Pain Management

First off, if anyone is telling pts they won't have post-op pain, they should be smacked upside the head!

PCAs are great for that first 24 hrs. I'd hate to have post-op orders for morphine q15min; I would never get anything done with some pts!

You have to do the best you can to control pain with the orders you're given and sometimes call doc for something more. With some pts though....well, you know, nothing you do is good enough. Do the best you can and refer to your co-workers for more ideas. Sometimes you just have to be blunt and tell them that the pain pills they took 15 minutes ago are not even in their system yet!

We also usually have orders for 1-2 norco or 1-2 percocets q4h and valium q6h. Toradol is also a favorite. For some pts, we are rotating through all these early on. Sometimes just turning / changing positions helps tremendously although pts often fear any movement and want to lay as still as possible. Also check how tight dressings are. We've occasionally had ace bandages that were simply too tight and causing most of the pain.

I recently had a pt for whom I could not get pain under control. She had refused her pca d/t hx of n/v with narcs but considering everything we ended up giving to her, I think she would have been so much better off using it. Eventually she was taking percocets, valium, oxycontin xr, and thorazine IM plus a TENS unit. Toradol did nothing but rotating through the above finally got things under control (with no n/v whatsoever - obviously not nearly as sensitive to meds as she thought).

First off if anyone is telling pts they won't have post-op pain, they should be smacked upside the head! .[/quote'] You took the words right of my mouth! When I'm floated to ortho I'm honest and tell the patients before surgery that we try our best to control their pain. But people have different tolerance levels and one medication may work for some but not others. But to tell a patient you will be pain free is just wrong. And they can get away with it because they aren't with the patient after surgery. We are and we look like the bad guys because the surgeon said they will be pain free.

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I again tell people that their pain may not be a "0" for a while and they might have to tolerate some pain.

What is your opinion on when to switch from IV pain meds to PO. I've noticed a lot of nurses like to use IV pain meds on the day of surgery, but like to switch to PO by the first post op day after surgery. Then I've seen some nurses say that going to PO on the first post op day is too soon. At some point they have to switch to PO to control pain because that's what their going to have a prescription to go home with.

Hey! I also work ortho! I have been doing ortho for a little over two years and pain management can def be tough.

Our hip patients receive a duramorph single shot and knees a fem sciatic block. Sometimes the blocks just don't work but, they do most of the time. When they don't work...look out!! My boyfriend is an orthopedic surgeon on our floor so, I have a little more insight into what goes on in surgery.

To answer your question about IV vs PO pain meds, we have a plain scale. For pain greater than a 5 give this etc. The problem with that though is each patient's tolerance is different. I try and start with PO and if it doesnt work or they are already a 10 give IV.

I had a lady yesterday who had gastric bypass surgery years ago and she had a total knee on Thursday. She was a small woman, but she took enough pain medicine to kill a small child! She always claimed nothing was working.

On night shift at 0400 she had 2 Percocet, at 0529 2 mg of Morphine.

As soon as I got there at 0700 she wanted more still a 10. I told her let's wait at least an hour.

I then gave her 4mg of morphine at 0820 as I was giving her this she was asking for more PO meds!!! Turns out the doc had written for lorcet.

At 10:00 she requested more PO meds. Lorcet order was not scanned yet so at 10:00 I gave her 2 more Percocet bc her husband was ranting and raving at the desk and she was in her room screaming and crying and pitching a fit!!! She even called her surgeon!!! (Not my bf)

I too was contacting his nurse prac. She gave me the order to give her 20 of lorcet. At 12:52 I gave her 20 mg of lorcet. She acted like she didn't know what it was etc. etc. Cried that she was afraid to take "so much medicine said if this didn't work she wasn't going home." SHe had a dc order.

At 2:30, she told me she was STILL hurting but the lorcet "took the edge off." She said, "I believe 30 mg would have done the trick." OMG! She then told me she wanted to wait to be discharged until her next dose at 5pm. I was going nuts.

I told her she had a script for lorcet and I could give it to her for dc and she could leave at 3 and go get it filled. There would be no delay on her next dose.

While going over her dc orders and reviewing her scripts, she asked me how many would be dispensed. Then told me she needed to know bc she hates having to call in a week and then a week later and a week later for MORE!!!

OK. I had a nephrectomy in 2008. I was prescribed 30 Percocet. I STILL have about 20 left in that bottle 5 YEARS later?!?! Turns out she did not disclose lorcet as a home medto her admissions RN but it was listed as a home med in her H&P. She had also been to our facility a couple ofttimes and pain management was consulted...

The moral of the story here is while pain is real and we do have to treat it. Some people have serious addictions and they will lie to you and manipulate you.

What is your opinion on when to switch from IV pain meds to PO. I've noticed a lot of nurses like to use IV pain meds on the day of surgery but like to switch to PO by the first post op day after surgery. Then I've seen some nurses say that going to PO on the first post op day is too soon. At some point they have to switch to PO to control pain because that's what their going to have a prescription to go home with.[/quote']

We never have orders for IVP morphine/dilaudid post-op. Pts have a PCA with protocol orders to dc on POD 1. Usually we dc pretty early in the day, but occasionally pts keep until late and rarely doc will allow to keep longer. We are given so many other po options plus limited doses of toradol that most pts do well. We do have one independent surgeon whose orders are to keep the PCA until POD2 but then he only orders 1 norco q4h. His pts tend to have poorer pain control imo.

PCA Dilaudid or Morphine / PCEA Bupivacaine is discontinued POD1 and we transition to PO meds....with having Dilaudid or Morphine IVP as Break thru q3hrs if the Percocets / Roxicodone is not adequate. Last week I had a knee replacement that came out on Perineural Marcain that was kept in for 2days. This particular Ortho MD is old school.

If the initial ordered PCA dose is not adequate there are usually orders to increase dosage or give a bolus

Oy, I hate that. Its like a Dr. who has never given birth telling the woman that it doesn't really hurt... um, yes, it does! I tell my patients to let me know if the pain is start to get to the point when it is not tolerable. I never say "if you start having pain" because you're right, it is not reasonable to expect a major ortho/spinal/neuro pt. to not feel any pain at all.

From a patient perspective as well, I was on a spine/neuro floor as patient myself last summer. (It was found that I have a severely large sacralmeningeal cyst, aka Tarlov Cyst.) Its eroding my sacrum. Anyway, I can tell you that even with Dilaudid my pain did not go away. I'm awaiting surgery still because the surgeon is completely backed up on elective cases, and no pain medication ever fully takes away the pain, it just dulls it enough to where its tolerable. I expect its much the same with other pts.

most of our pts have some sort of regional block maybe a PCA. we oralize with oxycontin/oxycodone w/ IV dilaudid for breakthrough. and tylenol of course. Joints get lyrica many times. All, of course if there are no allergies. the regionals cut down on the narcotics. I am surprised at the use of percocet, for the amount of narcotic needed sometimes, you would go way over 4 G of tylenol.