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Flylik3abr1 Flylik3abr1 (New Member) New Member

Pain management in nursing

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ADN student here! I was curious to know how you as a nurse approach your patients pain management in the hospital. I have seen plenty of nurses disregard their patients pain despite their medication being past due. I even had a case where a patient of mine who was unable to speak due to a head injury was screaming out in pain, very obviously so especially since his vitals on the monitor became very consistent with a natural response to pain, and the nurse I was working under said "He will be fine, he doesn't need his medicine right now". Is this considered normal? I mean I personally believe pain management is very important and I've heard all kinds of excuses about addiction and feeding into false reports of pain for drugs but that goes against what I'm learning in school so I am curious. Do you treat your patients pain as a priority nursing problem?

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2 hours ago, Flylik3abr1 said:

 Do you treat your patients pain as a priority nursing problem?

Yes. I am the who crushes PRN Norcos and puts them in non-verbal patient's feeding tubes. I give the addicts their "hospital heroin" right on time, too.
For half the patients, it makes their lives better when I make pain a priority. And for the other half, it makes my life better to make their pain a priority.
I feel no sense of power or accomplishment by making anyone wait.

I will spend time teaching patients who are new to narcotics and don't seem to be tapering themselves down in an expected way. Addiction is a huge problem, and it seems like a lot of my narcotic-addicted patients became that way after a past, legitimate illness or injury.

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13 hours ago, Flylik3abr1 said:

 a patient of mine who was unable to speak due to a head injury was screaming out in pain, very obviously so especially since his vitals on the monitor became very consistent with a natural response to pain, and the nurse I was working under said "He will be fine, he doesn't need his medicine right now". Is this considered normal?

No, this is not normal. In fact,  Flylik, this situation sounds like patient neglect/abuse and reporting it would have been an appropriately prudent action.

I've tried to understand such behavior from nurses and have come up  with a few possibilities:

-Apathy

-Fear of the patient or the intervention

-Laziness

-A power struggle

-A convoluted sense of righteousness

I'm with Sour Lemon- If they have the med ordered, it's time, they want it (or in this case truly need it), GIVE THE PATIENT THE **** PAIN MED!

Sheesh!

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Generally, I'll give pain meds whenever I can. I try to get new orders if the pain doesn't seem to be controlled. With people new to narcs, I try to educate them on the real possibility of physical addiction. With chronic narcotic users, I try to discuss with them the possibility that the meds they are taking don't actually help their pain. I also offer other stuff, heat or cold packs, repositioning, etc. Sometimes a back rub. If they want meds and it is available, I give it. I do get a bit stuck on the "every 4 hours" thing, I mean.. Normal meds are 1 hour before/after, but with those I generally don't give more than 5 minutes early...

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It is probably department-specific, but surgical ICU does take pain seriously. Getting hit by a car or being beaten with a lead pipe or dealing with necrotizing pancreatitis does hurt. Burn injuries are a whole different classification of pain control.

PCAs for the awake and able to use the pain button, sometimes combined with non-narcotic prn meds are common. Most sedated and intubated patients get a Fentanyl drip. Every once in a while a patient with chest injuries and rib fractures gets an epidural. There is an anesthesia pain team available for patients with complex pain needs (often chronic pain/ hard to treat pain). Part of rounds every morning addresses pain control.

In an ideal setting, the pain meds are gradually tapered down from IV to oral, and from high doses to lower doses.

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Pain is what the patient says, bottom line, even if their physical demeanor or perception does not meet "your" idea of what "you" should be able to see.  I give oral before IV when possible, especially if IV is ordered for breakthrough and you can not experienced breakthrough is there is not a barrier already being used.  Have I had patients that I have thought are seeking? Yes, all the time.  My job however is not to render judgment on whether they "need" the meds or not, but to take care of them.  If the patient is calling before I can give or asking for different meds in addition to, I reevaluate the situation and ask the doc for a different order, some  of the time the patient does not want the meds messed with and then suddenly their pain is better managed.  If a patient is stating their pain is not controlled and they are referencing their chronic pain, they get educated on pain management methods and not being able to receive IV meds at home for the chronic pain. 

 

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On 2/9/2019 at 1:25 PM, Flylik3abr1 said:

ADN student here! I was curious to know how you as a nurse approach your patients pain management in the hospital. I have seen plenty of nurses disregard their patients pain despite their medication being past due. I even had a case where a patient of mine who was unable to speak due to a head injury was screaming out in pain, very obviously so especially since his vitals on the monitor became very consistent with a natural response to pain, and the nurse I was working under said "He will be fine, he doesn't need his medicine right now". Is this considered normal? I mean I personally believe pain management is very important and I've heard all kinds of excuses about addiction and feeding into false reports of pain for drugs but that goes against what I'm learning in school so I am curious. Do you treat your patients pain as a priority nursing problem?

Treating patient's pain is a top priority for me as a nurse and many nurses do it poorly.  In patients that are not verbal, they don't look for outward symptoms of pain.  This is something hospice and ICU nurses do very well.

