I don't think I understand pain management.

[lisamc1RN, LPN]

It is drilled into our heads during class time that there is no reason for a person to have severe pain. We are to assess and reassess how pain meds are working and make sure that we get the pain level down to an acceptable/ manageable number. I've experienced at least 2 times in the last couple of months at clinicals that have confused me because I felt that the patient was undermedicated and the nurse disagreed with me and didn't seek additional pain relief. I'll give the two situations and maybe someone can help me understand the reasoning a little better.

The first lady, Mrs. A, was a terminal cancer patient who had been in the hospital for several weeks, with increasing pain. She refused hospice because she thought that she would get better. The last week of my clinical at that facility, Mrs. A was suffering greatly and asked for pain medication often. When I reported to the nurse that Mrs. A was still in pain even though she had been given all the medication that she could have, the nurse said that there was nothing more we could do for her because she refused hospice. Once she goes to hospice, the nurse said, they could increase her pain meds (she was on morphine and various other pain meds). I asked her why we couldn't manage her pain anyways and she said that there was some kind of limitation on how much morphine that could be given without being on hospice. ??? Could someone please explain this to me. I felt so awful for this poor woman. I don't know what happened to her after I left. I can only imagine that her pain got severe enough that she eventually requested hospice services so that she could get pain relief.

The second event happened today during my clinical at a subacute facility. Mrs. B is a post surgery pt. in pain, rating her pain at 7/10, with moaning and fidgeting. I didn't take her bp (someone else had taken it) but I took the rest of her vitals and they were within the normal range. She had had 1 vicodin 2.5 hours earlier and it was clearly not lasting long enough. She only had vicodin ordered-1 or 2 tablets. No tylenol, no nothing else for pain. I let the nurse know this and she said that there was nothing more to do for Mrs. B because she couldn't have more vicodin for another 1.5 hours. I asked her if it might be possible to get an order for something else, even Tylenol, and she said that we would just wait and the next time we would give her two vicodin instead of one. The reasoning was that maybe the vicodin would work longer next time with the higher dose. Ok, my question here is, I understand wanting to give the vicodin a chance, but what would be so bad about addressing the pain she was having that very minute? I felt so helpless. I went back to the patient's room and adjusted her and tried to make her as comfortable as possible. I checked her often and adjusted her as much as she wanted. I talked to my instructor and explained what happened and she pretty much agreed with the nurse that unfortunately, sometimes there is nothing more you can do for a person. I guess I'm just really confused. What would have been the harm in picking up the phone and letting the doc know the patient was in pain and needed something more for pain? I don't want to act like I don't trust my instructor's or the nurse's judgement. They know a great deal more than I do, so could someone please explain this to me? I wanted with all of my heart to get on the phone to the doctor and ask him for something more, even a little bit of Tylenol.

[maolin]

I'm sure someone more experienced will come along with a terrific detailed answer to your questions. I just wanted to comment that you wouldn't want to request Tylenol for Mrs. B's breakthrough pain because Vicodin already has APAP in it and you run the risk of going over the 4Gm/day. Maybe Ibuprofen instead? And I'd dose 2 tabs Vicodin the next time she's due to try to stay on top of the pain. Of course, you could try non pharmacological methods to tide her over until she's due again as well (distraction, imagery, relaxation, etc).

[athena55, BSN, RN]

Hi Lisa:

Oftentimes the caregivers are ignorant of what pain management is. I think I can say I understand your frustration, especially being a student and not having your opinions, concerns, thoughts being taken seriously. Obviously you were trying to be the best patient advocate you could. There are a few surveys that suggest that more than 40 to 50% of patients in routine practice settings fail to achieve adequate relief, and that among the numerous barriers to effective pain management, and near the top is clinician under treatment.

Here is a website that might help you better prepare for the "next time" this type of patient situation occurs:

www.stoppain.org It is maintained by the folks over at Beth Israel Medical Center's Pain and Palliative Care Center in NYC. I have been a patient there myself and I can attest to their knowledge and concerns dealing with people in pain, whether it be chronic or acute.

Good luck with the rest of your studies !

mary [family nurse practitioner/pain management student]

[weetziebat]

Lisa, it is making me frustrated just reading your thread. I have obviously met the very same nurses all through my career and have never understood their thinking. Especially the ones who are afraid of making terminal patients 'addicted'. Aaarrrgh!!

Don't know if it is country wide or not, but in Oregon you now have to take a pain management class before you can re-new your license. I certainly hope it can get through to certain folks that it really is unacceptable for patients to be in pain, with staff giving excuses like there is nothing that can be done. Personally, I would not be able to live with myself if I didn't try my hardest to make sure my patients were as comfortable as possible.

[purplemania, BSN, RN]

I don't agree with either nurse (or Instructor). Unless the state laws prohibit it, we are allowed to administer opioids for pain relief even at risk for double effect (pain is relieved but respirations are decreased). This requires CAREFUL documentation and much attention by the nurse. But the objective is not to let people die in agony.

Also, there IS something you can do. Call the MD and tell them pain is not being controlled by oral meds. Sometimes they order medications other than narcotics, such as muscle relaxers and antidepressants. JCAHO tells us to call the doctor and that is what I would do to protect my patient.

[tencat]

I, too, don't understand why patients are left undermedicated when orders are even there for PRN morphine. I'm still a student, too, and from what I can gather for some reason most of the nurses I worked with didn't want to give PRN morphine very often, but no one could give me an answer when I asked why they didn't give it even though it was ordered. My question also is why have PRN Morphine q 1 hr and not a PCA?

[Stephanie in FL]

Lisa,

Good for you for speaking up to try to help your patients that are in pain. We need nore nursing students/nurses like you.

I don't agree with either nurse or the instructor in the situations above.

