I've seen some pretty generous pain med orders, but two come to mind that take the prize. I will say that both of these patients had conditions that are well known to be painful, and I have no doubt at all that they were in honest-to-god pain, but I still think both were a tad over the top.
1) Methadone PCA= 8mg/hr basal, 4mg q10min bolus. Also on other PO pain meds.
2) Dilaudid 6mg q1hr prn, in addition to a fentanyl patch, and an epidural morphine & baclofen pump. I kid you not.
A pt. claims to have sickle cell wants pain meds-test show no evidence of illness pt refuses to give urine for tox. Md:jester: insists on giving diladud IVP , LESS TWO HRS LATER ,dilaudid 4mg po, percocet prn. pt wants IVP only, finally I told the doctor enough, is enough- told the pt. I need some urine before you get anymore pain meds. SURPRISE, urine positive for cocaine, etc.etc.
no more dilaudid IVP- pt signed out. later found out pt has been to 18 hospitals (yes-you saw correctly) within the past 2 weeks. Some doctors just want to shut the screaming patient up. I need my LIC. [TOO OLD TO FLIP BURGERS]
350 mg. MS04 IVP q1-2 hours PRN pain and she also was totally alert and oriented x4; unfreaking believable, I know. I read the order 5 times and questioned the nurse giving me report, I read the narc sheet and MARS multiple times, as well as the history; Ca w/mets, spinal stenosis
This may not be much for those of you working in Med Surg or ICU, but I work in Long Term Care. I have an 80+ yo res with osteoarthritis. She has an internal morphine pump, PRN oral MS, Oxycontin BID, PRN Oxycodone, APAP (for what that is worth) and a lidocaine patch. Some days this does not begin to alleviate her pain. She is always alert and oriented no matter how many drugs are in her system.
One time working in recovery room, had patient come out from back surgery, no tolerance for any kind of pain, on a pharmacies worth of meds at home, after anesthesia gave 10 mg morphine iv,I gave him:
additional 10 mg morphine ivp
50 mg demerol ivp
25 mg phenergan ivp
2 mg dilaudid ivp
po methadone 80 mg
and then, after many distressed calls to anesthesia(pt literally screaming non stop, disturbing every other pt in recovery, family irate that pt doesnt have proper pain control)
ANOTHER 2 mg dilaudid ivp.
This was all within 2 hours time. I couldnt believe the man was even still breathing, much less screaming after all this. Docs were REALLY familiar with him and sent him to the floor like this, yelling the whole way. Floor nurses also were very familiar with pt and family when he arrived. Made me glad I was not working the floor that day.
If the mu receptors are down regulated and shot to **** from chronic opioid administration try going after the NMDA receptors with a little ketamine. Giving 10-30mg of this liquid gold is enough to provide analgesia without inducing a dissociative state (). It works wonders and the family, floor, and patient will thank you.
Has anyone heard of opioid induced hyperalgesia? I think it is common in sickle cell patients and other chronic pain patients. These patients may be getting more and more pain by taking such high doses of opioids.
Fentanyl patches totaling 650 mg., changed every 2 days rather than 3. Well, actually, the person had been on 600 mg. for quite awhile and had needed break through po meds. She spoke her MD and together they decided to increase the patches knowing that it might be overwhelming. She was tired of the pain and ready to go. She died within 24 hours of the increase. Did the increase do it? Perhaps, but I was there at the time she became comatose and her respirations were not diminished. I like to think it was her time and the increase just made the passing easier.
). It works wonders and the family, floor, and patient will thank you.
RN516
13 Posts
A pt. claims to have sickle cell wants pain meds-test show no evidence of illness pt refuses to give urine for tox. Md:jester: insists on giving diladud IVP , LESS TWO HRS LATER ,dilaudid 4mg po, percocet prn. pt wants IVP only, finally I told the doctor enough, is enough- told the pt. I need some urine before you get anymore pain meds. SURPRISE, urine positive for cocaine, etc.etc.
no more dilaudid IVP- pt signed out. later found out pt has been to 18 hospitals (yes-you saw correctly) within the past 2 weeks. Some doctors just want to shut the screaming patient up. I need my LIC. [TOO OLD TO FLIP BURGERS]