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As a nurse, you are responsible for pain management and keeping your patients comfortable. This requires a basic understanding of common medication used to treat pain as well as simple drug conversions.
Seriously, this is even more important in hospice nursing so that you don’t over or under-medicate your patients.
All too often, patients aren’t given adequate pain medications and this can lead to decreased quality of life.
Honestly, once I figured this out, I was able to keep my patients more comfortable and had far less resistance from my patients and their families.
According to the World Health Organization (WHO), 67% of patients with heart disease and COPD will suffer from moderate to severe pain at the end of life. And, this number is even higher (80%) in patients with AIDS and cancer.
To begin, let’s discuss the top reasons nurses under-medicate their patients.
3 Reasons Nurses Under Medicate Patients
#1 Incorrect Calculations
First, miscalculations can occur when you don’t give the medication as it is ordered or prescribed.
Sometimes, this happens because your patient’s medication is not available by your organization’s pharmacy. Medication may also be available in various strengths that may be combined to make one dose.
Unfortunately, when nurses have to adjust medications based on availability, the doses aren’t always an exact match.
For instance, fentanyl is not the same as morphine. In order to get the correct dose, you will need to understand basic drug conversions.
Furthermore, incorrect conversions can be problematic when you don’t understand dose equivalents.
Errors often occur when patients are transferred from the hospital to the home setting. Often, when patients are in the hospital, they are receiving IV medications but are changed to pills by mouth when they go home.
As a nurse, it is your responsibility to understand how drug conversions work so that your patients are comfortable.
#2 Lack of training
Generally speaking, if you are a nurse, you understand how to calculate dosages.
After all, they only beat it into your head during nursing school, right? LOL
However, the calculations and conversions that are used in hospice may not be the ones you are familiar with and this can be frustrating.
Have you ever received an order from a doctor to convert your patient from oral Oxycontin to oral Morphine?
Well, this might seem like a “no brainer” but if you don’t know the conversions, you might just under-medicate your patient.
Additionally, if you are new to hospice, you might not have the required training and experience to know that you should consider PRN doses taken by the patient in addition to scheduled pain medications when adjusting their medications.
Specifically, if you want to be a great hospice nurse, get additional training and become a certified hospice and palliative nurse.
Pro-Tip: PRN doses should be approximately 10% of the 24hour total opioid dose.
#3 Suspicion of Abuse
Sadly, I saw this a lot when I worked in the hospital with certain patient populations and “frequent fliers.”
For example, if a patient says they are allergic to morphine and can only have Dilaudid then your nurse’s spidey senses may start to go off.
Unfortunately, your biases may cause the patient to get less medication than they need to stay comfortable.
As a result, the more uncomfortable they get, the more they demand additional medications, and thus the cycle starts.
If you want to manage your patient’s pain, you must first manage your own biases and fears about the medications that you will be giving as a hospice nurse.
You should also be aware that a common barrier to opiate use in the elderly is the fear of addiction. The CDC has great information that can be reviewed regarding opiate addiction.
So, what can you do?
First, you should educate yourself on common hospice medications and their dosages.
Secondly, develop your drug conversion and dosing skills.
Thirdly, learn to ask the physician for what you need. While this might not seem like your job. Many physicians are not trained as extensively as you may be as a hospice nurse.
As such, they may rely on you to make suggestions based on your formulary and other information that you have available to you.
Signs and Symptoms of Under Medication
Uncontrollable pain– Pain is subjective so just because you’ve not given a dose before, it doesn’t mean that it won’t work for your patient.
Increased blood pressure– This can be overlooked in dying patients because vital signs are not always routinely monitored.
Increased heart rate-Again, this can be a tell-tale sign that your patient is uncomfortable.
Irritability and restlessness– Often, irritability is a sign seen in elderly patients when they are having pain. You might want to ask the physician for an order for scheduled Tylenol.
Vomiting or diarrhea– Don’t always assume that vomiting is a GI problem because it could be related to pain.
Rapid physical decline– If your patient’s physical status starts to decline, don’t just assume it’s because they’re dying. Sometimes pain control will help patients become more alert.
Consequences of Inadequate Pain Management
While they may seem obvious, you will want to look for these additional signs that your patient’s pain is not being adequately controlled.
