Pt Pain..a pain in my butt!

[glovedgoddess]

Hi all, so another thing I am quite weary on is pain management!

1) how does the nurse make her/his decision on what pain med to pick if multiple analgesics are ordered? Even when there is more than one opioid in the MAR, how is one supposed to decide this? What factors does a nurse take into account (obviously: intensity of pain (pain scale)!)

2) What if a IV pain med is given to relief a pt's extreme for fast relief, but than the pt experiences breakthrough pain? How do you try and avoid breakthrough pain? What if the time period has not elapsed for their next dose of IV med!?..can you give a PO med? (but I suppose this will not kick in fast enough if they want quick relief!)

3)EX.. morphine is given IV as per MAR can be given qhr, and than pt has breakthrough pain in 40 mins. There is also morphine PO ordered, at this point would you give the morphine PO? again the whole instant relief isnt happening!

I haven't had a lot of practice with pain at all...but I have observed nurses who just seem to know the magic dose to give and the magic drug to give!? experience, experience I know! BUT if any of you could enlighten me I would me so glad!

Thank you !!

[glovedgoddess]

TO CLARIFY!!...lets narrow it down to postop surgical pts, that may help because I know this is a broad topic!

[Asystole RN]

hi all, so another thing i am quite weary on is pain management!

1) how does the nurse make her/his decision on what pain med to pick if multiple analgesics are ordered? even when there is more than one opioid in the mar, how is one supposed to decide this? what factors does a nurse take into account (obviously: intensity of pain (pain scale)!)

besides the factors you stated you need to look up and know the pain meds you have on hand. not all opiods are the same.

first you need to know how they work and which ones are more powerful.

look at their onset, peak, and duration times. the same meds through different routes can have a large impact on onset, peak, and duration. pain medication is a lot like insulin, each med works at different speeds and for different times.

you want to give a long term pain medication to decrease the base pain level (like a patch or er med) and then a medium acting pain medication (some type of pill like vicodin or percocet) to more acuity manage the pain, and a short acting med (maybe something iv) to fill in for the medium acting meds troughs, and/or breakthrough pain.

some medications work better if used in conjunction with other meds, such as percocet (oxycodone and acetaminophen). the mixing of nsaids and opioids can have a dramatic effect, often times the sum of their combined strength is greater than if given separate considering their different methods of action.

(phenergan iv given in conjunction with opioids like morphine or dilaudid iv is know to increase the effects of the pain medications, keep in mind respers are depressed even more so too.)

2) what if a iv pain med is given to relief a pt's extreme for fast relief, but than the pt experiences breakthrough pain? how do you try and avoid breakthrough pain? what if the time period has not elapsed for their next dose of iv med!?..can you give a po med? (but i suppose this will not kick in fast enough if they want quick relief!)

this is why pain management teaching is so important. try to use the po med to manage long term pain, think of it as taking the total pain level down a few notchs. then use the iv med to control the troughs and/or acute breakthrough pain.

3)ex.. morphine is given iv as per mar can be given qhr, and than pt has breakthrough pain in 40 mins. there is also morphine po ordered, at this point would you give the morphine po? again the whole instant relief isnt happening!

personally, for a post op pt i would be administering the po first and the iv second as a breakthrough med. remember though, the goal is not to have the pt comatose or 100% pain free, your goal is whatever the pt states their goal is. most of the time the pt will have a certain tolerable level of pain (i hear 2-3/10 most commonly)

i haven't had a lot of practice with pain at all...but i have observed nurses who just seem to know the magic dose to give and the magic drug to give!? experience, experience i know! but if any of you could enlighten me i would me so glad!

thank you !!

p.s.

look up your meds and get to know what their actions, onsets, peaks, and durations are, it will help you (more importantly your patients) tremendously!

[glovedgoddess]

Thanks! I think thats definitely the root to my problem is that I don't know my pain meds well enough. I'll get crackin with the drug book!

[rn/writer, RN]

Also, look up which meds are suitable for a PCA (patient-controlled analgesia) or a continuous drip. IV push meds are short term bolus amounts. But a continuous drip would act as a basal dose and then your IV push or PO meds would be for breakthrough.

Patches are also a basal form, meaning that the patient gets a slow, steady amount at a constant rate. The peaks and valleys are then controlled with your breakthrough meds.

Keep in mind that patients may have different kinds of meds for different kinds of pain. It is not uncommon for post-op patients a couple of days out to be taking both Percocet and ibuprofen as they have each have their own action.

JCAHO is now pushing docs to label their PRNs in order of preference or list criteria for their use.

Ibuprofen 600mg PO q 6hrs prn for mild post-op pain. Percocet 1-2 tabs PO q 4 hours for moderate post-op pain if ibuprofen not effective after one hour. 1-3 mg morphine sulfate IV q 1 hour for severe post-op pain if Percocet not effective after one hour.

They are supposed to lay out a progression in their orders.

This will help us (and the patient) when they are all finally cooperating, but you would be wise to learn the info mentioned above anyway.

Good luck with your studies.