Pain Management

i would certainly report that the pt's current pain regimen is ineffective, and i would nip this in the bud asap. pts should never have to be in pain. if i knew of a more effective narcotic, then i'd suggest it. but even if the md had to prescribe something different, my point is that i would never leave the md alone until my pt obtained total relief. remember, pain is the 5th vital sign.

leslie

I actually just went to a Chris Pasero Pain Management seminar last month.

It would really depend on the nature of the pain. Is it Physiologic pain (nociceptive; somatic, visceral), Pathologic (neuropathic) think tricyclic antidepressants and anticonvulsants, chronic?? Characteristics? If this is a chronic pain pt...ask THEM what works best for them and at what dose.

Using a multimodality approach, using appropriate combinations can attack more than one pain mechanism. Drugs that work synergistically reduce doses, which reduces adverse effects.

Also, utilize the pharmacist!! Let him know which meds you are using, the type of pain the pt has, what you've tried and has/hasn't worked and ask what meds would work best together. Use the WHO Analgesic ladder...non-drug intervention+non-opiod (NSAID)+opiod-etc

If you ever get the chance to attend one of Chris's seminars...I highly recommend her.

good luck

~ski

Pain is the 5th vital sign like Leslie said, it should not go untreated

Perhaps it wasn't a great question.

How often do you use sedatives or anxiolytic? This particular instance the patient had a vertebral fusion for intractable back pain so he had incisions on his abdomen and back plus the pain from back surgery. So it's neuro, visceral, and somatic. I found him laying on his side panting because he was in so much pain and his nurse said he had had all his pain meds for two more hours.

So get the doctor on the phone? Give something that he has in his orders such as phenergan? How often do nurses have to face patients postop that seem to have very little response to pain meds? Would you worry about your license if he was over- or undermedicated?

:no:Personally I don't like to see people in pain, but I was a guest.

yes, anxiolytics work well with narcotics. rightfully, pts. should and do become anxious if their pain is poorly controlled. so giving 1-2 mg of ativan often helps the pt deal with any remaining pain. there's a host of schedule II-schedule III narcotics an md can choose from. my point is that the doctor or the nurse(s) should never rest until the pt states relief. there's no room for apathy on the medical team's part. and actually there is more liability on the md/nursing team if they let a pt suffer. i'll tell you now it wouldn't rest well with jcaho if they were making a visit and heard the moaning/groaning coming from a pt's room. funny how suddenly everyone becomes super vigilant when jcaho's around....not a groan to be heard.

Sounds like this patient is a chronic pain patient and needs a multi-med appraoch.

These patients can be such a challenge because you tend to up and up their pain medicine and then one minute they are screaming in pain and then suddenly they're unarrousable and oversedated. I've had that happen several times. Perhaps this is why nurses and doctors are a bit hesitant to over medicate.

Patients have tolerances. I currently have a patient on a whopping 250 mcg of Duragesic patch, which we don't even carry a dose that high. Plus dilaudid every two hours. Chronic pain patients can tolerate higher doses. Unfortunately when they come in the hospital for any kind of surgery or trauma it takes a long while to get their pain under control.

I think the pca limits could be increased, then some break through meds, then perhaps even a duragesic patch for steady control during times of sleep. Great advice here.

About the license issue, I've never heard of anyone loosing their license for under and over medicating, but I'm sure it happens. What you should be concerned about is that juries are very sympathetic to patients who claim poor pain control and you could be drug into a lawsuit. Asking a patient with those symptoms to wait two hours could get you in trouble if you're honestly documenting.

thanks to everyone for their responses. i won't be using names. i'm not just doing it for my paper, i think pain control is important. i've seen patients in extreme pain aeb HTN and increased RR and HR and the nurse says that the patient can't have any meds because it's not time so they do nothing! it makes me crazy so i go over their heads to someone who can do something. that probably does not make me popular.

sadly, there are still many physicians that are reluctant to prescribe too many narcs. and there are still too many nurses that are reluctant to administer prn narcs. and finally there are the docs that do earnestly attempt to relieve pain but don't know what to do when the pain remains unrelieved.

as a hospice nurse, i have always been extremely vocal in getting one's pain under control. and you're right. often it doesn't make you the most popular person on the unit. i don't care. my responsiblity is to my pts. i've even had pts change doctors when their docs weren't looking out for their best interest. a good doctor will never stop trying for their pt. a good nurse will advocate for their pt's well-being. much luck to you.

leslie

add: bethena- often vs will escalate but in those w/chronic pain, that is not the case.

