Pain management in nonverbal patients

perfectbluebuildings, BSN, RN · Jan 29, 2006

I have a question re: a recent situation that I feel I should maybe have handled differently.

I work in peds and am used to the younger kids especially infants, just being irritable and crying more when in pain, and medicating for that with Tylenol (usually). The other night though, I had an older nonverbal patient with UTI. I hadn't ever had the pt before, and got in report that they were very active in the bed. On my first assessment, the pt was moving around a lot but seemed calm.

The aide did the pt's initial set of VS, and B/P was very elevated. I called the MD immediately, per our VS notification protocol, and she asked us to recheck and call back. DId that, and also tried things like cathing pt etc, to see if those could be sources of discomfort. In short, (ha ha ha, sorry it's not REALLY short :) ) I tried to figure out the source of the pain but in all this time pt didn't get Tylenol till more than an hour after that elevated B/P at beginning of shift, and had to have further pain mgmt w/Lortab. ANd after these meds, pt needed only one further dose of PRN pain med through the night and VS were stable the rest of the time. I feel like was a little slow to pick up on the fact that this was pain, back at the beginning of the situation, and didn't even clue to that till Mom got there and said the pt was never like this at home and "seemed uncomfortable". DUH, why didn't I think of that :uhoh3: and, I hate that the pt had to suffer while this was going on; should have thought of the obvious fact that UTIs ARE painful. So I want to be prepared for the next time such a situation comes up.

My questions are:

#1, with a pt like this will you give a med first and then try to figure out what is going on, or try other interventions before med?

#2, what are some tips for recognizing S/S discomfort in older nonverbal patients, and figuring out what might be causing that discomfort?

And, I guess, in short how might you have handled the situation? Thanks a lot in advance.

Noryn · Jan 29, 2006

Nurses beat themselves up so much even when it appears they did a great job but that criticism is often a valuable learning tool. First, most of us arent psychic so there was really no way you could tell what was going on with the patient. For the most part you always want to try to find out what is causing the pain first then you try and treat. If you give pain medication right off the bat you may hide some serious symptoms. It would always be easier just to give someone a Lortab but patients really do need to be assessed first.

It takes time to do assessments, read medical history and call the doctor. You were also doing things such as catheterizing the patient so it just takes time. This patient was non verbal so you didnt have very much to work with. Granted the patient did have a UTI but do most UTIs need Lortab for pain control? Not in my experience--usually Tylenol and Pyridium will do. But in this case there are things you have to consider. Check the temperature before giving Tylenol or any products containing Tylenol such as Lortab. Why is the patient getting worse? Usually after being on antibiotics the pain should start to diminish not worsen--if it does worsen then the pain does not need to be masked immediately but the uti should be further assessed to make sure you dont need to change antibiotics. With this type of behavior it may also be wise to make sure the patient isnt getting septic.

The previous report said the patient was moving around in bed a lot so you caught the problem another person had missed. It took you an hour but in that hour a lot was accomplished probably the most significant was that you obtained a pain medication order so for the duration of the stay they would not have to be in pain anymore.

In my honest opinion you couldnt have done any better. The medical field is so difficult because 2+2 always equals 4. In medicine sometimes infections get worse, sometimes people do need a Lortab for a UTI--there is never a definate correct answer.

In short my answers although I dont think there are true right answers would be.

1. No always assess the situation/pain and make sure there is not something else going on before automatically giving the pain medication.

2.You listed most non verbal signs of pain--high blood pressure, high heart rate, respirations, restlessness, moaning. Most caregivers can be invaluable in offering you information because they know these patients inside and out.

Noryn · Jan 29, 2006

I also do not mean to lower the priority of pain management--it is extremely important. However finding the reason for pain or picking up on changes in pain can be life saving.

perfectbluebuildings, BSN, RN · Jan 29, 2006

Thanks very much Noryn... you helped me out a lot, everything you say makes a lot of sense.

I didn't think about the "it takes time" part... till close to end of shift when I was writing all my notes and realized the length of time between initial high B/P and tylenol administration. At the time I was doing all those things, it didn't seem long at all! You're right.