You are a sharp student.  Pain is easier to treat when you give meds on a schedule and not wait until the patient is in agony.  Let it get out of control and you can spend hours before you get the patient comfortable.

What you are seeing is very poor nursing practice.

I have zero regard for previous addiction histories if a patient has true pain from surgery, an accident, etc.  Physicians review these and just because someone has a drug history doesn't mean they don't deserve to be treated. I do give the patient a choice and educate them to know, they deserve to be treated.  There is no evidence to support receiving a narcotic when having REAL, severe pain in a hospital somehow re-triggers the addictive behavior.  It doesn't.  That's because it has pain receptors to bind to.  

Edited by Jory

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On 2/9/2019 at 10:25 AM, Flylik3abr1 said:

ADN student here! I was curious to know how you as a nurse approach your patients pain management in the hospital. I have seen plenty of nurses disregard their patients pain despite their medication being past due. I even had a case where a patient of mine who was unable to speak due to a head injury was screaming out in pain, very obviously so especially since his vitals on the monitor became very consistent with a natural response to pain, and the nurse I was working under said "He will be fine, he doesn't need his medicine right now". Is this considered normal? I mean I personally believe pain management is very important and I've heard all kinds of excuses about addiction and feeding into false reports of pain for drugs but that goes against what I'm learning in school so I am curious. Do you treat your patients pain as a priority nursing problem?

These are very serious allegations, almost to the point of abuse.  Have you talked to your instructor about these situations?

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I have a soft spot for pain d/t an extensive hx with kidney stones (plural) as a teenager.  I started my nursing career with a firm belief in the adage from nursing school: "a patient's pain is whatever they say it is."  However, it took 2 nights of a patient asking me if he could crush and SNORT his q 1 hour Oxy for me to lose a little faith in that adage.  He was dealing with an infection in one of his cervical vertebrae, so I know that has to be painful, but he was the "typical" patient sitting calmly in the bed, watching TV, and eating pudding while saying "yeah my pain's a 10."  

I never ever ever let patients like that keep me from giving pain medication, though.  If it's available, I give it.  I do, however, educate on their different PRNs and I'll always start with an oral PRN before I give an IV PRN, with the education that "yes, the IV medication will work quicker but it will also wear off quicker.  A pill might take longer to kick in, so it's important to advocate for yourself whenever your pain is a 3 so I can give it to you before it's a 10.  This oral med will also keep your pain relief sustained and we can use anything IV for breakthrough." 

I've also had patients who assumed I'd bring their pain medications with their scheduled medications.  Have to do some education there, too.  I tell them that while I regularly assess their pain level and tell them when their next med is available, I don't just bring PRNs anytime I walk into the room.  

I guess what I'm trying to get at here is that I will always assess and treat pain, but I don't want to feel like I'm the Dilaudid fairy.  I know there are situations that warrant a heavy pain regimen (and the situation you described about the patient screaming in pain and the RN ignoring it is awful), but I guess I've just been in many situations that have jaded me, unfortunately.  

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3 hours ago, brownbook said:
On 2/9/2019 at 12:25 PM, Flylik3abr1 said:

 

These are very serious allegations, almost to the point of abuse.  Have you talked to your instructor about these situations

Unfortunately I am not confident enough in my "official" instructors ability to accomplish tasks to bring this up to her, however I did go out of my way to speak with my clinical instructor about her decision making and the actual nurse who's patient I was working with. The general consensus was that regardless of the pain that patient was experiencing there was a tighter schedule dealing with other patients that my clinical instructor was abiding by that resulted in that patient not receiving any medication until 30 minutes past the onset of the pain symptoms we observed. The nurse herself I observed was documenting at the station outside the patients room where she easily could have heard him screaming out in pain and the family was looking for nurses to assist but nobody was willing to intervene. I understand my instructors explanation about the other medication schedules we had to abide by but in my opinion someone needed to assist my patient sooner than what occured.

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Yes, pain control is a top priority. Pain interferes with rest, causes anxiety, and drives patients to stress-related behaviors. In the hospital I had worked at, we had a tiered pain med system where we gave narcotics for a reported pain level of 5+ and non-narcotics for 4 or less. I had a patient who was on chronic pain medication request an NSAID although his pain was a 7, but that was his call and I made sure he undersrood that there was no need to tough it out if he didn't want to.

In home care pediatrics, I do a lot more non-pharmacological interventions for pain (though there are always PRN orders for Tylenol/Ibuprofen). This is often because my kids are non-verbal and already on so many other heavy medications. Heat, cold, change of position, distraction, holding/cuddling, massage, music can all help too. I had one infant with an anoxic brain injury that could be instantly soothed from minor pain by swinging her rhythmically side to side.

I agree with the other commentors as well. Screw up your courage and report. I saw neglect in my nursing school days too, and it's never okay. Many nurses think that students can't or won't call them out, but we can and we should.

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