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!

[Morainey, BSN, RN]

I went through this same moral dilemma when I was a new grad. I couldn't agree more with the posters who say that in the three days we get them, we are not their to fix their addiction.

[Perpetual Student]

It's too much when the patient stops breathing sufficiently or becomes totally snowed. If a patient is awake and with it enough to realize it's been two hours it's obviously not too much.

[BuckyBadgerRN, ASN, RN]

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

I read an article while in nursing school about how NURSES tend not to believe the degree of a patients pain. "No WAY is that a 10/10, he couldn't function enough to tell me that if it were really a 10/10!", "She always says 10/10, even though we know its not. She just wants the meds"., etc. ( I need to find this article)

I've seen LOL's with a hip fracture that makes ME want to cry and they'll rate the pain at a 2 and likewise a big burly man with an injury that a layperson would roll their eyes at and they're breathlessly saying it's a 15!

We TRULY cannot judge anothers pain, especially if we have no firsthand knowledge of the condition that is causing it. IMO, of course

[OCNRN63, RN]

ill add that there was no decompression surgery, nor is she scheduled for one. to me, in my developing nursing judgement, it seems that our version of pain control is inadequate if q2 dilaudid leaves the pt with a continuous 10/10 pain. it seems to me she is in need of a pain specialist or the drs need to consider other treatments for the pain (as in surgery). she also has other pain meds ordered, so why not try toradol or something else for a bit to see how that treats the pain instead of just always giving dilaudid. also, at what point do we decide not to advocate for pts who may be addicted and voice our concern to the dr, who may then order further help for their addiction (psych consults, social work, whatever addiction therapy there is, etc). 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 ptthese are just ramblings of a tech and student who felt something was off about the situation. thank you all for your responses, they have helped me learn more about dealing with difficult pt scenarios!

Which is it? Texting, laughing, eating ice-cream, or gorked? Just because one patient doubles over doesn't mean the next will. Pain mgmt is not one-size-fits-all.

[SuesquatchRN, BSN, RN]

Her pain is being managed properly when she is no longer in pain. And the people who need IVPB meds Q1-2 should be on infusions.

[minnymi]

when a patient rates their pain as 10/10...every.single.time it doesn't mean they aren't having pain. it means they're afraid if they don't rate their pain high enough that they won't get pain meds or they won't get the same amount. what needs to happen is a little patient education. they need to understand that if they rate their pain as less than a 9/10 or 10/10 that they will still get their medication when it's time. just a simple talk with your patients letting them know that you WILL give them their medicine if it's within your power (ordered) but it's okay to rate it as it actually is so we know the medicine is working when they DO get it. unless, of course, it isn't working...but typically it IS working. they just don't realize that saying "it worked, my pain is a 5/10 now" is not going to change the medication schedule. just my opinion.

[tothepointeLVN, LVN]

When I was in short stay after a recent surgery I had two nurses at my bedside ( the nurses stayed in the room most of the time I got lucky census was down ) and it was interesting how differently the two nurses reacted to the same number 5/10. It was something I filed away in my head along with my reaction. Obviously I felt more comforted by the nurse by the nurse that was OMG thats a lot (not exact words paraphrased) than the one that was like oh your fine you don't need anything (again paraphrased.) Both of them were excellent nurses just different approaches.

[minnymi]

neither nurse was in the right in my opinion. it shouldn't have been "omg that's a lot of pain" OR "you're fine, you don't need anything." it should have been, "your pain is 5/10...charted. you can have something for pain now if you like, do you want something?"

one person's 5/10 might be a high pain rating while for someone else 5/10 is the best it gets. it doesn't matter what each nurse personally thinks is a lot or a little pain. it matters if the medication is ordered at that time and if the patient wants it.

[RainMom]

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

I understand that completely. When asked about her site of pain or pain r/t cancer she would say that it had not been bothering her, just her leg from a fracture 3 months ago which she had surgery on 3-4 wks ago. She was admitted with dehydration; prior to admit she was on scheduled methadone & a myo relaxer which was also continued. I understand that some pts can still fall asleep even with pain, but she would be so lethargic & slurring, having trouble speaking & telling me why she put her call light on every time I went in to answer it (it would take her a good 15-20 seconds to start talking), that I did not feel comfortable giving her the 1.5 mg every hour. Why the MD did not order a pca, I don't know; she was transferred off our floor yesterday to give room for new surgicals & had a planned discharge to LTC for rehab today where there will be no way anyone will be able to give her hourly doses. Hopefully, they had something put in place that will give her more adequate pain control.

[Tarabara]

Slurred speech and unsteady gait are both symptoms of chiari malformation, and to me it sounds like the pt is experiencing side effects of that, not from pain meds. If her vitals are all stable (especially respirations) then her pain management is important and should be addressed.

[MomRN0913]

It's too much when a patient who is full code has resps below 8 or a tanked BP in my opinion.

If the pain is not relieved, treatment and medication needs to be reevaluated. Perhaps a long acting med, a duragesic patch, MS Contin.... There should be a long-acting med and a short-acting for breakthrough pain.

Pain management should really be consulted.

[canned_bread]

It sounds like this patient would benefit from a PCA with a background dose running, as well as a small amount of top up.