Pulmonary Patients and Appropriate Pain Control: an editorial

Note: Typos are intentionally left as they are copied and pasted from facebook, the land of terrible typing errors and autocorrect ;)

I just came across a question in a nursing facebook group and I had a strong enough opinion that I decided to type up a quick reply. It ended up being a short novel, but I felt good about what I said and wanted to share.

For context, here's the original question:
I do not have consent to use the person's identity so I'll leave that out.

"Question for nurses? Question for these type of patients if there reading? As a pulmonary nurse, why are patients with bronchitis, COPD, pneumonia and even Asthmatics given DILAUDID MORPHINE DEMEROL FOR THEIR PAIN??? What happened to old-fashioned Tylenol?"

There were tons of replies and they all correctly cited that meds such as these can also alleviate dyspnea and labor of breathing in very ill patients, and it's routinely used in palliative and end-of-life care.

The question's author clarified that she was seeing 3-4mg doses given off the bat, instead of trying other things, simply because the patient asked/demanded that med or they'd had it on a previous admission. I think her concern is valid when she states that we're breeding patients with drug dependence and addiction when we're too lax with prescribing.

So I put my two cents in.

Here it is for your review, commentary, correction and/or accolades.

I work on a step-down unit that is both pulmonary and palliative care. I hear you loud and clear, despite agreeing with most of the rationales regarding chronic pain, dyspnea, etc. 

But you're right that sometimes people bypass the more reasonable attempts at pain control, aka non-opioid or even non-pharmacological methods - and jump straight for the big dogs. I feel 3-4 mg is a lot unless there are extenuating circumstances. We often see doses in non-palliative pulmonary pt of 0.2mg up to 1mg. or maybe a 15mg extended-release tablet. It could be the docs are being too loosey-goosey with the narcs. Are you making recommendations to your doctors or addressing concerns with them? remember, they can order it but you are ultimately responsible for handing it to them. if it's inappropriate, professionally and politely address it. If you feel they're doped up, it's your responsibility to refuse to give and speak up. A patient complaint may get you in trouble, but OD'ing a patient will wreck your life. so I encourage you to say to your doc in your SBAR format, "Mr. So and so is rating his pain 10 out of 10, but based on his symptoms and my assessment, I feel that a smaller dose/Tylenol/tramadol/some alternative is a SAFER choice." If you're in a place that would discourage that, find another job yesterday

Also, I care for cystic fibrosis patients that are in so much pain, pleuritic and rib - which dude, pleuritic pain sucks. when you breathe fire. remember the longest run you ever did in your life - then exponentiate it and make it permanent. I can't imagine the pain of hacking for weeks, months, years at a time. However, some CFers have issues with addiction too. so we walk a very careful line. 

As far as communicating with your patient, that's tricky. I always offer ice/heat packs, repositioning, I make suggestions they stop contributing behavior like laying in bad positions in bed, doing all their proper breathing treatments, getting good nutrition, not going out to smoke, etc. 

it's tough, but remember, you're protecting your license with every med you give and every decision you make.

Does this help?

I would love to hear all your thoughts! Comment! Follow me if you like this and I'll tackle similar topics in the future.

Happy Nursing, folks!



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