Sickle Cell Crisis and pain management?

kfarinato · Mar 25, 2010

I think you are doing the right thing. As nurses in general we are not supposed to judge pain. It is what the patient says it is. Medicate within the orders and let the other nurse's comments roll off your back.

Patients in sickle cell crisis also need fluids, so staying on top of that is a good thing too.

General E. Speaking, RN, RN · Mar 25, 2010

We currently have two patients on our floor in sickle cell crisis. I, too, find that they are immediately "labeled" drug seeker. You know they must have a tolerence to narcotics because of repeated admissions. This is afterall an expected outcome of longterm narcotic use. I am sure that some of those that come in are somewhat seeking but this is not my place to judge. I saw one of our patients had a lab test that determined what percentage of cells were "sickled". I think I am correct. His was 22%. Now I am not familair with what percentage causes more pain, etc... however, it still comes down to pain is what the patinet says it is. I will try and manage their pain. Anticipate there needs and if they are not over sedated and it is time, I will medicate.

It is a difficult patient to care for. You did just fine.

PurpleLVN · Mar 25, 2010

I'm usually a very calm, rational nurse but I've got to speak out!!! Although I do not have Sickle Cell, I do have several young relatives that SUFFER from the disease. This is a very painful disease and unless you've experienced or have actually seen a crisis, then a person will NEVER understand the extreme pain and anguish these patients go through. :no:

I'm sorry but this idea of questioning if these patients are "drug seekers" really p's me off. Purposefully dehydrating yourself-get real. There's even debate regarding just how much water an individual needs anyway.

OP, you are correct in not "judging". I know it can be difficult assessing and treating "pain" in all types of pt's. I think you're doing a great job!!!:)

General E. Speaking, RN, RN · Mar 25, 2010

I'm sorry but this idea of questioning if these patients are "drug seekers" really p's me off.

I hope your comments were not directed at me. :eek: When I said some may be drug seekers in my post, I meant it in a general term as with any admission for any diagnosis with any patient. I, too, despise the reporting off to other nurses about their suspicions. When I hear in report that "they watch the clock and ask for pain meds on the dot" my response is "wow, they really must need their medication then because they are in pain".

We have actually started a new Pain Mgmt team with nurses and doctors at my hospital. I am excited to see what we can accomplish with this group and to try and put a stop to the preconceived notions and judgments regarding pain management.

Kooky Korky, BSN, RN · Mar 25, 2010

Many moons ago, I cared for Johnny, a repeat patient in our ER, who had sickle cell anemia. If Johnny was faking, I'm the man in the moon. And I am not the man in the moon.

This poor guy was in so much pain, crying, holding himself stiffly since it hurt to move. And his parents suffered right along with him. It tore my heart out.

I really would like to kick the behinds of those smug idiots who call themselves nurses where you work, lola77.

Next time someone tells you that a patient is drug-seeking, ask them how they know that the pt is faking or induced the pain intentionally. Just a simple "how do you know that?". Of course, they'll give you an idiotic answer. Just take care of the patients, try to inform and teach your hateful coworkers, and try hard not to be as mad at them as I am. May they develop some painful disease, that no one can diagnose, that lasts much longer than anyone thinks it should, and have no one believe they're really suffering. :madface:

General, when I had surgery, I watched the clock, too. And asked for my pain med about 30 minutes before I thought I'd get it. Why? I knew it would take time for the nurse to find the narc keys, answer a couple of lights along the way, grab the narc, run up and down the long hallways, and finally give it to me. One jerk of a nurse told me that I could not have anything other than what was ordered, even though I had developed an extremely serious complication. Of course, the surgeon didn't think to increase my pain med. I told the nurse to please call him, she refused, I had to get DON involved, as I was really in agony.

PurpleLVN · Mar 25, 2010

I hope your comments were not directed at me. When I said some may be drug seekers in my post, I meant it in a general term as with any admission for any diagnosis with any patient. I, too, despise the reporting off to other nurses about their suspicions. When I hear in report that "they watch the clock and ask for pain meds on the dot" my response is "wow, they really must need their medication then because they are in pain".
We have actually started a new Pain Mgmt team with nurses and doctors at my hospital. I am excited to see what we can accomplish with this group and to try and put a stop to the preconceived notions and judgments regarding pain management.

I'm sorry General E. Speaking-not directed at you, OP or anyone other poster!! I saw a thread a few weeks ago where the OP was venting about Sickle Cell patients "faking" their pain and I regretably did not address that OP at that time. I was so angry that I didn't want to say something out of anger. :devil: No worries!!

I actually think your facility should be commended for the Pain Mgmt team!! Wish you the best of luck!! :yeah:

meadow85 · Mar 25, 2010

I'm with you. Pain is subjective. If the patient says he/she is pain then you have to assume he/she is in pain. If you felt they were drug-seeking then I would bring it up with the physician.

SharonH, RN · Mar 25, 2010

The nurses you work with are jerks. The idea that someone would deliberately subject themselves to the crippling pain of a SCC just to score some Dilaudid is so offensive , it is difficulty to respond civilly. As I wrote in the other thread, it seems that no other group with chronic illness is treated with as much suspicion as those with SCC except for known drug addicts. Do not let yourself become contaminated by those vipers. Continue to medicate your patients in a timely and compassionate matter and distance yourself from those who would attempt to cloud your mission to help restore your patients back to their normal state of health. You will never become a great nurse if you follow their lead, trust me.

