Treating Pt in Pain

How you ever encountered pt. who are in pain and you are helpless as to how to treat them? One of my first clinical experiences on the floor and I had this lady, age 69. She was admitted for dementia, social problems and OD on narcotics. She reported 9/10 on the pain scale on the left side of the neck, lower back, left leg and groin area. She had a Foley.

She was given analgesic (morphine, Tylenol ... not at the same time) q4h, once at 0300 and then 0900. I was there at 10:00 and she said that she had a pain of 9/10. I tried talking to her and repositioning her. When I came to check on her again at 1400 after another set of medications, she was still in pain. I didn't know what to do.... any advice?

I'm not an expert, and am not in nursing school YET, but I do work as a clinical assistant in the ER. I don't know this patient's complete history, but I do want to give you a couple things to think about.

First of all, I applaud your dedication to helping comfort this patient. secondly, I don't want to come off as dismissive towards this patient's pain, real or imagined. However, given your statement that the patient has "social problems and OD on narcotics" red flags are going off in my mind. A lot of patients I see who OD are chronic narcotic seekers, who will say a stubbed toe gives them a 10/10 on the pain scale. They may even put on a great show while you're in their room (although some have the nerve to be laughing, talking, smiling with you while stating 10/10 pain). If your patient is getting what SHOULD be sufficient medication to control pain, watch for signs she could be faking in order to fuel her narcotic addiction or to take advantage of the narcs available in the hospital.

If she complains that "nothing works except ___" (insert any narcotic name), or appears pain free when you peek in on her without her seeing you, or sleeps without apparent distress, she's PROBABLY faking it. Also, I have come to find that a lot of people don't utilize the pain scale properly. People who obviously have some real pain often tell me it's a 10/10, but do not appear in the distress I would associate with a 10/10 (which I equate to having some limb torn off without anesthesia, or undergoing surgery without anesthesia, being stabbed, shot, whatever. If you can talk and carry on a conscious conversation, in my mind that isn't a 10/10 but most patients have a different idea).

Also, people with severe dementia often complain of severe pain when they've had enough morphine to down a horse. I have a hard time too deciding if the pain is real, or if it exists only in their mind.

Like I said, I'm no expert on this matter, but discuss this with your clinical instructor, the nurse assigned to the patient, or the patient's doctor if you have a real concern about this. They may offer some insight into why no more pain medication was ordered, or decide that further medication may be necessary. However, with being an OD patient, it's tough to do the pain medication, because they've taken so much medication already, you can't overload their system anymore, and unfortunately, often the patient just has to suck it up and deal with the pain. Sorry if I sound unsympathetic by that, but when you OD, you can't expect to be given tons more pain medication to help you deal with the pain. You've already compromised your metabolism because your system cannot metabolize all that medication, and it would seriously compromise your system even further to continue to give pain medications.

Depending on what her dosage was maybe she was undermedicated. What condition did she have that she was previously recieving narcs for? I also note that though pain med was ordered Q4 she went 6 hours between doses. If pain is allowed to get out of control it takes much more medication to bring it back to a managable level.

I am guessing that she was out of the acute phase of her OD as she was again recieving morphine. This may also not be the med she needs for her pain. You could suggest another adjunct med rather than tylenol maybe toradol or ultram. If her pain is neuropathic in nature maybe she needs something like neurontin.

You can also employ some non medication type interventions like warm blankets, etc.

If this patient suffers from dementia and still administers her own meds her OD was probably not an intentional act. Social service consult is definitely in order.

I had two that were kind of opposites last night. One was obviously in pain, yet would smile sweetly and decline pain medicine, and tell me she was fine. I can't force people to take pain meds but it hurt me to see that sweet, excruciating little smile not a minute after she had been crying and hollering from being turned. Education, or my attempts at it, didn't work.

The other wound up being admitted for chest pain and a headache that he's had for a WEEK. Not a little tension thing, a whanging, awful, headache accompanied by two fainting episodes kinda thing. The ER just had to tell me 3 times in report that he was positive for THC. Ooooookeydokey. I wanna know, why were they surprised?! Before I went to nursing school, if I'd had a migraine I couldn't control and couldn't afford an ER or doctor visit, yeah, I could see getting stoned as one possible thing to try. Heck, I was happy to see that my patient was reasonably comfortable and cooperative even if his eyes were all red. He had more or less accomplished his goal of pain relief, but was worried about the fainting. When looking at his habits, I was more worried about the 2 packs per day of cigarettes than the recent joint that he didn't admit to (he didn't have to, lol).

One thing that I'm ill about; our admission form requires us to ask: "do you take any recreational drugs?" It's my opinion that a lot of illegal drug use is most certainly not recreational- take your chronic pain patients who wind up addicted to a bevy of narcotics, your ex-heroin users who can't quite get off methadone, etc. I see some of these on a regular basis and if I ask it just the way it's printed, they look at me like I'm nuts. If I use the word "addictive" they are more likely to talk about the "nerve" pills they overuse, etc. If all else fails I can just explain why I need to have some sort of forewarning of withdrawal symptoms.

Sounds like she needs something around the clock such as Ultram. Once that is onboard it may be easier to treat the breakthrough pain. Drug addicts have opened up receptors in their body that cause them to require much higher doses of pain medication than the average person. That must be taken into consideration when these individuals are hospitalized with pain causing ailments. However, sometimes you just can't make the pain go away no matter what you do and that is not your fault.

In my experience, those patients who have been on narcotics for an extended amount of time, their pain is much more difficult to control because they have built up a tolerance to the medication. But of course, pain is what the patient says it is. You will always have those few that are "drug seeking" and will tell you anything to get narcotics.

That is just my 2 cents.