dhudzinski

This is why we have a procedure for administering medications....we were all taught this procedure in Nursing school. Check your medications carefully everything must match or else you DO NOT give it. No matter WHO drew it up or prepared it. If anything is missing or does not match or you have a question about whether the medication is correct you get it checked and do not give it. That is why we have these national standards of care. to protect us and our patients. WE the NURSE, are the last check point and barrier to protect patients from errors. We know that errors can occur...we are all only human. Use some critical thinking!!!

I have used Epocrates for a few years and really liked it. I just recently was introduced to PEPID.com and Love it. It has a lot more than epocrates..sort of like having a med surg book in your pocket plus a drug resource...

I work with chronic pain patients. I try to lead them to sites that I have confidence in. Information is power and allows them to be a self advocate. It also encourages them to be a knowledgeable healthcare consumer. Some sites I like are: www.theacpa.org www.painfoundation.org www.paininfo.org www.partnersagainstpain.com www.aacpi.org www.forgrace.org I also will search for a site on a specifc topic that a patient might want more information.

If what the patient is saying does not correlate with the behaviors that you are seeing (ie pt is grimacing, guarding, refusing to move, irritable etc) then I usually have a little sit down with them and ask some more specific questions and share my observations. ex (You say you have no pain, but your body is saying something different to me. You are grimacing and guarding your movements and this says to me that you are in some discomfort. The pain medication that the Doctor ordered will take away some or all of your discomfort, would you like to give it a try.) Sometimes I will even ask them why they need this pain? It is amazing some of the answers you will get. We don't want to force pateints to take meds and they do have the right to refuse any intervention without fear of retaliation but we need to be sure that they understand and are making an informed decision based on fact and not some myth or other false information.

I disagree, It is not all that plain and simple. Chronic pain patients on a steady dose of opioid can and do drive and operate machinery safely. the operative word here is steady dose ie the same dose daily. Intermittant dosing does not qualify. NARCOTIC is a legal term used in the court system to mean illegal drugs, street drugs and does not apply to opioid medications that are prescribed for pain. The pain community of specialists are trying to educate healthcare providers and the lay public that the medical term is OPIOID and the Legal term is NARCOTIC. as a term "Narcotic" has many negative connotations and stigmatizes pain patients. It is all part of the "judgement", "value" and labeling thing that goes on which gets in the way of appropriate care.

The problem with that is... what are you basing your judgement on? Pain is so subjective and the only one who can judge how much pain and when it is there is the patient. Pain assessment is absolutely important BUT it must be a thorough systematic assessment if it is to be of any value. Judgement is a value statement. Assessing and then using Critical thinking to come up with a plan as to how you might best intervene...I know it is symantics and a bit picky BUT....

I think that is a difficult question to answer. It is not clearly black and white. there are too many variables. My advise to my patients is: 1. Do not drive if you have just started on a new medication 2. Do not drive if you have just increased a dose even if you have been on it for months to years. 3. Do not drive if you are having a flare of pain and using increasing numbers of rescue doses for breakthrough pain. 4. Do not drive if you Feel the effects of the medications ie you feel spacey, tired etc. This advise also is true for those operating machinery or having to make critical decisions. Now the short answer is I think that individuals can drive, operate machinery and make critical decisions safely if they use common sense. But there is monitoring and teaching that needs to occur up front for that to occur. Most chronic pain patients I know that are on Opioids of any sort for pain do not feel spacey or tired when they have been on a steady dose for several weeks to months. I take it on a case by case basis and try to facilitate the patient through a process of decision making that will help them to make the most responsible decision.