To clarify, they did already have the PRN Tylenol ordered as well as PRN Pyridium, but had just gotten the Pyridium a bit before I came on shift. I guess I'm just frustrated I didn't immediately connect the high B/P with pain and go ahead and give the Tylenol right away.

And that's true in a nutshell... about there never being one answer that's always correct in health care, unlike math. It must seem obvious to long-time nurses, but it's one of those things I never quite thought about as a new nurse.

Thank you, again. :mad:

button2cute · Jan 29, 2006

Hello, Rayrae & Everyone

Rayrae, You did the correct steps. You always assess the situation prior to administrator a pain medication.

I worked at a private facility for the mental, physical, and emotional handicapped individuals in the state of PA. Also, I am a bevhavior modification specialist and a crisis manager at the facility. I had learned how to communicate with the nonverbal individuals by learning sign language and the usage of a communication board as well. In addition, the parent, caretaker or an individual who works with the patient know the patient like the back of their hand. Always try to utilize those individuals in your assessment.

I do not know if every hospital have communication boards and sign language interpreters for individuals who are hearing impair and nonverbal individuals. I am not sure if nurses know how to communicate with nonverbals and hearing impair individuals. The hospital should provide those items and give short sign languages classes to all medical personal. This would enhance the knowledge and working skills with the nonverbal. Therefore, the hospital would be able to prevent any miscommunication, misinterpreting and wrongful diagnosis/treatment to these individuals.

It is not hard to show a nonverbal pain scale and allow them to point at a face that represent their pain. If you do not have one then draw one. It is not hard, to take your middle finger downward and the others upward, point to areas of the body and make a face of pain and watch the patient nod "yes" or make sound when you point at the part of the body. In addition, making a comunication board is very easy to produce.

In conclusion, I feel that each nurse and medical peronnel should learn sign language because the value if priceless. Also, you will be able to speak with trach as well. The hospital should consider of having an interpreter on board for these patients. Therefore, the hospitals are not providing the services and deny them a way to communicate to others.

Yes, I am a patient adovacator for all patients and especially for those types of patients. I have seen a lot of misdiagnosis by the medical personnel.

For example, A patient came in confused and combative. Patient was in a lot of pain from broken ribs, face contusions, and stomach lacerations. They sedated the patient and intubated for a week. He went to surgery, treatment applied and care. He continue to way his hands around and the nurse thought the patient was psychotic and called the dr. The dr. gave an order of Haldol. Well, you know the patient was really out of it. The nurse was happy and the psyche eval will be given later. In addition, they tied the hands of the indivuals to the bed. The next day, I walked in the room and I was wondering wwhat was going on. I read the chart and asked the nurse. She told me I could have the patient because he was a behavioral patient by waving his hands. I went back in the room and released one hand and then the other. He was signing that his leg was hurting bad. I told the nurse he is deaf and his hands waving was his signing. She was OMG and called the DR. He came up and they asked me how did i know? I told I know sign language. Therefore, was the patient mistreated?, Was the medical personnel neglectful? How would you had handle the situation? Would you learn sign and the use of the communication board?

The outcome the patient was treated appropriate and the hospital made a quiet deal alleged by the lawyer who represented the patient.

We all assume that we will have walkies and talkies all and nothing else. Well, it is not true, hearing impairs and handicapped individuals are not coming to health care facilities.

Buttons

perfectbluebuildings, BSN, RN · Jan 29, 2006

Hi Buttons,

Thanks for your insight. That is really interesting.

And I hadn't thought about the multiple uses for sign language too... like trach patients, etc. I had to edit and add this in, just realized what you were saying w/ that part of the post.

In peds we do use the "faces" scale for pain quite often, especially younger kids or if they are hurting too much to tell you a number. And ask the child to "point" to where it hurts. In the case of this pt, they were at a similar physical and cognitive level as about a 12-month-old so that was not really an option. We use the Non-Verbal Scale, for patients like this one and for the youngest patients who just aren't verbal yet, 0 being no s/s pain, 1 being s/s irritation, and 2 being s/s pain- I don't have handy exactly what is different between levels 1 and 2 officially but do use that scale quite often. I guess these scales could also be used for adult patients couldn't they?