Bklyn_RN · Mar 26, 2010

An inconvenient truth is that there are sicklers who have become addicted to highly addictive narcotics (read the drug info insert for dilaudid etc). Also a sickle cell crisis can be as painful as narcotic withdrawal symptoms. I do not know if they would intentionally dehydrate themselves. However as JCAHO mandates, patients reports of pain are to be given the highest priority. So as long as there was a valid order...

General E. Speaking, RN, RN · Mar 26, 2010

An inconvenient truth is that there are sicklers who have become addicted to highly addictive narcotics (read the drug info insert for dilaudid etc). Also a sickle cell crisis can be as painful as narcotic withdrawal symptoms. I do not know if they would intentionally dehydrate themselves. However as JCAHO mandates, patients reports of pain are to be given the highest priority. So as long as there was a valid order...

I often wonder after getting Dilaudid 3mg IV Q2 hrs for x amount of days then suddenly being taken off it, how it affects you. We try and decrease the amounts to wean. I don't recall anyone going home on any kind of maintenance narcotics. After the crisis is over the pain should cease? Correct? It has to be difficult because it is withdrawing...

Home Health Columnist / Guide · Mar 26, 2010

Please remember that in sickle cell disease, acute crises involve vaso-occlusive pain episodes often with tissue ischemia occurring.

sickle cell disease pain management:

evidenced-based clinical practice guidelines

enhance health related quality of life

http://www.aspmn.org/conference/documents/bazenscd1stpres.pdf

approach to the vaso-occlusive crisis in adults with sickle cell disease

the vaso-occlusive crisis, or sickle cell crisis, is initiated and sustained by interactions among sickle cells, endothelial cells and plasma constituents.1 vaso-occlusion is responsible for a wide variety of clinical complications of sickle cell disease, including pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.
a vaso-occlusive crisis is initiated and sustained by the interaction among sickle cells, endothelial cells and plasma constituents. clinical complications include pain syndromes, stroke, leg ulcers, spontaneous abortion and renal insufficiency.
acute pain in patients with sickle cell disease is caused by ischemic tissue injury resulting from the occlusion of microvascular beds by sickled erythrocytes during an acute crisis. chronic pain occurs because of the destruction of bones, joints and visceral organs as a result of recurrent crises. the effect of unpredictable recurrences of acute crises on chronic pain creates a unique pain syndrome.2,3
acute bone pain from microvascular occlusion is a common reason for emergency department visits and hospitalizations in patients with sickle cell disease.4 obstruction of blood flow results in regional hypoxemia and acidosis, creating a recurrent pattern of further sickling, tissue injury and pain. the severe pain is believed to be caused by increased intramedullary pressure, especially within the juxta-articular areas of long bones, secondary to an acute inflammatory response to vascular necrosis of the bone marrow by sickled eythrocytes.5 the pain may also occur because of involvement of the periosteum or periarticular soft tissue of the joints.
the approach to pain control must include measures to treat acute pain crises, prevent future vaso-occlusive crises and manage the long-term sequelae of chronic pain that can result from multiple recurrent bony infarction.

The management of sickle cell disease
tolerance, physical dependence, addiction, and pseudoaddiction
a major barrier to effective management of
sickle cell pain is a lack of understanding of
opioid tolerance, physical dependence, and
addiction. tolerance and physical dependence
are expected pharmacologic consequences of
long-term opioid use and should not be confused
with addiction.

■ tolerance is a physiologic response to the
exogenous administration of opioids, and
the first sign is decreased duration of medication
action. when tolerance develops,
larger doses or shorter intervals between
doses may be needed to achieve the same
analgesic effect.

■ physical dependence also is a physiologic
response to the exogenous administration
of opioids. it requires no treatment unless
withdrawal symptoms—such as dysphoria,
nasal congestion, diarrhea, nausea, vomiting,
sweating, and seizures—occur or are
anticipated. the risk varies among individuals,
but when opioids are given for more
than 5 to 7 days, doses definitely should
be tapered to avoid physiologic symptoms
of withdrawal.
genetic, psychologic, and social roots. the
use of opioids for acute pain relief is not
addiction, regardless of the dose or duration
of time opioids are taken. patients
with scd do not appear to be more likely
than others to develop addiction. the
denial of opioids to patients with scd
due to fear of addiction is unwarranted
and can lead to inadequate treatment,

pseudoaddiction (16) applies to patients
who receive inadequate doses of opioids
whose doses are not tapered, and therefore
they develop characteristics that resemble
opioid addiction.
understandably, some patients whose pain is
managed poorly will try to persuade medical
staff to give them more analgesic, engage in
clock-watching, and request specific medications
or dosages. staff often regard this as
manipulative or demanding behavior. patients
with scd often are quite knowledgeable
about the medications they take for their condition
and the doses that have worked in the
past. requests for these specific medications
and doses should not be interpreted as indications
of drug-seeking behavior. in addition,
patients who have had frequent painful
episodes often behave in ways learned from
prior experiences. a patient, for example, who
believes that a medication will not be given
unless he or she appears to be in severe pain
may lie quietly when alone but begin to
writhe and moan when a nurse or physician
enters the room. pseudoaddiction or clockwatching
behavior usually can be resolved by
effective communication with the patient to
ensure accurate assessment and by adequate
opioid doses.
as in the general population, some persons
with scd will use illicit drugs, such as
cocaine. patients who have problems with
substance abuse require individual treatment
to provide competent and humane management
of their pain.
http://www.nhlbi.nih.gov/health/prof/blood/sickle/sc_mngt.pdf

pain management in sickle cell disease: palliative care begins at birth?