Very interesting dialogue. I am always amazed at the variety of opinions there are about pain, and its treatment. This is very stimulating material for me. Pain is my passion. I want to know more about it. How does it do what it does? Why is it different in each person? Why can't we see it and measure it more objectively? (acutally there is research out there that shows that when a painful stimulus is administered in the lab that there are changes on the PET scan. So I think that is a breakthrough and a beginning.) How do we customize pain treatment? How do we know the pain is real? Pain is as unique as your thumb print. Even IF you were to administer the same measured pain stimulus to 100 individuals they would all have a unique experience, interpretation and coping skill to deal with it. The differences are in part related to their unique life experiences. Pain treatment needs to be unique also. No cookie cutter approach. What works for one person may not work for the next person. and that DOES NOT mean that the second person's pain is not real...IT IS JUST DIFFERENT. Let me tell you 2 stories...to illustrate something... At the age of 11 years old DMH had surgery to remove a "sebaceous cyst " from the top of her head. Within weeks after the surgery she began getting severe headaches. They were nauseating and she would vomit. her eyes hurt and her vision began to change. DIAGNOSIS: Malingering and wanting attention. After all she is 11 yrs old and is the second in a string of 12 children. each year the headaches continue. Until at age 20 she can no longer stand them and seeks medical help again (you see she thought she was going crazy since no one believed her) Well this physician did one thing he listened and examined very thoroughly. And made a referral to his buddy the neurosurgeon. Within 2 weeks DMH was in surgery to remove a meningeocele and an AV malformation from the very spot that the previous "surgeon" had removed the supposed "sebaceous cyst". RESULT: DMH still has migraines on a regular basis but thanks to Imitrex these are not as dibilitating as they used to be. and she no longer doubts her perception of what her body is saying. ************************************* A participant at the Academy of the Healing Arts was attending a weekend intensive training session. The topic was healing the traumas of the past. learning new techniques to cleanse the mind of the debris of these traumas and experiences. While on a break, this participant suddenly felt a sharp almost nauseating pain in her right shoulder. It was as if her shoulder had somehow been dislocated but it was not. The pain was excruciating a 10/10 pain. She went to the instructors and told them she would not be able to continue the session and would need to go home and possibly to the ER. After talking for a few minutes it was decided that this individual would stay and continue with the session and that whatever it was would be dealt with in the next 24 hours. She trusted the instructors and stayed. the pain continued and she was unable to take notes as it was too painful to move her right arm at all. the next day the pain was still there as intense as the day before. The session started and a new therapy was introduced to the participants and they all paired off to Practice the technique with each other. When the practice time was over and the group was brought back together they were each asked to share their experience with the technique. The individual with the shoulder pain volunteered enthusiastically, waving her right arm in the air. The pain was gone and she does not recall what moment it left she just knows that it was there and now it gone completely. ********************* These stories are my story. The first story illustrates true pathological cause for pain. (we did not have Cat scans or MRI's back then) The saddest part of this is that I know too many more stories like this one. I hear it from my hospice patients and others that I do consults on. People are dying out there because they are not believed and NO ONE IS ASSESSING the pain. Ruling out an organic cause with all the technology we have. LISTENING with every fiber of your being. The second story illustrates the power of the mind-body connection. I knew that I would have to deal with some tough stuff in this session and my mind did not want to go there so it manifested in a very painful shoulder. I wanted to disconnect (dislocate) from the painful emotional experiences of the past. I carry my stress across my shoulders and in my neck so it is not surprising that it manifested itself there. I am now convinced that psychological pain is just as real and hurts just as bad as physical pain. the problem is that not everyone has the coping skills to deal with the deeper issues. and there are not that many practitioners out there that can teach them the techniques that I learned at the Academy of the Healing Arts. We are on the brink of new discoveries. Keep your minds open to the possibilities and stop judging or placing blame on the individual before you know the facts. Addiction is a disease and needs to be attended to. I do not want to ignore that possibility but I do know that even addicts get migraines and have traumatic injuries and disease states that generate painful sensations. It is a difficult balancing act and we need to fine tune our skills and knowledge base. Pain management is a specialty with its own skills and knowledge base. The research is out there folks! start reading! OK I will get off my soap box for another day!

Duragesic Patches were a great invention but have a variety of cautions and drawbacks to them. First off Medicaid does not pay for them (many pts in nursing homes are on Medicaid) And I don't know about your state but many states are now Methadone only states. Meaning the only long acting opioid they will cover is Methadone UNLESS there is a clinical reason why Duragesic or Oxycontin or Kadian or MS Contin or Oramorph SR would be indicated. They are requiring that you try Methadone first and if not effective or the patient is allergic or intolerant THEN they will pay for the more expensive alternative. (my personal experience has been that the methadone works 9 times out of ten and in some cases where we converted the patient to methadone they did better on the methadone.) Methadone is tricky to use but we have an algorithm we modified that we received from MD Anderson that works like a charm. If anyone is interested I can sent it to you. (just email me and I will send as an attachment or via snail mail. second caution is cachexia in the nursing home resident. If they do not have adequate subq fat it will have unpredictable absorption. Fever and heat also alters the apsortption. third caution is frequently when Durgesic is ordered in a nursing home patient the nurses and physicians just stop paying attention to the pain. Since the patient now has a "patch" on and everything is "hunkie dorie" in their estimation. fourth caution is if the pain is acute and the pain is greater than 5/10 you chase the pain rather than treat it. The instructions for Duragesic are clear...assess the pain and get it under control with fast acting opioids and then convert to Duragesic. the patch takes about 18 hours to load up in the subcutaneous fat and it takes 48 hours - 72 hours to reach steady state. Additionally When you put a patch on you are delivering 25 mcg PER HOUR (or 50mcg, 75mcg or 100 mcg) if this is too much for this particular patient and they become over sedated ,you are in trouble for 18 - 24 hours rather than 2-3 hrs with a fast acting opioid. REMEMBER you can always add more but you can't take it back once it is in the system even if you take the patch off. Fifth caution is some elderly patients have become psychotic on Duragesic patches.. All drugs have their down side none of them are without risk. But we must minimize the risk as much as possible to protect our patients. There, that is my soap box speech for today. Thank you for "listening"

