Two Big Questions For Pain Experts

Specialties Pain

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If it's assumed that the patient's pain is ALWAYS what they say it there are two major questions that arise. The questions arise because they are real-life situations.

1. A patient has had surgery that isn't expected to be painful. The patient has had 4mg of Dilaudid for pain that is reported as 10. The patient has a goofy grin and says: "I'm going to say that my pain is a 10 because I like pain medicine." (This actually happened)

Do you continue to administer Dilaudid in this situation? Do you take his report of pain at face value? I was advised by my co-workers to send the fellow home and I did so.....He left smiling......Did we do the wrong thing?

2. A patient is close to being in a Dilaudid coma after receiving 10mg of Dilaudid. The patient appears very comfortable and, when awakened, rates his pain at 10. (This actually happened)

Do we have a pain emergency here? (I've seen many situations that are clearly pain emergencies but this one doesn't seem to be a pain emergency.) Can you in good conscience send the patient to the floor with a pain of 10 under these circumstances?

O.k.....I asked more than two questions but the other questions are tied to the main ones.

Never send a patient to the floor with a rating of 10. While this method of assesing pain has become obsolete. Let the physician know of your findings and let them decide in what condition they want the patient to be in when they get to the floor

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Specializes in PACU.
As a fellow nurse and one that suffers from chronic pain. I will say this. Because a surgery is not expected to be painful does not mean that this is the case with Every patient.

That is very true. It was only part of my assessment of the patient in this example.

They should be tapered off and referred to substance abuse counceling.

That's not a bad idea. The thing is that I can't really do that. I'd have to have the cooperation of a surgeon.....I get along well with the surgeons but they tend avoid referrals that don't pertain to their care of the patient......It's the way of the Hospital world these days.

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Specializes in PACU.
Never send a patient to the floor with a rating of 10.

I hate doing that but sometimes there is no choice. If a Dilaudid stupor doesn't cause the report of pain to drop below 10 there is good reason to think that nothing else will do it.

Some people rate pain at 10 no matter what. Luckily very few do that.

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Specializes in Hospice.
I hate doing that but sometimes there is no choice. If a Dilaudid stupor doesn't cause the report of pain to drop below 10 there is good reason to think that nothing else will do it.

Not so ... several of us have suggested IV toradol - maybe with a small fluid bolus if kidney function is iffy and cardiac status permits. I've read reports here on AN of people with acute pain, ie migraines or kidney stones obtaining very good relief with toradol. Too bad we don't have iv tylenol in this country.

Combining NSAIDS or tylenol with opioids is something I often used in hospice, the theory being that the central-acting opioid and the peripherally-acting NSAID might potentiate each other. No one strategy works all the time, but I've had a fair bit of success with this move so it's worth a shot.

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Specializes in PACU.
Not so ... several of us have suggested IV toradol -

I love that stuff. It's really good at relieving pain in many cases.....Including mine when I had a kidney stone.

It's what I said about the Dilaudid stupor is still true.....There are some patients who never report pain less than 10.

Too bad we don't have iv tylenol in this country.

We do. I've given it a couple of times.....It works really well in normal pain situations.

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Specializes in Emergency & Trauma/Adult ICU.

IV Tylenol - brand name Ofirmev - is available in the U.S.

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As a fellow nurse and one that suffers from chronic pain. I will say this. Because a surgery is not expected to be painful does not mean that this is the case with Every patient. Blood pressure is a useful tool when assessing pain. Goofy smiles can be because the patient may have just recently taken a dose of pain meds. But if they admit to you that they're going to say it's a 10 because they like the medicine. They should be tapered off and referred to substance abuse counceling.

I agree that every patient should be assessed on an individual basis. Individuals react differently. A surgical procedure that isn't very painful for most patients can certainly be more painful for some.

I don't agree that blood pressure is a helpful tool. An elevated blood pressure could indeed indicate pain but there could be a any number of other reasons for it.

A normal or even low blood pressure does not in any way mean that the patient isn't experiencing pain.

Many factors other than pain can influence vital signs. Also individuals can physiologically adapt in the presence of pain meaning that pain can present in other ways than what we might expect.

While I agree that substance abuse counselling might be useful if a patient is struggling with addiction I don't think that the short postoperative phase in the PACU is the time or the place. I'm not sure if that is the setting you intended the "tapering off" should take place?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I get suspicion.....I remember the first time I got wind of the current pain control theories being put into practice almost 20 years ago.

I was at a talk one of the Hospital Dr's was giving and he said that opioids only worked to decrease pain directly at the pain receptors rather than working centrally to make the patient not mind the pain. I argued with him....I cited "The Pharmacological Basis of Therapeutics" and he told me I was wrong.......He told me that opioids don't work by making a patient mind the pain less.

Right then I knew that incredible stupidity was being introduced into pain control. I knew that getting stupid with pain control was going to lead to serious problems.........I hate being right all the time!

Anyhow.....Nurses invested in current pain theory (based completely on the patients report of pain and whatnot) have a strong tendency to resent it being questioned.......I've encountered that many times.

I am not vested into any theory....and I am not resentful of anyone or anything.

I am however..... cautious of too much advice given on anonymous website that mat be actually being asked by a patient or lawyer without having all the facts about the scenarios in question and discuss practice issues that when taken out of context can be misleading and used by the patient inappropriately and subpoenaed to a court of law....or being used in research.

So again what are you looking for in your posts about pain, pain scale, definitions of addiction, abuse of prescription meds, and patient care?

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Too bad we don't have iv tylenol in this country.

My hospital (large academic medical center) uses it -- not too often, so far, but I've seen it.

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Specializes in Hospice.
IV Tylenol - brand name Ofirmev - is available in the U.S.[/QUOTO

Our ortho floor uses this a lot.

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Specializes in Hospice.

We do. I've given it a couple of times.....It works really well in normal pain situations.

IV Tylenol - brand name Ofirmev - is available in the U.S.

How cool is that! I would have paid a pretty penny to be able to save some of my AIDS patients a stint on the cooling blanket with that stuff. Glad to be wrong :cool:

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

IV Tylenol came around 2010.....The Official Site of OFIRMEV® (acetaminophen) injection

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