Pain Management

[moosicle]

Hello,

I am a new grad in the ICU since February.

During my orientation, I have noticed that we care for a large number of nursing home patients with Stage III and IV decubitus ulcers. Usually, these patients have little or no way to advocate for their own pain management for multiple reasons.

In February, I asked my original preceptor if these decubiti are painful and she looked at me like I was stupid and said "of course." That just confused me more; why is my patient not on any pain management at all? And why isn't my preceptor trying to educate me on this issue? She told me that FLACC scores of 7 or higher are usually when we give meds at all. I know that is way too high for me; I would want an opioid at about 5 and a non-opioid at about 2-3. Additionally, I have been able to get verbal pain scores of 9/10 from chronic pain patients who would earn a 2/10 by FLACC.

My questions:

I am curious if any units have a strong pain management culture or policy. If so, how does it work?

When do you, the nurse, administer meds?

Should all patients with Stage III who are unable to to speak get scheduled pain meds or a patch, etc unless contraindicated?

[RNperdiem, RN]

Do you have a NAPS pain score system for nonverbal patients? You could look into that first.

When I float to the burn center, they have a strong pain management culture. It has gotten me into the habit of premedicating patients before dressing changes.

[dorie43rn]

The doctors in our hospital are pretty leinient about pain meds if we need them. If I tell them I need something for pain for the patient, they will order it. I can never understand why some nurses just don't use pain medications, especially before they do dressings on huge ulcers. I had a patient the other day with a stage lV on her bottom, and I premedicated with a simple ultracet before, and she was very comfortable during the process.

It makes me mad that I will come on a shift, the nurse reports pain in some patient, but never gave one medication to relieve it! I assess the patient, and they are grimacing in pain, afraid to ask the nurse for a shot. Then some of the older people are afraid the will get "addicted" to morphine. I talked one gentleman into trying it one time, and he was ever so grateful. When patients are in pain, BP goes up, HR goes up, ect.

Keep the pain medications coming!

[BlueEyedRN]

It really depends on the patient. I had a verbal patient with a huge stage 4 sacral decub the other day who didn't feel a thing when I changed the dressing. I've also had the same type of decub on a patient who screamed and hollered even after getting tons of pain meds and versed. If you feel like the patient is in pain, ask for meds. It is very hard with nonverbal patients, but we usually go by blood pressure and heart rate and grimaces. You just do the best you can.