How much pain medicine is too much?

[jlwerley]

I am a PCT at a hospital and i just got home from work and experienced a situation that I would like the opinion of outside parties on. A patient has been in our care for several days for pain control of a type I chiari malformation. The pt has orders for 2mg dilaudid q2 which she receives constantly (literally 24mg in a days time) as her pain is always a 10/10, etc. I mean the kind of pt that will set a timer on their phone to go off every two hours so that they may ask for pain meds. Essentially this pt has not slept for the three days she has been with us because she is always, always asking for (and receiving) dilaudid day and night.

Her vitals are fine every time they are checked (which, by our policy, is 30 min after every admin of dilaudid; pt also kept on continuous pulse ox) but is clearly "high" off the meds. Slurred speech, stumbling gait, can hardly keep her eyes open, cant recall her last med time. what really drove me to write all of this, however, was what happened this past evening. The pt wandered out of her room topless (no gown, no shirt, no bra) and just in pants looking for the RN.

Upon discovery she was immediately helped back to her room and attempted to be reoriented. I believe (but am not 100% sure) the nurse then held her next dose of dilaudid. at the next scheduled time the RN definitely administered it. The way this case has been handled does not seem right to me at all.

It seems we are clearly encouraging what appears to be drug abuse and not considering any other options nor treating current problems properly. Please advice and opinions, because as a future nurse, I would not be simply following the others and continuing to give the drug to please the pt. Thank you!

[RNsRWe, ASN, RN]

Have medicated many patients who I believed were probably there just to get high. This patient, however, does not have a situation that automatically warrants the tag "seeker". She might just need the amount of narcs to kill her pain that also make her a stumbling fool. Keep her safe in her room, monitor her frequently (as is the case in your hospital policy about cont p/ox and vs checks). And give her the drugs as ordered.

However, if I see that the patient is having decreased respirations or any sign that tells me that giving her the dose of Dilaudid may do her actual harm, I'll call the doctor to see if there's something else I can give her instead, stretch out the time between shots, and get something else ordered for an in-between-Dilaudids dose.

Wonder why this patient isn't on a PCA, actually? Assuming she isn't so stoned she can't operate the button....?

[Horseshoe, BSN, RN]

also, again in my developing nursing judgement, i try to take in the whole picture when i see pts asking for pain meds and describing the pain they have to our nurses. for example, i saw said pt describing her pain as beyond 10 out of 10 and that it was killing her meanwhile she is texting on her phone, eating ice cream etc. when ive seen other pts describe pain like that, they can barely verbalize, doubled over etc. i know you have to take pain at what pts say, but again at what point do you start to advocate for the pt

Be very careful here. I don't know if your patient has had chronic pain or whether she is a drug seeker, but patients who are in chronic pain not only no longer show the typical symptoms of those in acute pain (increased heart rate, pupil reactions, etc,), they may also have developed very good coping skills such as you describe above. They may be able to laugh, eat, or sleep, talk animatedly, etc. This DOES NOT mean that they are not experiencing the pain they say they are. Veteran nurses often make this same mistake-they assume someone with normal vital signs and behavior such as you describe above means that the patient cannot be experiencing the level of pain they claim, so of course they are faking, simply looking for a high, and therefore deserve no consideration. Not always true. Don't be the nurse that makes that same mistake.

[dirtyhippiegirl, BSN, RN]

As someone who routinely medicates patients with extremely large quantities of narcotics, my main concern for this patient (aside from signs of overdose) would be the possibility that she her altered level of consciousness on top of not sleeping puts her at risk for an acute onset of delirium. So, not only is her pain presumably not being properly managed, but she may end up with physical or chemical restraints to keep herself safe, increased length of stay to get her back to baseline, etc.

[tothepointeLVN, LVN]

Without going into all the rest of it fear of pain reoccurring can also be a factor with the requesting pain meds so often. It certainly has been a factor for me after injuries and surgeries requiring hospitalisation. I always requested pain medication before I felt the pain again because I simply didn't want to. Am I a drug seeker? No just a wimp with a reason.

[Fiona59]

My first thought was unless you've had to narcan her, nope.

[Nurse SMS, MSN, RN]

Your developing nursing judgement honestly sounds a lot like simple judgementalism. Do some research on chronic pain behaviors as well as the difference between tolerance and addiction.

[morte, LPN, LVN]

remember, that the symptoms you described could have been from lack of sleep and/or desease process.

[That Guy, BSN, RN, EMT-B]

Hmmm setting alarms on the phone to have meds.....turn the alarms off when she is stoned out of her gord and see if she miraculously gets sleep?

[Asystole RN]

Your developing nursing judgement honestly sounds a lot like simple judgementalism. Do some research on chronic pain behaviors as well as the difference between tolerance and addiction.

#truth

[RainMom]

Wow, almost sounds like my pt last night! Her order was dilaudid q1h PRN, 0.5, 1.0, or 1.5 mg. She was getting to the point of asking for it literally on the dot, one hour. I stopped giving her the 1.5 she had been getting & reduced it to .5 because of the degree of her slurring. Often when I went to answer her light, she was slow to open her eyes & it seemed like she really had to think about what it was she had wanted me for. Changing from the 1.5 to 0.5 mg didn't change her pain rating or how often she asked for it. And when I went in to do a scheduled flush to her PICC, she thought I was giving her more dilaudid & didn't even go ahead and ask for it that hour. I've no doubt she had pain because of a recent trauma, cancer w/mets. I spoke to the MD when he came in & mentioned the frequency & that it wasn't really affecting her pain, but he made no changes at all. I was hoping for a pca at the least! She's also supposed to be d/c to a skilled LTC rehab tomorrow so something has to be changed; I don't see how she would be able to get her dose hourly there.

[One2gofst]

Judging the patient as a drug seeker and addict is not advocating for the patient, FYI!I don't think examining every option for the best possible pain control is a bad idea necessarily. However, what one person does when experiences pain is a horrible indicator of another individuals pain.

[LaughingRN]

wow, almost sounds like my pt last night! her order was dilaudid q1h prn, 0.5, 1.0, or 1.5 mg. she was getting to the point of asking for it literally on the dot, one hour. i stopped giving her the 1.5 she had been getting & reduced it to .5 because of the degree of her slurring. often when i went to answer her light, she was slow to open her eyes & it seemed like she really had to think about what it was she had wanted me for. changing from the 1.5 to 0.5 mg didn't change her pain rating or how often she asked for it. and when i went in to do a scheduled flush to her picc, she thought i was giving her more dilaudid & didn't even go ahead and ask for it that hour. i've no doubt she had pain because of a recent trauma, cancer w/mets. i spoke to the md when he came in & mentioned the frequency & that it wasn't really affecting her pain, but he made no changes at all. i was hoping for a pca at the least! she's also supposed to be d/c to a skilled ltc rehab tomorrow so something has to be changed; i don't see how she would be able to get her dose hourly there.

cancer with mets, or terminal illness is very legitimate pain.

and it's terminal.

in a layman terms: it eats you from the inside out

i wish more people understood this and just gave these people their pain meds, despite what they appear to look like, despite the frequency.

i wouldn't wish cancer on my worst enemy