Pain management ;)

[Sassy5d]

Just wanted to review everyone's almost favorite topic.

Is there an unwritten rule that getting into the ER equals IV dilaudid? Or just because the last time you were here you were given iv mor or dilaudid, that means you should get it again??

Just reflecting on my evening last night...trying to review in my head what went ok, how I can improve next time.

This 1 pt, everything was wrong from the time they rolled in. I heard about every horrible experience they've ever had and I'm getting yelled at like I did it to them.

I was slightly put off that they were telling me they had all this swelling and edema, but they were, no joke, grabbing at their 'saddle bag' on their thigh that was equal on the other side, telling me this is new onset edema. (She was larger).

She pointed to her calf, explaining all this edema. Both legs were equal. There were no indentations, no sock marks, no color change, no bruising, no temp change. Pulses great. Had numerous xr and ct's 3 days prior, all negative.

Long story short, she was given po pain med, and continued to complain that it wasn't going to help. Had visitors complaining to me every 5 minutes.

I kept notifying the doc and charting, he wasn't ordering anything else.

Additional ct scan showed nothing. No soft tissue swelling.

So reflecting.. What are your experiences when dealing with these sorts of pts? You know it falls on the nurse for quality for pain management. As if it's somehow the nurses fault that a patients pain level is not being controlled, when they can't order the meds.

Should we really be rallying and pushing doctors to order iv narcotic pain medications because a pt is demanding it?

[Altra, BSN, RN]

You know it falls on the nurse for quality for pain management. As if it's somehow the nurses fault that a patients pain level is not being controlled, when they can't order the meds.

Should we really be rallying and pushing doctors to order iv narcotic pain medications because a pt is demanding it?

Take a little time to step back from this and examine it without emotion. Assuming that you assess appropriately and document well, including reports from a patient that s/he is still having pain and that you notified Dr. X ... what exactly are you afraid will happen? What exactly will "fall on" you as a nurse related to a patient whose workup is negative?

Ya gotta let the verbal stuff roll off of you.

[Sassy5d]

I don't really think it's 'afraid'..

I was just exhausted. Ha! Just thinking back and am I forgetting something? Pain control is the new 'standard' that is being addressed. They say 10/10, you get a pill ordered, you get hounded constantly by multiple people, no matter what you say. So your reassessment documentation is 10/10 pain after an hour.

On paper, it looks like we let someone's suffer in pain. I'm not saying she wasn't uncomfortable, but the appearance and behaviors didn't mesh. I did document all this.. But it makes me wonder.

On the flip side, another doc will order 4 of ms for someone coming in for a splinter that's laughing and eating and giggling saying 10/10..

[Anna Flaxis, BSN, RN]

I'm sure the patient really was experiencing pain, but in the absence of any clinical diagnosis warranting the use of IV meds, I can understand the prescriber's hesitance to order IV narcs. It sounds to me like you handled it just fine. You documented your assessment data, the patient's condition, and your actions in relation to pain control.

[LakeEmerald]

No. We should not hound the MDs for IV pain meds just because the pt requests it. I have a few pts who seem to not experience any relief from pain meds, they usually end up being abdominal or chest pain of unknown origin. Don't worry. If you gave the medicine and they still report no relief at all, your supervisors and MDs will know something's not right, especially if the patient is sitting calmly and appears to be in no distress except when asking for IV pain meds.

You can only bug MDs so much before you have to tell the pt that the appropriate dose and route have been given. Since when do patients come into the ED and dictate their care (like they are ordering fast food)? Wait. Don't answer that. :) Seriously though, you need to stand up to these patients and let them know they can't come in and dictate care. Yes, they will be disatisfied. Still, be nice. As always, if they don't stop hounding you, let the MD step in and explain. Sounds like you did fine. A typical day :)

[thelema13]

There is Tylenol for a reason!

[ezgreazin]

As stated above, let it roll off your back.

Did she have you running for boxed lunches and soda as well...and another warm blanket, and reposition my bed?

[Sassy5d]

Ha ha. No. Just told me about how much pain she was in, and that she was letting me know of her high tolerance to pain meds because she's needed to take so many po ones.

Her visitor was the one who felt the need to remind me that she was in agonizing pain every 5 minutes.

All I'm thinking about is the huge emphasis that is being placed on pain management. At least where I'm working. The feedback I'm getting here is just 'cya' with documentation and doc notification.

[Anna Flaxis, BSN, RN]

I think there are some very good reasons why there is so much emphasis on addressing pain. That being said, this kind of situation can be so very difficult for the nurse.

Prescribers are obligated to consider the most appropriate pain control strategy given the clinical situation. As nurses, however, we're supposed to believe the report of pain because "pain is what the patient says it is and exists when the patient says it exists", so as long as they are complaining of pain, we're supposed to keep addressing it despite the lack of any objective evidence of its existence.

Where is the middle ground?

[Altra, BSN, RN]

OP, you might ask your former preceptor, a charge nurse, or some other nurse mentor if the "emphasis on pain management" at your hospital is intended to focus on excellent assessment & documentation ... or really the magical expectation that you can make every patient pain-free. The answer might make you more comfortable.

[Anna Flaxis, BSN, RN]

...or improving patient satisfaction scores....

[nurseEnurse]

I always roll up a warmed blanket or two if stomach pain and offer ice pack to "cover" my pain control until to Doc figures out if or when they will get actual medications. Also good to chart it was given b/c that is considered addressing their pain/discomfort.