Isn't pain whatever the patient says it is???

Home Health Columnist / Guide · Jun 10, 2004

Great replys. Trial and elimination sometimes difficult but worthwhile in the end. Have seen low dose steriods added and beneficial to those with MS.neurological disease.

Don't forget to assess THE BED patient is in! Too many times mattress is old , patient sacrum / buttucks easily felt w hand underneath mattress. Have seen patients pain relieved with 4# thick eggcrate mattress, low airloss matress, even sheepskin underneath legs. Keep up the good work.

Blackcat99 · Jun 10, 2004

I am wondering why some patients who are in pain deny it? You ask them if they are having pain because they seem miserable but they always deny it.

Why won't these patients admit that they are in pain?

hock1 · Jun 10, 2004

I always give pain meds when requested. The drug seekers always seem to be A&Ox3 when it comes to dosage and timing, so why fight it. I'm not going to set them straight in my short stay unit anyway. For my other patients I fight for the highest dose possible. I'd never want to suffer through my last days. All in all, I follow the 'pain is what the patient says it is' rule. Better safe then sorry.

dhudzinski · Jun 10, 2004

There are many reasons why an individual might deny they are in pain. They may fear the treatment or the tests that they feel might be warranted to find the cause of their pain. They might have a belief system that dictates that if they endure the pain they will earn a higher place in the hereafter. Or another reason is that they think they deserve the pain for past transgressions (real or perceived) Or they might not want their loved ones to know they are in pain so they deny to protect them from their suffering. There are probably as many reasons as there are individuals and I have heard dozens of reasons from my patients.

I could tell you dozens of stories of patient's who endured pain needlessly because they thought they had to. But I will not except to say that if you see a patient who you think is in pain despite the fact that they deny it...explore the incongruity of their verbal reply and their behavioral indications of pain. I come right out and say..."you say you have no pain but your body is speaking something different. Did you know the negative effects of having untreated pain? ( I then talk about all the negative effects on the body, the emotions and the spirit when pain is left untreated) (9x's out of 10 they will give in and allow me to medicate them with at least a small dose) I even had one patient tell me that after I medicated her she could not believe the difference and said "I did not realize I really was in that much pain, thank you"

Blackcat99 · Jun 11, 2004

:) Thanks dhudzinski. Very good information about pain.

teeituptom, BSN, RN · Jun 11, 2004

Just remember that drugging someone up all the time isnt necessarily the best way to treat chronic pain

I have 3 bad discs in my back

Ive been in pain so long

accunpuncture helps

dieting helps

exercise helps

Tai Chi helps, Im sure yoga does also

Copper bracelets and magnets help, even if there is no documented reason that they should.,,,they do help.

These ways work for me and a lot of others I know

dhudzinski · Jun 13, 2004

Just remember that drugging someone up all the time isnt necessarily the best way to treat chronic pain
I have 3 bad discs in my back
Ive been in pain so long
accunpuncture helps
dieting helps
exercise helps
Tai Chi helps, Im sure yoga does also
Copper bracelets and magnets help, even if there is no documented reason that they should.,,,they do help.
These ways work for me and a lot of others I know

I too have chronic pain from a variety of causes, congenital, trauma, arthritis and surgery. And I use A LOT of non pharmacologic interventions, such as heat, cold, magnets, aroma therapy, reike, therapeutic healing touch, music, massage and accupuncture to name a few. But sometimes the pain is just too much to handle and the phamacological interventions come into play at that time.

Each person needs to decide how much is too much and how much energy they have to devote to these interventions. Sometimes we just need a vacation from the pain and everything that it entails. Sometimes we need to regroup and we need our energy to heal and refocus.

If a person does not believe that a certain intervention, whether it be pharmacologic or non pharmacologic, will work then it will not work. the mind is a very powerful force.

I like to think that the non pharmacological interventions are complimentary to conventional treatment...they are not an alternative as in either/or...they work best together for the majority individuals.

When I help to develop pain plans I like to incorporate mind -body- spirit interventions. It is important to treat the whole person. Everybody is different and what works for one may not work for another.

Trvln Nurse, RN · Jul 10, 2004

Hi,
I'm pretty P.O.'d too.... Am a Hospice nurse with a patient who's had a lifelong hx of neurological pain. Each time I see her she c/o pain "all over", is grimacing, moaning, cries out when moved, etc. when I ask if she needs pain meds she says yes...Requested her order for be increased to 30 gm oxycodone TID (now on 20 gm TID) w/breakthru pain meds PRN. The facility and the NP in charge claim that "she's always been like this - it's just what she says. We don't even ask her about her pain, and she doesn't bring it up so she's fine" Urgggghh!!!! So they never give her any PRN pain meds.:angryfire I've been gradually titrating her up, and it hasn't touched per pain, hence the request for the increase. What on earth happened to "Pain is whatever the patient says it is?" Is that only for patients under a certain age, or does it exclude dementia patients, or what?
This small battle may be lost for now, however, the war is not close to being over!