To be valued for what I (we) do is very important and high on my list. Caring is important because if we do not care then why put up with the long hours and thankless work. Now the money is important too. As a society we put monetary value on things and people. We pay for quality. "You get what you Pay for" (Well, At least most of the time). I am worth more than I am paid. And some days if I concentrate on that fact I get angry and what to do something about it. But most days I am just happy to have a job with some sense of security and portability. Nursing as a profession has done itself an injustice in accepting the wages we do. We live in an upside down society. Those who do the most meaningful and valuable work get paid the least. Nurses, Teachers, and child care workers. We think nothing of paying a plumber or electrician or mechanic $100/hr but we are embarrassed to ask for the same pay as a nurse. Not only do we not value the nurses but we do not value our children and our elderly. I love my work and I have advanced in my career over the past 35 years but I work hard and have little to show for it. I don't want to be a millionaire (now that is really a lie, because I would love to have all that money) but I do want to live comfortably and be able to do some extra things like afford to go on mission trips and help my family. there is no getting around it we need money. Money makes the world go round. We need to stand together and demand the money that we deserve. I agree with whoever said that we value what we pay for. and we determine value based on what we pay. I am going around in circles with this so I am going to quit now.

I too have chronic pain from a variety of causes, congenital, trauma, arthritis and surgery. And I use A LOT of non pharmacologic interventions, such as heat, cold, magnets, aroma therapy, reike, therapeutic healing touch, music, massage and accupuncture to name a few. But sometimes the pain is just too much to handle and the phamacological interventions come into play at that time. Each person needs to decide how much is too much and how much energy they have to devote to these interventions. Sometimes we just need a vacation from the pain and everything that it entails. Sometimes we need to regroup and we need our energy to heal and refocus. If a person does not believe that a certain intervention, whether it be pharmacologic or non pharmacologic, will work then it will not work. the mind is a very powerful force. I like to think that the non pharmacological interventions are complimentary to conventional treatment...they are not an alternative as in either/or...they work best together for the majority individuals. When I help to develop pain plans I like to incorporate mind -body- spirit interventions. It is important to treat the whole person. Everybody is different and what works for one may not work for another.

IN home care they are invaluable. It directs our care each and every visit and is how we get reimbursed for our services. If it is not in the care plan we don;t get paid. The nursing care plan also assists when another nurse needs to go out and see your patient. And the nursing care plan is only as good as the nurse who writes it. Most nurses never learned how to really write an effective nursing care plan. I teach nursing students and my students know how to write a realistic nursing care plan by the end of the semester.

I went into nursing to help people. BUT it certainly made it nice to get paid...compassion and altruism does not pay the bills. My first nursing job paid $3.75 /hr and after 35 years I make $30/hr that is less than a $1/hr increase per year. I certainly have not stayed in Nursing because of the money. I love what I do and can't see myself in any other profession/career. Although making better money would be a plus!

I wholeheartedly agree. Most people, healthcare providers included do not know about nor understand the benefits of palliative care.

There are many reasons why an individual might deny they are in pain. They may fear the treatment or the tests that they feel might be warranted to find the cause of their pain. They might have a belief system that dictates that if they endure the pain they will earn a higher place in the hereafter. Or another reason is that they think they deserve the pain for past transgressions (real or perceived) Or they might not want their loved ones to know they are in pain so they deny to protect them from their suffering. There are probably as many reasons as there are individuals and I have heard dozens of reasons from my patients. I could tell you dozens of stories of patient's who endured pain needlessly because they thought they had to. But I will not except to say that if you see a patient who you think is in pain despite the fact that they deny it...explore the incongruity of their verbal reply and their behavioral indications of pain. I come right out and say..."you say you have no pain but your body is speaking something different. Did you know the negative effects of having untreated pain? ( I then talk about all the negative effects on the body, the emotions and the spirit when pain is left untreated) (9x's out of 10 they will give in and allow me to medicate them with at least a small dose) I even had one patient tell me that after I medicated her she could not believe the difference and said "I did not realize I really was in that much pain, thank you"