"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.

[blondy2061h, MSN, RN]

I'm not sure what the capabilities of an SNF are, but I'm always amazed when I start a PCA on someone and they got from needing 2mg of dialaudid q1h when I give it to getting maybe 0.5mg/hr. They just get less anxious having that control.

I definitely agree with the anti-depressant, diversional actives, and med review that everyone else has mentioned. I like the idea for the spinal pump too. One more idea I have to offer would be lidocaine patches.

[nurseprnRN, BSN, RN]

stadol plus other opioids? what's wrong with this picture? doesn't anybody read the drug inserts anymore?

this poor guy needs a professional pain management consult stat, and i don't mean by the docs who have been writing his med regimen so far. if your facility doesn't have a real one on staff, have the family call (or you call) the local rehabilitation hospital and ask to speak to the nurse practitioner in the pain service for a referral. you can also get a good pain consult from the local hospice/palliative care service. he doesn't have to be statutory hospice material to qualify for palliative care.

[carolmaccas66, BSN, RN]

Try fentanyl patches too.

[Whispera, MSN, RN]

Alprazolam BID probably isn't often enough--it doesn't last 12 hours--nowhere near! Also, is the dose big enough to help even when it's given?

Maybe he wants company and that's why he's nice when you're with him....

[xtxrn, ASN, RN]

Try fentanyl patches too.

Already there :)

(in a reply-not op)

[VivaLasViejas, ASN, RN]

Has anyone given any thought to nerve-pain meds like gabapentin, and/or NSAIDS such as Ultram or naproxen given as an adjunct to the opioids? Has he been tried on a TENS unit, lidocaine patches, antispasmodics, a morphine pump? There is even surgery to consider.....seems I've heard something about a procedure that can "short out" the conduction of stimuli to the pain receptors.

Yes, there are a few rare patients who have intractable pain, and this poor man may be among them. But unless he sees a pain specialist and the other associated conditions such as depression and anxiety are treated adequately, no one will know if he's truly unable to be helped. Thank you to the OP for advocating for him!

[xtxrn, ASN, RN]

Has anyone given any thought to nerve-pain meds like gabapentin, and/or NSAIDS such as Ultram or naproxen given as an adjunct to the opioids? Has he been tried on a TENS unit, lidocaine patches, antispasmodics, a morphine pump? There is even surgery to consider.....seems I've heard something about a procedure that can "short out" the conduction of stimuli to the pain receptors.

Yes, there are a few rare patients who have intractable pain, and this poor man may be among them. But unless he sees a pain specialist and the other associated conditions such as depression and anxiety are treated adequately, no one will know if he's truly unable to be helped. Thank you to the OP for advocating for him!

Lyrica

Voltaren Gel

Soma & Baclofen

Big problem- on Stadol :) The narcs are getting whacked by the antagonist in the Stadol

[SuesquatchRN, BSN, RN]

Alprazolam BID probably isn't often enough--it doesn't last 12 hours--nowhere near! Also, is the dose big enough to help even when it's given?

Maybe he wants company and that's why he's nice when you're with him....

More and more, I think this is behavioral.

[rn/writer, RN]

More and more, I think this is behavioral.

Yeah, but it could be behavioral aggravated by inadequate pain management. I know when I'm in pain, I'm not easy to deal with. (DH might put that in stronger terms.)

[xtxrn, ASN, RN]

Any updates, Brazoria??? :)

[BrazoriaLVN]

Any updates, Brazoria??? :)

Yes! Stadol D/C'd yesterday, Fentanyl patch upped. I'll keep you updated on how it goes but unfortunately no changes so far.