I understand your frustration. Have you thought about trying this patient on a duregic patch....they start at 25 mcg's and you change them every three days....it takes 24 hours to start working....but I've had great sucess with this when I used to work as a hospice nurse. Then after a week you can increase the dose to 50mcgs etc...up until patient comfort is achieved. The continued dosing stops the up and down rollar coaster of pain management and I've seen patients lives just turn around after using this. Give it a try. Most MD's will prescribe if you ask...though I rarely see a doctor ordering this on their own. We still have a long way to go with pain managment education. And I think a lot of caregivers (MD's, nurses, CNA's, etc) have forgotten about the "CARE" in Patient care. Good luck to you and your patient. Judy

dhudzinski · Jul 12, 2004

Duragesic Patches were a great invention but have a variety of cautions and drawbacks to them.

First off Medicaid does not pay for them (many pts in nursing homes are on Medicaid) And I don't know about your state but many states are now Methadone only states. Meaning the only long acting opioid they will cover is Methadone UNLESS there is a clinical reason why Duragesic or Oxycontin or Kadian or MS Contin or Oramorph SR would be indicated. They are requiring that you try Methadone first and if not effective or the patient is allergic or intolerant THEN they will pay for the more expensive alternative. (my personal experience has been that the methadone works 9 times out of ten and in some cases where we converted the patient to methadone they did better on the methadone.) Methadone is tricky to use but we have an algorithm we modified that we received from MD Anderson that works like a charm. If anyone is interested I can sent it to you. (just email me and I will send as an attachment or via snail mail.

second caution is cachexia in the nursing home resident. If they do not have adequate subq fat it will have unpredictable absorption. Fever and heat also alters the apsortption.

third caution is frequently when Durgesic is ordered in a nursing home patient the nurses and physicians just stop paying attention to the pain. Since the patient now has a "patch" on and everything is "hunkie dorie" in their estimation.

fourth caution is if the pain is acute and the pain is greater than 5/10 you chase the pain rather than treat it. The instructions for Duragesic are clear...assess the pain and get it under control with fast acting opioids and then convert to Duragesic. the patch takes about 18 hours to load up in the subcutaneous fat and it takes 48 hours - 72 hours to reach steady state. Additionally When you put a patch on you are delivering 25 mcg PER HOUR (or 50mcg, 75mcg or 100 mcg) if this is too much for this particular patient and they become over sedated ,you are in trouble for 18 - 24 hours rather than 2-3 hrs with a fast acting opioid. REMEMBER you can always add more but you can't take it back once it is in the system even if you take the patch off.

Fifth caution is some elderly patients have become psychotic on Duragesic patches.. All drugs have their down side none of them are without risk. But we must minimize the risk as much as possible to protect our patients.

There, that is my soap box speech for today. Thank you for "listening"

teeituptom, BSN, RN · Jul 12, 2004

Duragesic Patches were a great invention but have a variety of cautions and drawbacks to them.
First off Medicaid does not pay for them (many pts in nursing homes are on Medicaid) And I don't know about your state but many states are now Methadone only states. Meaning the only long acting opioid they will cover is Methadone UNLESS there is a clinical reason why Duragesic or Oxycontin or Kadian or MS Contin or Oramorph SR would be indicated. They are requiring that you try Methadone first and if not effective or the patient is allergic or intolerant THEN they will pay for the more expensive alternative. (my personal experience has been that the methadone works 9 times out of ten and in some cases where we converted the patient to methadone they did better on the methadone.) Methadone is tricky to use but we have an algorithm we modified that we received from MD Anderson that works like a charm. If anyone is interested I can sent it to you. (just email me and I will send as an attachment or via snail mail.
second caution is cachexia in the nursing home resident. If they do not have adequate subq fat it will have unpredictable absorption. Fever and heat also alters the apsortption.
third caution is frequently when Durgesic is ordered in a nursing home patient the nurses and physicians just stop paying attention to the pain. Since the patient now has a "patch" on and everything is "hunkie dorie" in their estimation.
fourth caution is if the pain is acute and the pain is greater than 5/10 you chase the pain rather than treat it. The instructions for Duragesic are clear...assess the pain and get it under control with fast acting opioids and then convert to Duragesic. the patch takes about 18 hours to load up in the subcutaneous fat and it takes 48 hours - 72 hours to reach steady state. Additionally When you put a patch on you are delivering 25 mcg PER HOUR (or 50mcg, 75mcg or 100 mcg) if this is too much for this particular patient and they become over sedated ,you are in trouble for 18 - 24 hours rather than 2-3 hrs with a fast acting opioid. REMEMBER you can always add more but you can't take it back once it is in the system even if you take the patch off.
Fifth caution is some elderly patients have become psychotic on Duragesic patches.. All drugs have their down side none of them are without risk. But we must minimize the risk as much as possible to protect our patients.
There, that is my soap box speech for today. Thank you for "listening"

How do you feel about people using Methadone or duragesic patches and driving cars and operating heavy machinery or even working as a nurse

lawrencenightingale · Jul 14, 2004

I think pain might be whatever the patient says it is. So, it needs to be taken seriously. In psych, I regularly have pt's reporting pain as a "10" whose pain disappears prior to the admin of an analgesic(1-2 minutes in some cases), within 5 minutes of receiving Tylenol, if they receive an unexpected but pleasant surprise, if they get a 1:1 with just about any staffmember, etc. Subjective experience is something to strongly consider but not the only thing,in my opinion. LN

Tweety, BSN, RN · Jul 14, 2004

Good luck in being this patients advocate. Pain not only is what the patient says, but they should know from doing the care when the patient moans and groans that she's in pain. What kind of nurse could care for a patient moaning and groaning and not ask if she needs prn meds? Good luck.