pain management for bone ca

jilliebean · Sep 7, 2005

I'm the weekender too. I can't tell you how many times I come in to problems like these. It helps that we have a new DON who becomes involved in these situations. These nurses are extremely uneducated on pain issues (and I bet alot more) I would and have raised heck on matters like this. Of course she's "whiney" ...she is in pain. What I end up doing is recomending pain meds to the doc and get an order for it. When the rest of staff complains..Tell them...its what the doctor ordered.
What about a long acting pain med and Roxinal for break thru. Of course you can taper or increase them as needed.

roxanol q 1-2 hrs (give it faithfully) and duragesic patches, just watch those resps.

Daytonite, BSN, RN · Sep 7, 2005

What we used to do was write the pain medication as a routine order so that it had to be given every 4 or 6 hours around the clock, not as a PRN. Then, anyone holding the medication had to make a notation as to their reason for not giving it.

My response to the people who say it is bad nursing judgement to follow a narcotic order and that she could get addicted is "She's dying, so what." Keep after these ignorant nurses and stick to your guns. I'd ask the off-going nurse specifically when she medicated this lady last and if it was time for another dose, one of the first things I'd do coming out of report is medicate her. I wouldn't wait for her to call for pain medication.

chip193 · Sep 7, 2005

:angryfire I have never been a hospice nurse but have worked with them when a supervisor for homecare. They have always worked hard at keeping the pts pain at a low level. I work ltc now and we have a sweet little lady that has had cancer in her lung, on her liver and now in her spine. The nurses have been "managing" her pain with ASAP. She has an order where they can give either that or percocet 5/325. Because they don't want her to get addicted they give her the asap. Everytime I have worked this wing she has cried most of the day because of pain in her back and leg. I called the doctor this weekend because she was in so much pain she couldn't eat. He ordered the percocet doubled every 4-6 hours. You have never heard such complaining. "well she'll get addicted, she od on it at home." "She needs to take as little meds as possible." I seldom lose my temper but I said, "SHE HAS BONE CANCER!!!" :argue: I know it is one of the most painful types of cancer. ONe said it was bad nursing judgement to follow that order. I called the md again, 3rd time, and asked for clarification.:angryfire, he said do what you think is necessary for her, we settled on the percocet q6 for 4 days and then try alternating it with the asap. I talked with a hospice nurse earlier that day and she felt it would be managed better with morphine and ibuprofen. I knew this wouldn't fly so that is why I stuck with the percocet. How do I convince these nurses that her pain isn't going to be controlled with just asap? I don't feel that with ca that addiction is something to even be concerned with. She's not going to get better. She is in denial about it so won't get hospice involved.

It goes something like this - she gets addicted. So what? So you have to give her more and more of it. So what? So you have to change to a different opiate. So what? Give the lady a break!

It's like telling the terminally ill lung cancer patient to stop smoking. So what if he keeps smoking. It's too late now!

(And no, I'm not endorsing smoking!)

Chip

aimeee, BSN, RN · Sep 8, 2005

Sad. Just so sad that you have to fight so hard for what should be just good basic nursing. Assess the pain. Treat the pain. If ineffective, adjust the intervention. Repeat until comfort is achieved. End of story. If tolerance develops, rotate to another med. Acetaminophen is almost completely useless in treating bony pain. Keep singing the same song. Maybe somebody will start to listen.

dinkymouse · Sep 8, 2005

Thank you for reafirming my thoughts on this case. I can't believe the attitudes of some of our nurses and cna's. Today was a bad day but I will live through the Wedensdays I work. :rotfl:

jerseyRN · Sep 22, 2005

We use ibuprofen a lot, but rarely trilisate. How much & how often do you recommend?

dinkymouse · Sep 22, 2005

Finally the family has become involved. Her cancer doctor told the family that she will not get any better. They have changed her meds somewhat. She gets oxycontin now at bedtime and prn, tylenol still the other times and they increased her durogesic dose. Hospice started with her yesterday and had an electric bed with a pulsating air matress. I worked on her hall today and she said she slept better than in a long time and that her pain was mild. 1st time she has said that. The nurse that had told everyone to give her just tylenol was fired a few weeks ago, for other reasons, but now I can get things done for her without all the hassles.

Home Health Columnist / Guide · Sep 22, 2005

She gets oxycontin now at bedtime and prn, tylenol still the other times and they increased her durogesic dose. Hospice started with her yesterday ...now I can get things done for her without all the hassles

:yelclap: :yelclap: :yelclap:

Dinkymouse receives the allnurses advocacy award for 2005!

:balloons: :balloons: :balloons:

txspadequeenRN, BSN, RN · Sep 22, 2005

This is what I would do.... Get a order to D/C the percocet, Virtually useless with this type of pain and get some PO morphine on board with Roxanol for breakthrough . Ibuprofen works well in some patients to bridge the pain gap. These nurses are just uneducated on hospice and hospice medications . I wouldnt care the least bit if it fly's with the other nurses or not. THIS PATIENT NEEDS PAIN RELIEF!!!!! The last thing in the world they should be concerned about is addiction... she is dying, load her up and give her a least some peace to enjoy her last few days!!!!!

