Pain management in med-surg.

[Becca608]

Hello all! I've got a question regarding pain management. Let me start by saying what I believe:

1. Pain is what the patient says it is.

2 My position is that patient's should medicated as ordered by MD and as requested by the patient. I am not an addiction specialist and it is not in my staff description to determine who is addicted and who isn't.

3. Yes, there are drug seekers out there. But they usually make themselves pretty obvious.

So here's the question. Client is 5 days post op AKA on one leg. The other AKA done previously is a gross infected mess that we are doing wound care on. He is ordered oral meds q4h and IV pain medication q1h. He also has a large dose of IV pain med prior to dressing changes. Client has woken up after 4 hrs of sleep with a 10/10 pain rating and is moaning and begging Jesus. Oral meds take 1-2 hrs to reach maximum effect. Is it appropriate to medicate with both meds at the same time--the oral pain med for the long-term control of pain and the IV pain med to get control over the pain while waiting for the pills to work?

I know this seems like a stupid question, but I was slammed at the time and asked my charge if she could medicate this patient. She claimed that he could only have his oral med and would have to wait a full hour before getting anything IV. She claimed it was hospital policy and I don't believe that.

Thanks.

[morte, LPN, LVN]

YOU are making pharmacologic sense, get the doc to order that way, and the charge should back off....

[tewdles, RN]

With a report of 10/10 pain I would administer the IV dose ASAP to get control of the pain immediately. I would then be certain to provide good pain assessments and would administer the oral meds when the pain creeps back to the level that the patient reports as his/her tolerance baseline...for some that is around 3-4/10, for some it is 2-3...you get my point. It sounds like this patient would benefit from a continuous infusion opioid while in the acute phase...waking with a pain level 10/10 is not acceptable in the hospital setting, IMHO. Perhaps you could advocate for a PCA? As he/she nears discharge make the switch to oral meds keeping in mind that a long acting opioid with fast acting "break through" meds may well be a good idea. With amputations the patient will often benefit from meds to control their neuropathic pain...elavil or neurontin perhaps. Good luck.

[Becca608]

Thanks Tewdles,

Neurontin is already use. Part of the issue is that no one is consistently medicating this guy across shifts. Some nurses are exclusively giving him IV pain meds and he isn't getting the PO as he should. I talked to the oncoming nurse about getting the po pain med to him around the clock and was told to essentially mind my own business and she will medicate as she sees fit. So much for implementing a plan of care .

But when a client tells me that he can feel the pain down to the tips of his toes 5 days after an AKA, I would presume that phantom limb pain is setting in. (I hate the term 'phantom pain' it implies that the client is not experiencing real pain). I felt horrible when I told this man he could not have this IV med until he had the oral pain meds and had to wait an hour for the IV med.

I don't even want to work with this charge anymore. She finds something to criticize me about constantly and I really resent her accusing me of trying to turn this man into an addict. Addiction should be the last thing that a nurse considers when medicating a patient in an acute med-surg setting given that so few people in genuine pain go on to develop an addiction. It makes wonder if she even understands the difference between physical tolerance and addiction.

Thanks for letting me vent.

[tewdles, RN]

thanks tewdles,

neurontin is already use. part of the issue is that no one is consistently medicating this guy across shifts. some nurses are exclusively giving him iv pain meds and he isn't getting the po as he should. i talked to the oncoming nurse about getting the po pain med to him around the clock and was told to essentially mind my own business and she will medicate as she sees fit. so much for implementing a plan of care . i would recommend speaking directly with this man's physician, give him a good idea of what the quality and frequency of the pain is...make sure he is aware of the opioid totals for your shift as well as the previous 24 hrs as well as the pain level. advocate for a pca, ask about it directly.

but when a client tells me that he can feel the pain down to the tips of his toes 5 days after an aka, i would presume that phantom limb pain is setting in. (i hate the term 'phantom pain' it implies that the client is not experiencing real pain). [color=#ff0000]the term "phantom" refers to the missing limb...not the pain. i felt horrible when i told this man he could not have this iv med until he had the oral pain meds and had to wait an hour for the iv med.

i don't even want to work with this charge anymore. she finds something to criticize me about constantly and i really resent her accusing me of trying to turn this man into an addict. addiction should be the last thing that a nurse considers when medicating a patient in an acute med-surg setting given that so few people in genuine pain go on to develop an addiction. it makes wonder if she even understands the difference between physical tolerance and addiction. [color=#ff0000]print out a couple of recent articles exploring pain management, there is a wealth of info available with a simple search (bing works well). make sure to leave one out for your co-workers and give one to your charge. she may criticize you, and accuse you of ridiculous stuff, but you will rest well if you know that you did what you could, in your capacity as a nurse, to ease this man's pain.

thanks for letting me vent.

we all need to vent occasionally. good luck.