What is wrong here???

[AtlantaRN, RN]

I have a patient with lung cancer with mets to brain and spine and initially she was on lortab 10/500 qid in december. Her affect is flat, there is never any moaning or any indication of increased pain ( I know that pain is what the patient says it is, but hear me out). we have increased the opiods and additional meds to:

abh 1/25/1 q4h prn, dilaudid 8mg po a4h prn, morphine 45mg qid, soma qid, lortab 10/500 qid prn, neurontin 300mg bid,

plus the roxinol 20mg/ml restoril 15-30mg qhs prn (she had been on ambien but said it wasn't working....

using regular abh has stopped her nausea/vomiting, also she has been on phenergan 25mg q4h prn. When we add another med it works for a while, and then she requires an increase. At one point, the social worker came with me about the narcotic count because she was taking waaaayyy too many lortab, it if was ordered 4 times a day, she would use 6, same with soma, if it was ordered 4/day, she would use 6.....initially we wrote it off to the vomiting (which no staff has yet to witness). also patient is having regular daily bowel movements with NO colace or senna or ANYTHING for bowels. Now I know this lady is ill and declining, I encouraged family member who gives her the medications to use the prn roxinol for breakthrough pain instead of using soooo many lortab, yesterday I think she finally "gets it." but I'm going to have to report her to the social worker in the AM because narcotic count of lortab is off (she should have 28 left, but there is only 12), yet she is hardly taking the dilaudid at all according to the count.

I've never had a patient on this many medications. I have trouble keeping up with the medications. we have even tried 2 pill dispensers that have slots for 4 times a day.

She is less than 80 lbs, so I wouldn't consider fentanyl patch because she has so little fat to absorb patch.

Any recommendations? I want her to go into the IPU for a few days to get her meds adjusted.

Any help is greatly appreciated.

linda

[caliotter3]

I agree with you that she needs to have her meds adjusted. Can you advocate for this? Too bad you can't get tox reports on the family members. Maybe she isn't taking all of her meds after all.

[Whispera, MSN, RN]

What she's been prescribed is a boatload for such a thin patient...even considering the development of tolerance... getting her meds adjusted through an inpatient stay sounds like a good idea...

Given all you've said, I really think family is using her meds. Do report to the social worker and whoever else needs to be involved in the situation.

[marachne]

What she's been prescribed is a boatload for such a thin patient...even considering the development of tolerance... getting her meds adjusted through an inpatient stay sounds like a good idea...

Given all you've said, I really think family is using her meds. Do report to the social worker and whoever else needs to be involved in the situation.

Diversion was my first thought (should've said something when I thought it so I wouldn't look like a "me too" oh well).

And family may be using, may be selling. My second-guessing this thought came from the comment about all the dilaudid not being used up.

Also, while I know that Fentanyl is fat soluble, and theoretically you need fat stores for it to work, I have had good results on cachetic individuals.

[Whispera, MSN, RN]

Without fat stores though, the patient gets a blast of Fentanyl at first and not a steady dose over the time of the patch being on. Was that your experience too?

[Valerie Salva, BSN, RN]

I agree w/ the others here- sounds like family diversion. I've seen it happen.

[marachne]

Without fat stores though, the patient gets a blast of Fentanyl at first and not a steady dose over the time of the patch being on. Was that your experience too?

Not that I observed, but it was just part of the pain regimen, so it is hard sometimes to tease out.

[tencat]

I'd try to get her into an inpatient unit, if you have one available to you, or at the very least into respite care for a few days to see what she is really needing and using. I'd also have social work in on it ASAP. I have had a couple of cases of family members stealing drugs and selling them. It happens a lot, unfortunately. Fentanyl patches do help nip that in the bud, and though it's not ideal when someone is that tiny with no fat, it has helped. In one case of diversion in the home a nurse I worked with had to hide the patches by taping them underneath drawers in the bathroom so the devertee couldn't find them.....but it worked out.

[megjrn]

Her family is either taking or selling her meds.

[AtlantaRN, RN]

just an update, she passed yesterday morning. My boss went out and destroyed medications.

linda