:angryfire I have never been a hospice nurse but have worked with them when a supervisor for homecare. They have always worked hard at keeping the pts pain at a low level. I work ltc now and we have a sweet little lady that has had cancer in her lung, on her liver and now in her spine. The nurses have been "managing" her pain with ASAP. She has an order where they can give either that or percocet 5/325. Because they don't want her to get addicted they give her the asap. Everytime I have worked this wing she has cried most of the day because of pain in her back and leg. I called the doctor this weekend because she was in so much pain she couldn't eat. He ordered the percocet doubled every 4-6 hours. You have never heard such complaining. "well she'll get addicted, she od on it at home." "She needs to take as little meds as possible." I seldom lose my temper but I said, "SHE HAS BONE CANCER!!!" :argue: I know it is one of the most painful types of cancer. ONe said it was bad nursing judgement to follow that order. I called the md again, 3rd time, and asked for clarification.:angryfire, he said do what you think is necessary for her, we settled on the percocet q6 for 4 days and then try alternating it with the asap. I talked with a hospice nurse earlier that day and she felt it would be managed better with morphine and ibuprofen. I knew this wouldn't fly so that is why I stuck with the percocet. How do I convince these nurses that her pain isn't going to be controlled with just asap? I don't feel that with ca that addiction is something to even be concerned with. She's not going to get better. She is in denial about it so won't get hospice involved.

txspadequeenRN, BSN, RN · Sep 22, 2005

I have given much MUCH higher dosages of Morphine than this.. I have had orders for every 10-15 min Roxanol even 2mg ativan intensol every hour, but these patients are in their final hours...

With bone cancer the percocet is probably not going to do much. If your facility has a contract with a hospice agency and the family and MD agree, the hospice can come into the facility and help manage this patients pain. The hospice agencies are a wealth of knowledge when it comes to pain management. I work for an agency that does both home care and hospice. We see MDs who are afraid of ordering the "hard pain meds" due to the fear of law suits. Unfortunately, some MDs dont understand pain management either.
Stick to your instincts and fight for this patient and her comfort. See if your DON or if you know a local company, see if they can come in and offer a class on pain management. The information that they learn from that class, will change their minds.
When I went back to working flexi in a hospital as a 2nd job, I was in ICU, had a nurse talking about 4 mg of Morphine for a patient. They made the comment that "the new nurse (me) may think we are trying to knock the patient out or kill her with that much pain med". I smiled looked at them, and said 4 mg is nothing when you are talking to a nurse who helps patients manage pain and breathing and has patients that take Ativan 2mg q 4 hr and Roxanol (liquid form of Morphine) 1 mg q 1hr..........and oh btw..... they are more coherent than I am in the mornings.
Needless to say their mouths hit the floor and couldnt believe that patients were given that much.
And if a pt with bone ca gets "addicted"........ who cares....... bone ca doesnt get better.

Home Health Columnist / Guide · Sep 22, 2005

how much & how often do you recommend?

check out this great pain mgmt monograph. dinky print it out for work and don't forget to ask hospice team for pain mgmt inservice.

pain mgmt monograph 3 [color=#292526]a pharmacologic overview of pain management

[color=#6f6f6f]file format: pdf/adobe acrobat - view as html

www.ashpadvantage.com/website_images/ pdf/pain_management.pdf

innovations in end-of-life care

some sample decision tree charts:

1. global cancer pain algorithm

2. pain assessment: routine

6. flow chart

choline magnesium salicylate - arthritis and arthritic conditions ...

dose we started with in hospice was 500mg bid---increase 300mg increments to 1500mg bid as needed ; nice thing is it's also available as liquid so when swallowing became and issue just switched to liquid prep.

was good for those pts who couldn't tolerate other nsaids: ib or naproxyn

dosage guidelines: http://www.rxlist.com/cgi/generic3/trisalicyl_ids.htm

[color=#ff6600]* first-line pain medications

[color=#ff6600]* pain medication delivery

[color=#ff6600]* adjuvant medications

[color=#ff6600]* breakthrough pain

[color=#ff6600]* the myth of addiction

[color=#ff6600]* radiation and chemotherapy

[color=#ff6600]* surgery and special procedures

[color=#ff6600]* alternative & complementary methods

cancer pain management guidelines: ucla 2004

the nccn/acs cancer pain treatment guidelines for patients is one of a series developed by the nccn/acs partnership. nccn and acs plan to provide guidelines in this format for the 10 most common cancers, with lung cancer, bladder cancer, ovarian cancer and non-melanoma skin cancer scheduled for release in the next year. treatment guidelines for patients have also been written for breast, prostate, and colon cancer. the pain management guidelines will be available in spanish later this month. to order a free copy of nccn/acs cancer pain treatment guidelines for patients or any of the other nccn patient guidelines, contact the national comprehensive cancer network (1-888-909-nccn) or the american cancer society (1-800-acs-2345). the acs also has spanish speaking cancer information specialists who can respond to cancer related inquiries. you may also visit their web sites at www.nccn.org or www.cancer.org. requests by email may be made to [email protected]. http://www.fccc.edu/news/2001/acspainmgt-05-23-2001.html

encourage anyone who can attend fox chase cancer centers pain resource program--that's where i received some of my training 15 years ago.

pain resource nurse program program description: oct 5+6th,2005 philadelphia: this two-day core instructional program is intended to develop pain resource nurse leaders (prns) who will transform the quality of pain management at their institutions by getting current pain management principles and practice standards to the bedside

abnerRN · Dec 7, 2005

How very sad and unfortunate that there are still nurses who withhold pain medication based on the addiction principle. Bone pain from CA is the most diffucult to relieve, our team MD advocates NSAIDS together with opioids. ASAP!!for crying out loud, this lady is suffering unecessarily!!! :madface: