"I just can't help you..."

Nurses General Nursing

Published

I have a resident at my SNF...rheumatoid arthritis with contractures of upper and lower extremeties. This man is sometimes confused, but mostly with it. Gets Norco, Oxycodone, Soma, Lyrica, Stadol, Voltaren Gel, Baclofen with no relief whatsoever. Screams constantly. All PRN meds are given exactly at the intervals (i'm there 6 hours to the dot.) He is friendly when we are in the room, then when other staff goes in he tells them how we never give him any meds, are such bad nurses, nobody cares about him etc. I frequently have the aides tell me he is complaining of chest pain and when I go in he wants to talk about his TV show. When I ask about the CP he denies ever saying it. I feel so guilty for saying this, but I am SICK and tired of hearing "OH GOD HELP HELP HELP" all day long. I am sick of being told I don't do anything for this man. I am so sick of other residents telling me to give him something. I already did! There's nothing else I can do! Turned, repositioned, offered a snack, one on one, everything...nothing works! MD knows...has ordered everything under the sun...she is just as frustrated as us...I'm so tired. :crying2:

Poly pharmacia. Chronic pain sufferers often need different pain intervention. This medication salad as you see it, all his meds are short acting.

Where is his long acting medication? MS Contin. Fentanyl patch, Kadian. Oxycontin.. anything . Then use the other bits of "salad:" for break through.

Where is this man's pain consult?

Up Vote Up Vote ×

Yeah, it sounds like he needs some 'round the clock meds like MS Contin or Duragesic patches. Breakthrough kinds of meds shouldn't be used for long-term severe pain management.

Also, how about an anti-depressant? And an anxiolytic for waking hours, not just at hs?

What Sue said is true--sometimes the opioid meds can cause hyperalgia. This in turn gets docs to crank up the dosages, which leads to more pain, which leads to even higher doses, and so on.

I'm wondering, too, if this guy is just flat out bored and fed up with his life. I don't imagine he's able to do much with both upper and lower extremity contractures. Does he have any family or other regular visitors?

He sounds like someone who might benefit from headphones and music or pet therapy or having staff find a way to get him out of his room for a couple of hours each day. Anything that could give him something to look forward to.

How sad to be cooped up inside the same four walls all the time. As sick as you are of him, he's probably even more sick of himself.

Up Vote Up Vote ×
Specializes in LTC.
Yeah, it sounds like he needs some 'round the clock meds like MS Contin or Duragesic patches. Breakthrough kinds of meds shouldn't be used for long-term severe pain management.

Also, how about an anti-depressant? And an anxiolytic for waking hours, not just at hs?

What Sue said is true--sometimes the opioid meds can cause hyperalgia. This in turn gets docs to crank up the dosages, which leads to more pain, which leads to even higher doses, and so on.

I'm wondering, too, if this guy is just flat out bored and fed up with his life. I don't imagine he's able to do much with both upper and lower extremity contractures. Does he have any family or other regular visitors?

He sounds like someone who might benefit from headphones and music or pet therapy or having staff find a way to get him out of his room for a couple of hours each day. Anything that could give him something to look forward to.

How sad to be cooped up inside the same four walls all the time. As sick as you are of him, he's probably even more sick of himself.

He actually has had a fentanyl patch for quite a while. His alprazolam is bid so it's given when he is up. The boredom aspect is really something to think about though. He does have extensive family that visits 5-6 hours every day, and he gets up in a geri chair every day, but it seems like when he is alone in his room his pain is worse. Not to discount his pain at all, but I wonder. An anti depressant would be a good think to think about, and I love the pet therapy idea. I hate to say I am sick of him, but I am sick of the behaviors. But when you have pretty much everything wrong with you, as he does, I can't say I wouldn't do the same.

Up Vote Up Vote ×

If family is with him that much of the day, maybe they could get him a small, manageable dog or cat to bring in with them. He wouldn't have to do much to let a little Maltese or bichon lick his face. Or a pug. Pugs don't generally bark a lot.

Just something to think about. If they're interested, they might be able to do some research to find out what kind of breed would be suitable.

A pet might help him feel he has something to live for. When it's a away, he could have pictures of it and talk about it. Much more interesting for bystanders than TV.

Up Vote Up Vote ×
Specializes in Post Anesthesia.
... The boredom aspect is really something to think about though. He does have extensive family that visits 5-6 hours every day, and he gets up in a geri chair every day, but it seems like when he is alone in his room his pain is worse....

Sounds like a conversation with the family is in order- What were his intrests before his illness?, Any hobbies?, Favorite movies,TV shows....?Favorite books? Books on DVD, a cheep DVD player and a subscription to netflix may do more to help your patients pain than all the opioids in the pharmacy. With his condition he is very limited in what he can do for himself, but exploring adaptive options that give him SOME independence would be a benefit to you and him. I know that is going to be hard for a nurse with all you have to do for all patients, but don't you have a PT or OT department? How about the "activity director"? Is there any resource you could reach out to to help find something for this "generaly with it" man to do with his days. Distraction is a great pain reliever- boredom is the most aggravating factor I have ever seen.

Up Vote Up Vote ×
Specializes in Hospice / Psych / RNAC.

When was the last time his meds were re-evaluated ... it's time. I'll bet he's been on that patch at the same dose for some time now. Who does pain management?

Up Vote Up Vote ×

I went to a drug interaction site (2, actually). The stadol (and the opiod antagonist in it) can induce withdrawal symptoms....???? He truly may be getting much less benefit from the opiates than one would expect.

http://reference.medscape.com/drug-interactionchecker (this had the most info about the relationship between opiates and stadol...but didn't save the entries)

http://www.healthline.com/druginteractions?addItem=voltaren%20topical&addItem=baclofen&addItem=soma&addItem=alprazolam&addItem=temazepam&addItem=restoril&addItem=fentanyl&addItem=norco&addItem=oxycodone

For some reason, this one didn't save the stadol- easy enough to enter.... :)

I'm hoping the specific meds I entered (from what the OP listed throughout the post) will show up. If he's getting the Stadol, and opiates, the opiates are being blocked to some degree by the stadol (the antagonist in it).

He REALLY needs someone to go over his meds....it could very well be reversible. :o

Just sounds very organic, imho :)

Up Vote Up Vote ×
Specializes in Med/Surg, Ortho, ASC.
Do you think he is in physical pain or seeking attention?

I was wondering about a psych consult....

Up Vote Up Vote ×
Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

We have all had these patients. I don't know what a SNF is, but he sounds very institutionalised. He is probably playing one on another and is bored out of his skull.

Can anyone get him outside perhaps, has he family who can take him out for a day? He needs distraction ++. He is getting too obsessed with his condition/s and that is what is making his pain seem worse.

U need to realise that u can't help, save or fix everyone. U can only do what is humanly possible. It sounds like he is too far institutionalised to be turned around.

I would get the Dr to refer him to a psychiatrist & pain team for assessment. U & the Dr have done all u can.

I hope things get better.

Up Vote Up Vote ×
Specializes in Gerontology, Med surg, Home Health.

All great suggestions.....long acting pain meds instead of the PRNs. One statement the OP made is very telling. "He's fine when we're in the room". The man is either bored or perhaps he's afraid. Everyone reacts differently to pain and illness. Do you have volunteers to sit with him? or maybe his family could come one at a time so he'd have less time alone.

A hospice/palliative care consult might also be helpful.

Up Vote Up Vote ×
Specializes in Oncology; medical specialty website.
He actually has had a fentanyl patch for quite a while. His alprazolam is bid so it's given when he is up. The boredom aspect is really something to think about though. He does have extensive family that visits 5-6 hours every day, and he gets up in a geri chair every day, but it seems like when he is alone in his room his pain is worse. Not to discount his pain at all, but I wonder. An anti depressant would be a good think to think about, and I love the pet therapy idea. I hate to say I am sick of him, but I am sick of the behaviors. But when you have pretty much everything wrong with you, as he does, I can't say I wouldn't do the same.

Why is he on Stadol? You shouldn't mix narcotic agonists with narcotic agonist-antagonists. Sounds like when it comes to meds, the doc is just throwing anything/everything at the wall to see if it sticks.

Up Vote Up Vote ×
Specializes in Hospice, LTC, Rehab, Home Health.

@ Carolmaccas66,

SNF = skilled nursing facility (i. e. nursing home)

Up Vote Up Vote ×
+ Add a Comment