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

[BrazoriaLVN]

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.

[SuesquatchRN, BSN, RN]

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.

Or just bring hm to the nurses' station, where he can see people.

[evolvingrn, BSN, RN]

He sounds lonely, if you give a sob story people are more apt to stay longer.... we often bring those patients to the nurses station.

[mindlor]

Hmmm it almost seems like dementia could be at play here?

[canesdukegirl, BSN, RN]

Has the doc has considered having a neurostimulator pump implanted? Many times, this is the best approach for chronic pain that is not relieved with oral pain meds.

This poor man....how awful for everyone.

[giveface]

Oh my God I know how you feel. There is a patient I know of and we have tried everything. Dr. is so frustrated, staff are at their witts ends, and this patient is either with it and abusive to everyone or vegetative like, or screaming, "Nurse, nurse, nurse, help me, help me, help me." All day!

As for help with pain, maybe a Rhizotomy?

[giveface]

Why is he on Stadol? You shouldn't mix narcotic agonists with narcotic agonist-antagonists.

That's for sure.

[cherrybreeze, ADN, RN]

There is now speculation that opioid metabolites actually contribute to hyperalgesia, a perverse reaction to the build-up that increases pain. This is particularly possible with elders who have reduced renal function.

I would agree with Leslie that an anxiolytic be considered. If behavioral issues can be r/o it may be time for a narcotic rotation.

I didn't quote the posts about the Stadol, but you learn something new everyday....I wouldn't have thought to check that interaction. Some smart folks we've got here. :)

If his behavior coincides with certain events (being alone in his room, etc), then it may not be an issue of poor pain management at all (although it also may just be that he is more aware of it barring the distraction of family, etc). I think a psych consult would be reasonable. Anti depressants could very well be in order, especially one like Cymbalta, which may also help the pain.

Hypergesia is also definitely a concern. Sometimes LESS pain meds are more effective...too high of a dose, and it can actually induce pain (I've been there, it's really quite interesting).

I would start first with the possible med interactions, that's the path of least resistance at this point. If the doc blows off your concerns, be persistent. I took care of a young man a while back, he was hospitalized for several weeks. Pain issues, quad, large wounds, etc. He had good reason to be depressed, but his mood issues got quite severe. And no kidding....they had him on Chantix. People with a history of mental health dx's, especially depression, should NOT be on that med; it can make depression worse and even cause suicidal ideation. I had to bring that concern up to the docs SO many times before someone would DC it. It's not a med to play around with. It's great to help smoking cessation (my sister was successful with it), but I was another story. I thought any increase in depression would be gradual. WRONG. I went from baseline one day to the next, if I'd have had a gun in the house, I would've shot myself. No one else seemed concerned that that med might be making this man's moods worse. When they finally did get rid of it, things did improve. It just took more than one approach for them to listen!

[SleepynurseRN]

I think a psych consult and pain/ palliative care consult should be the first thing ordered. As stated above, there also may be some drug interaction involved too.

Does he have any friends in the facility? He may be one of those people who is very appreciative of lots of human interaction and attention( thats the nice way of saying he's needy) How busy is his day? My uncle gave his facility hell when he was alive. I thought this was due to his natural high energy level when he was healthy years ago. So, we brought in jigsaw/crossword puzzles and bought him an Ipod loaded with his favorite blues and jazz songs. He then proceeded to hum and sing all day much to the irritance of his roomate. Oh well...

Continue to be patient with him. I have a dad who has been diagnosed with Alzheimer's, bad heart and vascular system, double amputee, ESRD w/ HD who is busy as he&*. I fear he is headed for the Nursing home and I pray he has nurses with a lot of patience and a kind heart. Stay sweet to your patient.

[mindlor]

Also we need more assessment data. How old is the pt? Does he act out even when he has visitors? Underlying conditions? History? Mental Status? A list of all of his medical and subsequent nursing diagnoses would be awesome......

[rn/writer, RN]

Also we need more assessment data. How old is the pt? Does he act out even when he has visitors? Underlying conditions? History? Mental Status? A list of all of his medical and subsequent nursing diagnoses would be awesome......

It wouldn't be a good idea to list those things here. But they certainly should be looked at within the facility.

[nerdtonurse?, BSN, RN]

If I had a patient like that, I'd advocate for the review of meds, and at least try a x1 dose of haldol. We had a fella on the telemetry unit that would just scream himself hoorifice -- not a good thing on a floor full of cardiac pts. Haldol calmed the behaviors, they dc'd the constellation of pain meds and just put him on one -- the different meds kept getting ordered to address behaviors, not pain, and it just made him crazier. Haldol, and he calmed down, family could enjoy visits, the patient was happier as well.

[BrazoriaLVN]

It wouldn't be a good idea to list those things here. But they certainly should be looked at within the facility.

I agree. With the amount he has going on, I wouldn't have the time anyway!