Two Big Questions For Pain Experts

Specialties Pain

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If it's assumed that the patient's pain is ALWAYS what they say it there are two major questions that arise. The questions arise because they are real-life situations.

1. A patient has had surgery that isn't expected to be painful. The patient has had 4mg of Dilaudid for pain that is reported as 10. The patient has a goofy grin and says: "I'm going to say that my pain is a 10 because I like pain medicine." (This actually happened)

Do you continue to administer Dilaudid in this situation? Do you take his report of pain at face value? I was advised by my co-workers to send the fellow home and I did so.....He left smiling......Did we do the wrong thing?

2. A patient is close to being in a Dilaudid coma after receiving 10mg of Dilaudid. The patient appears very comfortable and, when awakened, rates his pain at 10. (This actually happened)

Do we have a pain emergency here? (I've seen many situations that are clearly pain emergencies but this one doesn't seem to be a pain emergency.) Can you in good conscience send the patient to the floor with a pain of 10 under these circumstances?

O.k.....I asked more than two questions but the other questions are tied to the main ones.

Specializes in PACU.
..it is your personal opinion that these patients were mishandled in some way.

I don't think there are right answers in the two examples. I think it's a question of making the best guess.

The two patients were in my care.

Have I not medicated a patient because they are smiling and state they like pain meds...NO, not usually.

The patients were Medicated.....The smiling one had been given 4 mg of Dilaudid and the semi-comatose one had recieved 10 mg of Dilaudid.....The question is whether they should have been given more. Do you think they should have received more Dilaudid?.....Pain rating of 10, smiling and looking very pleased, states that he's rating the pain at 10 because he likes pain medicine, vitals are perfectly normal......What would you do?

Semicomatose after 10 mg of Dilaudid looks extremely comfortable states that his pain is 10 when you wake him up......What would you do?

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Specializes in PACU.
Do you have a comprehensive assessment to determine if the patients had a sensitivity to the opioids?

No.....There wasn't anything in either history that addressed response to opoids.

There was no reason to suspect delirium in either case. Neither patient showed any signs of the effects of anesthesia.

Most people don't know they have sensitivities to opioids or anesthetics.

The two patients had been taking pain pills for a long time.

What would you have done?

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Specializes in PACU.
There's something hauntingly familiar about this thread

It's widely agreed upon that there are a whole lot of problems putting the pain scale into practice.

It would be interesting if someone was able to tell me what I should have done wouldn't it?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I don't think there are right answers in the two examples. I think it's a question of making the best guess.

The two patients were in my care.

The patient was Medicated......He'd been given 4 mg of Dilaudid......The question is whether he should have been given more. Do you think he should have received more Dilaudid?.....Pain rating of 10, smiling and looking very pleased, states that he's rating the pain at 10 because he likes pain medicine, vitals are perfectly normal......What would you do?

Your insistence for a definitive response makes me wonder why is "MY decision" so important....as I have said I cannot give a definitive answer without proper assessment of the patient. Each nurse makes their own decision based on the facts. He/she has to determine what is comfortable for them.....there are no definitive answers as they are based in individual patients. Each situation will have a different decision/outcome.

What is your purpose for perusing this particular patient and case scenarios...what are you looking for or what are you trying to prove/solve?

I have learned to be evasive and cautious when people I don't know want definitive answers to vague question.....for anything posted, even in an anonymous forum, for anything is searchable and usable...even for a court of law or the BON.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
It's widely agreed upon that there are a whole lot of problems putting the pain scale into practice.

It would be interesting if someone was able to tell me what I should have done wouldn't it?

It would be interesting if you told us why.....wouldn't it?

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Specializes in PACU.
It would be interesting if you told us why.....wouldn't it?

I want to know what the expert opinion(s) are on the management of the two patients. There is no mystery there.

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Specializes in PACU.
What is your purpose for perusing this particular patient and case scenarios...what are you looking for or what are you trying to prove/solve?

My purpose is to find out what the experts say to do. In the examples I mentioned do you treat pain ratings of 10 with more medication(s) or not?

I have learned to be evasive and cautious when people I don't know want definitive answers to vague question...

The examples aren't, or weren't, vague......Decisions had to be made about what to do with the patients.

I'm very interested in knowing what a pain expert would do in those situations.

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Specializes in Hospice.
I want to know what the expert opinion(s) are on the management of the two patients. There is no mystery there.

The experts have told you their next steps in management - ie a more thorough assessment of the individual patient. If you provide better information and you might get a more satisfactory answer.

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Specializes in PACU.
- ie a more thorough assessment of the individual patient.

What should be assessed further?

If you provide better information and you might get a more satisfactory answer.

I provided the information that was available in the examples.

We don't get histories that deal with response to pain medications. These examples are real-world examples.......The real world isn't idealized and often doesn't lend itself to theoretical models.

Why can't anybody tell me how to manage the patients?

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Specializes in Hospice.
What should be assessed further?

I provided the information that was available in the examples.

We don't get histories that deal with response to pain medications. These examples are real-world examples.......The real world isn't idealized and often doesn't lend itself to theoretical models.

Why can't anybody tell me how to manage the patients?

They just did.

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Specializes in PACU.
They just did.

No....Nobody has told me how to manage the patients. Should they have received more medication(s) or not?

In the case of #2 administration of more opioids would likely have necessitated reversal with Narcan. Given that is it O.K. to discharge him despite a pain rating of 10?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
What should be assessed further?

I provided the information that was available in the examples.

We don't get histories that deal with response to pain medications. These examples are real-world examples.......The real world isn't idealized and often doesn't lend itself to theoretical models.

Why can't anybody tell me how to manage the patients?

In the real world I always look at my patients past record for input on my decisions. One of the first things a ED nurse asks....what have you been hospital for in the past. If I am having a difficult time deciding about a patients appropriate care I look to the previous record. Just as a patient having chest pain if they have EKG changes that can be chronic or acute.....I look for previous EKG's for base line changes.

It is an integral part of assessment and appropriate treatment of our patients.

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