Pain/Anxiety Control Can Go a Long Way

[UnbrokenRN09, BSN]

I've been seeing a trend lately where doctors have become very reluctant to treat pain and anxiety. Especially with pulmonologists and cardiologists. They just cannot get past the whole "they'll stop breathing" thing. Well, I actually had a patient that worked himself into alkalosis because he was hurting (back surgery with lateral approach and CT in place), so he was breathing more shallow, then he became distressed because he "couldn't breath", which caused him to panic....worsening the problem of hyperventilation. I had given 4mg morphine 2 hours earlier when this occured and it corrected the problem. Problem is, the guy had to be reversed earlier during the dayshift, but they were hitting him with 8mg of morphine at a time, which was why I opted for 4mg. I felt coupling this with a small dose of a benzo might work nicely for him and last longer, as he was NPO, so PO meds weren't an option. Pulmonologist was called twice, would not give any orders whatsoever other than to "maintain O2 sats above 92% and use bipap if needed". Well, bipap isn't a good option for someone who is freaking out and not cooperative....and nothing for anxiety is ordered. But, he also wouldn't even let me finish a sentence, must less request the drugs I wanted. The charge nurse made the 2nd call....did manage to ask for valium/ativan, but was told that "we would make him code" To make a long story short, we had to basically RAT him and he ended up on 100% NRB after gases were drawn, which temporarily corrected the problem. We then switched back to nasal canula and let him rest. 2 hours later, we're back where we started after the morphine wore off. I ended up drawing his labs early, saw the hgb had also dropped 4 points, so at that point I just opted to call the surgeon and requested an ICU transfer, which I got. He would've ended up on the vent if that cycle continued, IMHO, I just didn't have the time to constantly deal with all that in addition to 3 other patients.

I really think this would've been prevented just by more effective pain/anxiety management, but doctors just don't want to hear that. I mean, isn't something that reduces RR desireable if your problem is resp alk? Pain/anxiety control just seems to be overrated these days. I realize a PE or cardiac event could also have been a possibility, but my gut feeling was pain. Bottom line is, the doctor just should have let me paint the picture of the patient so he could make a more educated clinical decision.

This is not the only time I have had to call doctors multiples times because of resp issues arising from either pain or fighting a Bipap. I mean really? Who wants a suffocating mask on their face without something to calm them down enough to just let the machine do what it's designed to do? But every time it's "they'll stop breathing". I just want to say no, they'll stop fighting so they CAN breathe!

If you think there's anything else I could've or should've done differently, I'm open to your comments! I'm a newer nurse, but am well past the new grad phase and always open to learning how to be better. I still find myself struggling with how to effectively communicate with physicians, which is probably the main reason I haven't made the jump into CCU yet....

[Cardiac-RN]

I have seen this a lot in the past with pulm docs who do not want their patients to have benzos or pain medications because they are afraid it will "depress their respiratory drive" and make the situation worse. But really it is almost a danged if you do or danged if you don't situation, especially if you have a really nervous patient who is hyperventilating. I generally try the approach with the physician that I would prefer to give them smaller doses of 2 medicines (pain + benzo) than a higher dose of either medication independently because they might act as synergists and work well together with less side effects than administering a higher dose of a single medication independently. I might also add, if the patient is well on their way towards intubation, what harm is a little ativan really going to do when we already have BIPAP in place, oxygen going, ambu on stand-by, and RT o provider close by for possible bagging/ intubation if needed? I know that if it were me, and I couldn't breath, I would certainly be anxious. Please give me something for my anxiety in that situation!

Cardiac-RN

[UnbrokenRN09, BSN]

Exactly! Please medicate me in that situation! Lol.

I've had good luck with IV Tylenol/Ofirmev. It's great for older people you don't want to give narcs to and seems to work very quickly and last awhile. I am also a fan of toradol, but few docs will give it for more than 24hrs because of the harsh effects on the kidneys.

This was actually good experience for me even though it was miserable and stressful at the time.

I'm really starting to wonder if benzo's and opiate pain medications really have as profound of an effect on respiratory drive as we're taught? I have never had to reverse a patient from Ativan, Valium, morphine, dilaudid, etc. Conscious sedation with versed/fent is another story, but that's a completely different animal. I'm not saying it doesn't happen, but if you are careful and give appropriate doses taking age and renal function into consideration, I think it tends to do more good than harm for someone really needing the relief.....

[CapeCodMermaid, RN]

I've been a nurse for more than 30 (yikes!) years. I was recently a patient on a telemetry unit. The nurses were pushing me to take IV morphine for pain control. I told them I'd do better with a Tylenol PO or something less drastic, but NOOOOOOOOO....they were told to give IV morphine for any chest pain. They didn't seem to be the least bit concerned over my respiratory status....pushed 5mg of morphine in less than 10 seconds and then left the room! I think so much depends on where you practice and what the protocols are.

[UnbrokenRN09, BSN]

There have actually been some studies done that showed better outcomes when using morphine for chest pain. It can help lessen ischemia due to it's effects on lowering the blood pressure, which takes workload off the heart. Forgive me for not citing any of this, I can't at the moment.

Either way...I would never push morphine that fast. Usually over 2 minutes....in a more urgent situation 1 minute. I never just "slam" anything into an IV though, so many nurses have a bad habit of doing this, especially with lasix!

[exp626]

I think I'd have called the surgeon about the pain issue, as they'd be more understanding of what their patients are experiencing. This patient sounds like he could have benefitted from a PCA pump. Pulmonologists never want to give anything, and cardiologists run the gamut...some will give nothing, and others will give you whatever you want just so you don't call them again. We have a pain specialist nurse at my hospital who we can consult (M-F 0800-1700...which is when most pain is, right? lol). As to the morphine for chest pain, AHA recommends Nitro SL then if the pain is unrelieved after 3 doses Q5min, then Morphine IV 2-4mg, which decreases preload and venodilates. Needless to say, slamming 5mg is inappropriate!