I also wanted to tell you about my experience with pain. I am 38 and have ovarian cancer. But I am not dying! And I'm not in denial! I am on Avastin and Taxol and my tumors are decreasing. I have had severe abdominal pain for several months due to these tumors and also scar tissue from the TAH/BSO to remove my 1st tumor. At first, Percocet was helping. When it was no longer decreasing the pain, I told my GYN oncologist. She prescribed Oxycontin. This did not help. Then she prescribed MS Contin. This did not help. Now, I am on Fentanyl (Duragesic) patch all the time with MSIR (po morphine intermediate acting) for breakthrough pain. This regimen does work. So, pain can be managed-and I am not on hospice (nor should I be on hospice). As, someone posted above, cancer patients do not need to worry about addiction.

Please keep speaking up to the nurses/instructors and when you are on your own, to the MD, for your patients in pain. That is what being a patient advocate is about.

Good luck!

Stephanie RN

[nurse4theplanet, RN]

This is what I was taught in school about pain management.

Pain is what the patient says it is, not what the nurse thinks it is. Pain is to be managed where it is acceptable to the patient. Certain chronic conditions are not managed with narcs, such as chronic pancreatitis, due to the patient developing a tolerance and addiction but effective pain management measures are just as important. Terminal illness is much different, and every effort is made to decrease the pain without regard to worrying about addiction. We have special nurses that specialize in pain managment especially for the term. ill, and if we ever have questions we can call them for a reference and second oppinion before we call the doctor.

I always look at pain from how I would feel if I was in the patients position. I would not want to die after suffering months or years of unbearable pain. Pain is the "fifth" vital sign and controlling it is just as important as controlling blood pressure. You want to use the minimum amount of medication ordered, but if you have to use the maximum, perhaps you should consult with the doctor about strength of med or alternate med. This is your job as the nurse, because the MD trusts you to monitor the patient's response to the treatments that they order.

[nurse4theplanet, RN]

I love PCA pumps. I have noticed too that pt's with them feel more in control of their pain psychologically, and less apprehensive which heightens the perception of pain.

In our facility, since most pain meds are ordered PRN...most pt's don't know they have anything and give vague responses about their pain because they think they have to grin and bear it. I have seen nurses who don't even check if there are PRN pain meds, and disregard the pt's complaints of pain until it is almost unbearable. I have also overheard a nurse say that she avoided wasn't going to give pain medication to a pt because the lady was just being a 'baby' and she didn't want to do the extra documentation because of it. I reported her to my instructor and the charge nurse. Don't know what came of it because it was our last day of clinical.

[NurseyBaby'05, BSN, RN]

I think sometimes people equate pain management with "miracle drug." They're not meant to completely erase all of the patient's pain. They're to manage it. If you have just had back surgery or a crani, or any kind of surgery, it's going to hurt for awhile. I usually try to keep pt's pain level to where they are able to function in relative comfort. Completely pain free may not be realistic. I agree with trying the non pharmacological interventions to help the pt get by until the next PRN. I often use warm and cold compresses, positional changes, massage or distractions to get the pt through that last 45 min. It's also important to get them moving around sooner rather than later so the rest of their bodies don't tighten up and make them more uncomfortable. Now, in your particular post-op scenario, if pt was in severe pain and still had 1.5 hr to go, I may have called for a one time order for IV morphine and gone from there.

I just had a similar discussion with a patient last night. They discontinued his PCA. Was in a bad MVA. Had broken everything and gaping wounds. Told him they were going to put him on oxycodone BID. No one bothered to get the SureMed stocked and just left him waiting. Oxycodone was ordered @ 14:00. The docs also did not tell him that he was able to get PRN percocet 1-2 every four hours in between the oxycodone. I walked in to my shift and found him in agony. He had been give ONE percocet @ 14:30 and had nothing since. It was 20:15!!!! This man thought he couldn't get another med for pain until 8 am!:angryfire That should have been addressed long before I got there that night. Needless to say, I got him medicated and we had a little talk about pain control. We went over his regimen and got him settled. I also told him that it was not set in stone. If what he was prescribed was not working that we needed to know. If one of us needed to get a one time order to get severe pain under control that we could do it. Not everyone fits under one treatment umbrella. I mean if the percocet is getting him 3.5 hours out of four and his pain is in the middle of the 1-10 scale, that's one thing. But if it's 7, 8, 9, 10 and he has three more hours to go, it needs to be addressed.

Sorry, off my soapbox . . . . . . . :sofahider

[hospitalstaph]

My husband saw a lot of this in the hospital. He had his colon removed after being hospitalized for a month. By the time he had the surgery, he was having such a hard time finding anything that worked. He had been through Dermerol, Vicodin, you name it. Doctors and nurses were reluctant to try anything different. Post op they gave him Diladid after our CRNA really pushed for it. Then he was switched to Fentanyl which worked great, and he didn't feel a "need" for it unless he had pain. At discharge our insurance would not pay for Fentanyl pops so we paid out of pocket ($400 a week) until we could no longer afford it. Then he was switched to Oxy and is now addicted:angryfire We are working with pain managment to get him off of the Oxy, but everytime we get him down to one or two pills a day, he ends up back in the hospital.

I really think that pain management is so important! Patients should not be suffering.

T

[lisamc1RN, LPN]

Thank you all for the wonderful feedback. I learn so much from all of you! I'm really seeing that undermedicating for pain is a problem in healthcare. I know that I want to be a part of the solution. Question for you... Since Mrs. B had a prn order 1-2 tabs and had only been given 1 tab, would it have been ok to give her the other vicodin? I know it would have messed up the time schedule, but could that have been a solution? No one suggested it so I didn't even think of it until this evening.

Thanks to athena for the site on pain management, too. :) It's very helpful!