I work on an Ortho/Neuro surgical unit and pain control is a huge issue. For total joint surgeries our patients usually have either a PCA or epidural with PO meds for breakthrough pain. If these methods are not controlling the pain and I have tried all breakthrough pain relivers I contact Doctor. If I let a patient stay in agony just because the next dose is 2 hours away I would be in so much trouble. It amazes me though how some of our docs seem to have no concept of pain control. One of the doctors will only let his patients have T-3s and Demerol & Vistaril IM injections. If you call him for further meds he usually will not prescribe them. So frustrating. We do have a pain team that I utilize quite frequently and they routinely follow patient with epidurals. Another frustrating issue is when the patient recieves an epidural with only a -caine in the bag and no narcotic for pain control. It is so hard to try to get their pain under control even when the anesthesiologist is notified for pain meds. When pain is controlled I always make it a point to routinely ask the patient if they would like more meds and to educate about why it is better for them to take pain medications instead of just "biting the bullet." Education for patients is another way to help them to get good pain control for themselves, especially since they will be discharged with PO pain meds.

thanks to everyone for their responses. i won't be using names. i'm not just doing it for my paper, i think pain control is important. i've seen patients in extreme pain aeb HTN and increased RR and HR and the nurse says that the patient can't have any meds because it's not time so they do nothing! it makes me crazy so i go over their heads to someone who can do something. that probably does not make me popular.

You aren't there to be popular, you are being a great patient advocate, which is what nursing is all about. Hopefully very soon...the nurses and doctors will be required to take continuing education (we are required 8 hours of CE) about pain relief. It's VERY eye opening. There are so many options and different ways to treat pain, a patient doesn't HAVE to be in pain. We may not be able to get thier pain down to a 0 out of 10, but if we can find what number (say a 3/10) that they can live with...it's sure better than letting them suffer. Was it Tweety (and me) that said, chronic pain patients are some of the hardest to treat. We need to know GOING in, what meds and what amounts they have been using to treat the pain they are finally getting surgery to treat. You can't just treat them like the opiod naiive and expect 2 percosets to do the job, when they are taking 45 (or more) of morphine (+ whatever else they take) at home just to get along. kwim? There may be "toxic" levels on non-opiod drugs, but to those that are long term opiod users - there IS no ceiling to the amount that they can take and often, they are on HUGE doses PRIOR to surgery (I can remember saying HOLY cow they really need THAT much!?! and questioning orders...to find out that they've been suffering for years and have been on these meds for years..that does NOT make them an addict). In addition, it is so much easier to control the pain by staying on top of it, not just trying to treat it after it is out of control. Just remember that sedation precedes respiratory depression...if they have a RR of 6 and are nearly obtunded, it's not the time to up their dose..but if they are talking to you and say "hey my pain is an 8!" Geez, let them have their meds. I've been lucky enough to usually have patients that have numerous pain meds for us to choose from PRN, in addition to the scheduled meds. When in question, go to your RN, if no luck then, go to your instructor...then go from there. Remember, this isn't a popularity contest, you are there to treat the patient and be their advocate. I better get off my soapbox now... :behindpc:

Oh, and Visteril IM? Can you say OUCH!!!! It feels like a freaking branding iron, they usually do an IV push now. (having btdt) Not all pain patients show those increased RR and HR, and just because they are "sleeping" doesn't mean they aren't in pain...would you wake a patient to give them thier insulin or anti-infective? Of course you would...so think the same way about pain control meds. Shutting up now

In my experience, I have yet to find a pain that can't be controlled with adequate, but safe amounts of Dilaudid. I'm not a big fan of morphine. It appears to simply take the persons mind off of the pain whereas Dilaudid really seems to block up pain signals. I like the dilaudid because it acts more rapidly too; although, the shorter duration will keep you busy. I think it's critical to use prescribed PO analgesia such as Hydrocodone or Ultram in a round the clock manner and then use the IV narcotics for breakthrough pain; however, all too frequently, I see the PO meds being forgotten about and the IV meds being used solo. At night, I think there's nothing wrong with giving IV phenergen with the intention of both reducing nausea but promoting rest as well. A soundly sleeping PT is, IMO, not suffering. If there's any benzodiazepines available, I'll probably give them too provided the PT's respirations are good. Also, the use of the pain scale is pretty mandatory in assessing the effectiveness of your measures. Frequent VS observations are pretty useful too.

I'm sorry everyone I misspoke earlier when I said I would not be using names. I need to reference the screen names. I'm not used to writing papers referencing information from a forum. Please let me know if you would rather not have your posts referenced in my paper.

Bethena:imbar:imbar