Pain relief with elderly...

Nurses General Nursing

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Specializes in Ha! I am gaining experience everyday!.

I have had about 5 patients in the last month that were on some kind of pain relief during the night. These meds are usually on the lists: Lortab, Morphine, Demerol, and Dilaudid. I had one patient that was on comfort measures with hospice that was getting morphine sublingual QHour, which didn't bother me because these were comfort measures. What did bother me was my patient that had broken her hip. She was 88 years old, and had not gotten any pain medication on the day shift. Which meant that on night shift I was probably going to be chasing her pain. That is exactly what happened. I started with lortab to achieve some kind of relief for her, but she ended up calling back 2 hours later stating that her pain was still 8/10. I started her on the lowest dilaudid dose possible 1 mg for every 2 hours prn. I ended up giving her two doses throughout the night. Finally at 4am, she drifted off to sleep. Her pain had finally been quenched enough to rest. I gave day shift report and headed home. That same night coming back into work, I was tsked tsked because the patient had been asleep the whole day. I held my tongue. I wanted to say, well if her pain was adequately managed during dayshift, she would have had a restful night and furthermore an even better morn. Was I wrong to adequately manage my patients pain at the expense on day shift having a drowsy patient? It wasn't her first round with Dilaudid. She was getting it on a surgical floor every two hours religiously only a day before she was transferred to the floor that I work on. I just feel like we are told one thing at nursing school, but then do a completely different thing on the job. Did I make a mistake? :confused:

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Specializes in CMSRN.

I understand how you feel. I work nights too. Firstly you did a good thing managing her pain. But I would have not held my tongue for the day shift and let them know why she is sleeping during the day. Ask why she was not given any pain meds during the day. It could have been a simple "she declined or never c/o pain." That happens alot with my pt's. Staying mentally and physically active could help hide pain. When it is time to rest the aches come out. I see it all the time.

Good luck.

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Specializes in Utilization Management.
I understand how you feel. I work nights too. Firstly you did a good thing managing her pain. But I would have not held my tongue for the day shift and let them know why she is sleeping during the day. Ask why she was not given any pain meds during the day. It could have been a simple "she declined or never c/o pain." That happens alot with my pt's. Staying mentally and physically active could help hide pain. When it is time to rest the aches come out. I see it all the time.

Good luck.

I agree. Many times the elderly are worried about addiction and about losing control, so they try to tough it out. Their whole generational culture was that life = pain, so you might as well get used to it. But when it's time to sleep, the pain really starts bothering them. Eventually, they're so exhausted and in so much pain that they accept a medication. This patient is the one who'll say she doesn't need anything for pain because " it only hurts when I move" or "I don't want to be drugged up and out of it."

Unfortunately, my elderly patients were usually dealing with a fall or some sort of trauma where they did not get basic pre-op teaching about controlling their pain. Postop, you're trying to teach someone who's still feeling fuzzy from anesthesia as well as in pain and in new surroundings. Some elders degenerate into confusion.

You might try to discuss with elders the difference between medicating for pain relief and drug addiction. They need reassurance. I also used to get compliance by quoting a study (and my own experience) that the less pain, the faster the recovery in the long run, because the body gets a chance to rest and repair with adequate pain control. Good pain control equals better mobility and this also helps the healing process. Better mobility prevents blood clots, deconditioning, and pneumonia.

This discussion gives the elder "permission" to deviate from her cultural norm and take the pill. I'd describe the pain scale and I would tell them that if the pain gets to a 4, they need a pain pill, because it usually takes more doses to get relief when the pain level is higher than 4. So the deal was, I'd peek into the room and and for a number. Higher than 4, I'd go get the pill.

You'll always have those who refuse. Even after this discussion, my own mom refused anything better than a tylenol at night for a couple of broken ribs. *sigh*

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Specializes in Acute Care Cardiac, Education, Prof Practice.

Though I understand the opinions of the previous posters, my view might be a little different...

1. No one should "tsk tsk" anyone, yourself included, in the sleeping issues of a patient. In the hospital the thing we do best is break a patients normal routine. If my patient gets to sleep during the day after a particularly rough evening, than so be it. As long as they get some rest at some point, and since when should a day shift nurse be mad about a resting patient? Anyway.

2. My #1 least favorite patient is the elderly hip fx. This past week I had a 102 y/o hip fx. Why are they my least favorite? Because sometimes you can't make them comfortable no matter what you try. Now this lady was a trooper and managed 2mg of morphine Q2 hours well. However I was constantly in her room checking respirations, because in the past I had a 80-something whom I had to Narcan after one Percocet and 1mg of Dilaudid three hours after that. It would be a blessing! to get someone who didn't want pain meds for fear of addiction, but more often than not I can't give a hip fx enough because of age and just how uncomfortable that type of break is. My new mantra with hip fx (and thank goodness we don't get them often) is "I know you are in pain, and I am going to give you as much relief as I can and still keep you safe".

3. Discussing pain control with other shifts is something I rarely do because it can be such a touchy subject. I generally just ask "hey did you notice if he was handling 2mg ok or do you think I should use 1mg". Now I will make my own decision, but it is often helpful to understand exactly what the previous nurse thought was doable.

Everyone has their threshold on how much pain medication they will give. Breaking into a debate on that, I have found from experience, can often be as volatile as discussing religion.

The best you can do is use your "range" to determine a good course for the patient on your shift, and then pass along "I gave 1mg Dilaudid at 0200, 0400 and 0600 and she is handling it well with adequate pain control. The Lortab didn't even seem to touch it so I didn't try that again" and let the do what they will with it.

Tait

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it's certainly true that many elderly refuse pain meds, r/t various etiologies.

however, it has also been my experience that there are nurses who are reluctant in administering strong analgesia.

i wouldn't hesitate to confer w/the other shifts, about the lack of pain mgmt.

often you will hear, "but they weren't in pain".

whatever.

just keep on doing what you're doing, and nevermind what others think.

and of course, document thoroughly.

big pet peeve of mine, those in pain being undermedicated.

leslie

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Groggy? She was probably exhausted from fighting the pain all day on top of it all.

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