act out but if I am hurting, I don't want someone telling me that I can have pain because I am not "acting" like they thinik I should be if I was really in pain.

[subee, MSN, CRNA]

This is true but you still can not refuse to give a patient pain meds just because you think they are not really in pain. That nurse should not be trying to get meds changed just because she thinks the patient is not really hurting. I have a high pain tolerence so I do not necessarily act like someone who does not. I do not yell, scream, ect or act out but if I am hurting, I don't want someone telling me that I can have pain because I am not "acting" like they thinik I should be if I was really in pain.

Maybe this nurse has addiction issues in her family and pain patients press all her buttons. Certainly, she needs some education. Its a big problem when people bring their problems from home to work (unknowingly).

[fultzymom]

This is just an issue that really gets to me. It is because I was on the receiving end of this. I had just given birth to my second daughter. She was almost 10 lbs and I had her naturally. I kept telling the nurses, doctor, and STNA''s that something was wrong and I could not hardly walk. No one would listen to me. Finally on the day I was supposed to go home, I asked my doctor how I could go home when I could not even walk. She did a x-ray of my pelvic bone and found a one inch gap where your pelvic bone comes together in the front. The baby had actually torn the cartilige off of my pelvic bone in the front where it holds the two sides together! The ortho doc who came in to look said that it would heal back on its own but it would take about 6 weeks like a broken bone. Man he was not kidding. And she is now 4 years old and sometimes it still hurts there if I lay in certain positions!! But after they did the x-rays, one of the staff members actually came in and told me they did not believe me that I was in that much pain until they saw the proof that something was wrong. I learned that day that just because someone does not look like they are hurting that much does not mean that they aren't. Any ways, why would they not believe me? I had just given birth to a sumo baby naturally and did not complain about that !!:roll

[TazziRN, RN]

Mac, pain is very subjective, that's the whole idea behind the pain scale, etc. Chronic painers also often do not have VS changes, you know that too. And somebody needs to tell this silly twit that most people can be distracted from pain for a short time; it doesn't mean they're not in pain.

I'm not telling you anything you don't already know. I'd talk to the supervisor if I were you.

[Creamsoda, ASN, RN]

Pain is what the patient says it is. It really irritates me that some nurses think they "know" if a person is in pain. If they are in pain, give them the darn medication. For one thing, they are 70 years old, and living in a LTC, whats the point of holding back? Let them live their final years in comfort. I truely hope these nurses are in the same position later on in life, they obviously need inservicing on pain management.

[medsurgnurse, RN]

I would rather medicate a person NOT in pain than not medicate a person that is in pain. Let this other nurse try to turn you into state, she'll just be drawing attention to her not properly medicating pain.

If it's chronic pain, of course her VS don't change, and she can walk around. She's grown used to it. Doesn't mean she likes it or should have to stay in pain. And of course activities distract her. Doesn't mean she isn't hurting while she's doing them. Best course of action would be medicate her, then give her an activity to take her mind off things until it kicks in. Of course, that should be for breakthrough pain. If she's got chronic pain, she should be on something scheduled, easier to keep pain down than to get it down.

Just what I was thinking. Let her "turn you in" for what giving an ordered medication appropriately.

[Phen]

If pain could be measured objectively like say Hb levels, then interventions could also be addressed as such; One would therefore not have to rely exactly on the pt's own assessment.

In this case however, one's decision is greatly influenced by what the pt reports(plus other observations of course) & it will be very difficult to justify or defend a nurse's stand like 'she is really not in pain' since PAIN itself is a sensation defined by the pt & expressed quite differently by individuals.

[ginger58, ASN, RN]

If the new nurse doesn't watch herself she may be looking for a new job or a new occupation.

Does she have any clue about what 20 surgeries must do for you?? All the scarring, the abscess formation, pressure, healing scars, adhesions. She should be glad I'm not her boss!

No one should be judging what a patient does--watch TV, talk on the phone, laugh, to decide if they need pain meds. Would you want everyone in pain never to laugh, watch TV? These are coping skills.

I think your boss did give you an answer--if there's a doctor's order...give.

You've had 14 years experience. Go by your gut feeling and continue on with what you're doing. This new nurse will get caught someday holding back meds and there will be a price to pay.

[hollyvk, BSN]

As an RN with plenty of experience with both acute pain and chronic pain, it is my opinion that this patient is not being well served, even when she does receive the meds that are currently ordered for her. She is not sleeping well and it appears she frequently has breakthrough pain. Here are some excellent resources regarding pain:

http://nursingworld.org/ojin/topic21/tpc21_6.htm

http://www.rnao.org/Storage/11/543_BPG_assessment_of_pain.pdf

http://www.americangeriatrics.org/products/positionpapers/JGS5071.pdf

On a more immediate note, it appears to me that this patient is in dire need of a pain specialist consult. If the only meds she has precribed are opioids, her medication regime is inadequate (possible additions include acetaminophen, NSAIDS, antidepressant--e.g. nortriptyline).

