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"

Don't give up! You are on the right track. You have received a lot of great advice. THE biggest thing that needs to be done is a VERY thorough pain assessment. I have found that even the most confused or demented patient can let me know about their pain as long as I am observant and patient with them long enough. I have been working on Pain managment for the past 29 years and have been a pain management Nurse specialist for the past 15 yrs. I see RED :angryfire when I encounter individuals whether they be nurses, or physicians or family members who discount a patient's pain complaints. BUT I try to use each incident as a chance to teach about the effects of untreated pain. The research is out there that shows that when pain is not treated and is allowed to continue the nervous system changes and nerve endings that normally do not transmit pain are now being recruited to transmit pain messages. Thus the patient's pain grows and they will say I hurt all over and even my skin hurts. and confused patients will become agitated and combative when they are touched and turned. I have had personal experience with severe pain that was not believed. I also had a sister who died (at the age of 42) from metastatic colon cancer because she was labeled as a drug seeker, neurotic over anxious female and NEVER really assessed for the pain that she had for three years. Compassionate care demands that we treat each person as we would like to be treated if we were in the same circumstances. No one is immune from pain and my continued dream is that one day I will be called to the bedside of one on the "unbelievers" and have the opportunity to teach them about pain treatment, in a compassionate way OF COURSE! I could go on and on about pain managment but I will stop here.. keep us posted! and good luck, you are in my thoughts!

The difference is huge and yet they are similar. Palliative comes from a latin word Pallido (I think that is the word) any way the latin word means "to cover up" When we palliate we cover up the symptoms in such a way that they are diminished or completely covered and no longer visible. Palliative care treats the symptoms without curing the illness in any substantial manner. BUT the patient may be seeking active curative treatment such as chemo or radiation treatment or dialysis. We palliate many illnesses not only those that are "terminal" or "end stage". Diabetes is palliated via the use of insulin. We "cover up" the effects of diabetes. We do not cure it nor do we change its ultimate outcome. We Palliate Renal failure through the use of dialysis. We do not cure the renal failure but we cover up the symptoms. heart disease is also many times palliated with the various medications we use to control or "cover up" symptoms. Hypertension is often palliated. It really is always there we just control or cover up the symptoms. Stop the medications and the hypertension or the heart symptoms "reappear" or "get uncovered" Hospice is a subdivision of palliative care BUT it is more extensive than palliative care. Hospice is intended for persons with a life expectency of 6 months or less if the disease were to run its normal course. Hospice treats the whole person and the whole family. We do pain and symptom management i.e. palliative care but we also treat the relationships, the spiritual side of the person, Hospice neither extends nor shortens life. The intention of Hospice is to increase quality of life not quantity BUT in palliating the symptoms and in treating the whole person and the whole family we many times extend the life of the person. Patients who do not qualify for hospice can get palliative care and their insurance will cover the treatment costs according to the policy coverage. Hospice is a philosophy of care NOT a funding source, Although there is a medicare or medicaid hospice benefit. And many private insurances also have a hospice benefit. I am a nurse consultant for Pain and palliative care. I work with patients who have life limiting illnesses and assist their health care providers with the pain and symptom management of the disease. I also consult with the hospice program for complicated cases. I hope that I have helped to explain the similarities and differences and answered your question.

My Dad died in 1975 before Hospice had really gotten started in the US. Hospice began in New Haven ,Connecticut in 1974. I have been a Hospice nurse officially since 1982 and unofficially since 1974. It is the most rewarding job I have ever had. I take brief respites from it to renew myself but I keep finding myself drawn back to it. AND I know for sure that I never want to go back to in hospital "floor" nursing. As a hospice nurse you are allowed to participate and become a part of the most intimate and intense part of another person's life. They invite you in and you become a integral part of their caregiving team. It is my firm belief that Hospice nurses are born and not made. It takes a special kind of person to do the job of taking care of patients who know that they are dying. What do hospice nurses do? They listen with their whole being. They guide patients and families safetly through mine fields., Successfully Guiding them over hills and into the valleys and up the other side again. They expertly and efficiently palliate (Palliate means to "cover up") the symptoms of the dying process. They assist patients to find meaning in the dying and help them to complete life tasks. They facilitate the mending of relationships. They support the family caregivers who do the bulk of the work. Hospice nurse help to coordinate the care. There is a lot of teaching that goes on each visit. There is also a fair amount of paper work as there is for any job in nursing these days. I have recieved much from my hospice patients in terms of life lessons and insights. BUT One of my Hospice patients gave me the most incredible gift he taught me to be a professional clown before he died. He was a Shriner Clown and wanted to pass his passion for Clowning on to someone prior to his death. That was 1995 and I now teach others how to become a clown and I have formed a Caring-clown Alley and we are a part of Wellness House.

Interesting question you posed. The choices are numerous, Certificate, Diploma, ADN, BSN. This is a question that has been debated over and over. It is not always clear what the "correct" answer would be. But let me give you my opinion and perhaps some advice. As a profession, Nursing really needs to look at what we do that NO ONE else in the healthcare field does. This multi level entry dilemma is hurting us as a profession. Are we technicians or are we professional, critically thinking Healthcare providers? I am actually surprised that there are certificate or diploma schools left in the USA. I came up through the ranks. I started as a CNA 1966, then ADN 1969, Then BSN 1984, then MSN 1988, now I am looking forward to one more year of post graduate schooling and I will be a nurse practitioner. The more I learn the more I realize what I do not know. I believe that what I learned from the ADN program was excellent bed side nursing. the BSN program taught me excellent Critical thinking skills, and the MSN program helped me to fine tune those skills and specialize in the field of Nursing that I love, pain and palliative Care. Each step has increased my professionalism and critical thinking. I can teach any one on the street to insert an IV or a Foley or NG tube BUT do they KNOW how to assess that tube..do they know when there is a problem? and would they know what to do? Yes, they can pass meds and change a dressing BUT these are all tasks that ANY ONE can do...what nurses do that no one else can do is ASSESS and DIAGNOSE response to disease and devise a wholistic plan of action to return the patient to as optimum functioning as is possible or realistic. I know too many nurses who can not critically think through a pt problem. They are excellent technicians but terrible critical thinkers. That's the long answer. Now for the short Answer. I think that if you want to be a technician, go be an LPN (LVN) If you Want to be a Professional nurse and cannot afford the 4 years of tuition then START with the ADN and then work toward a BSN. And if you want to specialize then MSN.