As to your new nurse colleague and your nursing manager, neither of them are promoting this patient's well-being, and frankly the new nurse should be ashamed of herself for her prejudice, ignorance, and bullying tactics towards you. Your manager appears to have failed to grasp the inadequate care by that nurse as well as the fact that this patient is probably not receiving adequate and appropriate care for her pain.

I suggest you use the resouces I've provided and do some education for your peers, and that you discuss this patient's need for better medical care of her pain with her PCP (see if you can get her a pain consult with a chronic pain specialist).

Good luck with this situation.

HollyVK, RN, BSN, JD

I work in an LTC. Most of our residents are quite young...most of them are under age 70. We have a few residents who have a long history of severe pain and receive narcotics on a regular basis. We have a new nurse who has been there less than a month who doesn't believe that they are in pain and is working to get their mediations reduced. One of the ladies has a long history of abdominal pain to to benign cysts and abcesses...she has had over 20 surgeries, but the cysts and abcesses continue to come back. Apparently, the cysts are back and causing her a great deal of pain. I have no idea if she is really hurting or not. There is no obvious change in vital signs, but she does become diaphoretic, guards her abdomen when she walks, and grimaces. So..since she stated she was getting no pain relief, I talked to her doctor, who increased her pain meds until she can see her surgeon on Monday. The new nurse is really upset that I did this. She told me that she does not believe for a minute that the resident is having that much pain and that when she is distracted by activities that she doesn't request pain meds. She makes the resident wait an 30-60 minutes before giving PRN meds that are due. She also told another nurse that I am just a sucker and that the residents can talk me into anything...she says that she is going to tuirn me in to the state.

I'm not sure what to think about this...I really don't know if this lady is having that much pain or not. She acts like she is having that much pain, but she has a long history of narcotic use (abuse?) and is probably a good actresss. She is not sedated, gets very poor sleep, walks with a steady gait...I just don't know. I am starting to question whether I should be giving the meds or not...I am concerned that I am just feeding an addiction rather than trying to treat her pain...I am concerned that I may be putting my license in jeopardy. I would hope that if I were out of line in giving meds when residents say they are in pain, that someone would have said something to me by now, but maybe it just takes a new set of eyes to see that I am messing up.

My manger is really no help...I've asked her point blank whether I am overmedicating the residents and I've never gotten an answer...she just says things like, "If you have an order, you should be OK."

[flashpoint]

Grrr! This lovely nurse went through all of the MARs on Friday and wrote huge notes to fax to the doctors of our two most chronic pain patients telling them that they are sedated, don't eat well, slur their speech, etc. Our chronic pain patients now have their q 4º meds reduced to q 6º....their q 6º meds are q 8º. She got a dose of Cymbalta reduced and one resident's Ativan is cut from 1 mg to 0.5 mg. She told one of the CNAs that her goal is to have the facility "narcotic free" by summer. Naturally, she does this while the DON is on vacation and we have a PRN nurse doing RN coverage. I could just scream...and the two residents did not do very well Friday and Saturday...one of them spent all day yesterday lying in bed weeping from the pain...and the doctor on call refused to change the doses back because he doesn't know the patient...and he doesn't want to be involved in a "dose changing tennis match."

The administrator really doesn't want to get involved, which is odd becasue she gets involved with every other nursing issue there is...she even does things like call 911 when she thinks a resident is sick enough, but the charge nurse and the doctor don't.

Still looking for another job...not many are available in this area though...and not sure I want to drive much further to go to work.

[hollyvk, BSN]

Grrr! This lovely nurse went through all of the MARs on Friday and wrote huge notes to fax to the doctors of our two most chronic pain patients telling them that they are sedated, don't eat well, slur their speech, etc. Our chronic pain patients now have their q 4º meds reduced to q 6º....their q 6º meds are q 8º. She got a dose of Cymbalta reduced and one resident's Ativan is cut from 1 mg to 0.5 mg. She told one of the CNAs that her goal is to have the facility "narcotic free" by summer. Naturally, she does this while the DON is on vacation and we have a PRN nurse doing RN coverage. I could just scream...and the two residents did not do very well Friday and Saturday...one of them spent all day yesterday lying in bed weeping from the pain...and the doctor on call refused to change the doses back because he doesn't know the patient...and he doesn't want to be involved in a "dose changing tennis match."

The administrator really doesn't want to get involved, which is odd becasue she gets involved with every other nursing issue there is...she even does things like call 911 when she thinks a resident is sick enough, but the charge nurse and the doctor don't.

Still looking for another job...not many are available in this area though...and not sure I want to drive much further to go to work.

"and the two residents did not do very well Friday and Saturday...one of them spent all day yesterday lying in bed weeping from the pain..."

Sounds like elder abuse to me, time to notify state dept of health (or other state agency that licenses the facility) if your DON/administrator fail to act. You could also make a complaint to the board of nursing regarding this RN, and if the PCPs won't prescribe adequate orders, to the medical board as well.

I hope you will not just walk away from this situation. If nothing else, you need to ensure that there is adequate documentation in place to show the effect the inadequate pain relief is having on these patients.

Good luck to you,

Hollyvk