- Impaired quality of life
- Poor sleep quality
- Decrease in physical activity
- Psychological distress
3 Types of Pain
Honestly, my first RN job was on an inpatient oncology/hospice unit so I had to get comfortable with morphine drips and drug conversions pretty quickly.
Opioids were essential to managing my patient’s pain and so was understanding the cause of their pain.
If you are like most nurses, you are not a fan of giving a ton of morphine, Ativan, and Haldol.
Well, maybe not ICU nurses. Anyways, I digress.
However, for hospice nurses, it is just par for the course.
So, let’s talk about the types of pain and common medications used to treat them.
3 Questions to Ask Your Patient About Pain
Sometimes, you might be tempted to go straight to the common questions about pain such as how do you rate your pain.
However, if you really want to know what’s going on with your patient, it might be helpful to ask more detailed questions like the ones listed below.
1. How often are you taking your pain medication?
(It’s ok to use terms that the patient understands.)
For instance, you might ask “How often are you taking the little white pill for pain?”
This question is good for when your patient is taking PRN pain medications.
It can help you determine if your patient needs to be started on a long-acting medication or if they need to have their medication adjusted.
2. When you take your pain medication, how long does it last?
For some patients, this question will help you understand if they need to have their dosage increased.
Often, if the pain medication isn’t lasting, they may complain of increased fatigue and irritability.
3. Does it get rid of you pain?
When you ask this question, you can get closer to understanding what’s going on with your patient.
You might be surprised to learn that your patient stopped taking the medication completely because they didn’t think it was helping. Pain is subjective so keep an open mind when probing for answers about your patients’ pain.
Common Opioids Used to Manage Pain in Hospice
Although there are many great medications used to treat pain, you will likely encounter these common opioids as a hospice nurse.
Morphine Sulfate (aka Roxanol)
Roxanol is a concentrated liquid that is used to manage moderate-to-severe pain. This is usually part of the standard comfort kit.
Just the name alone can cause anxiety for patients and families because they may associate it with “killing” the patient.
Make sure to take your time and explain the side effects and benefits of the medication.
Pro-tip: If you can give the first opioid dose, you should. This will allow you to teach the family and be present to explain any side effects such as drowsiness or changes in respiration.
Dilaudid ( aka hydromorphone)
Dilaudid is similar to morphine and is another opioid used to treat moderate-to-severe pain. However, Dilaudid is stronger than morphine.
Sometimes, your patient may be switched from morphine to Dilaudid because of their age or medical history.
For example, the elderly tend to have less drowsiness with Dilaudid and as a result, it can help reduce their fall risk.
Dilaudid is also preferred for patients with kidney disorders because it’s removed from the body by the liver, not the kidneys.
Duragesic patch (aka fentanyl patch)
The fentanyl or “pain” patch is also an opioid used for chronic pain. Most often, individuals such as cancer patients, who have been stable on other opioids may have a patch by the time you get them on hospice.
In addition, the patch may be used for patients who have trouble swallowing or gastrointestinal disorders.
Pro-tip: The patch should be avoided in patients with severe weight loss and cachexia because it may not be as effective.
Note: There are other opioids such as oxycodone and hydrocodone that you will also want to become familiar with as well.
What is a Drug Conversion?
Simply put, drug conversion is changing your patient from one medication to a different medication.
Let me put it another way, it’s math!
Regardless, from time to time, you will need to make adjustments to your patients’ medications.
I will admit that I am a bit of a math nerd so nursing pharmacology and math never scared me. But for some nurses, this brings chills down their spines.
If the thought of math makes you shiver, you are not alone!
Because I know math can stink, I am putting the most common conversions below for you.
Basic Conversions
Oxycontin x1.5= Morphine
fentanyl patch x 2=24 hours morphine dose (oral)
Example:
- What do you have on hand and what do you need?
- What is the dose equivalent of oxycontin to morphine?
- Do the Math.
SAMPLE Problem
Mr. Smith is taking Oxycontin 10mg PO twice daily for pain at the time of admission. The pharmacy only has morphine sulfate tablets available at this time. When the nurse calls the physician, they receive an order to switch the patient to morphine.
How much morphine does the patient need?
Problem: 10mg(Oxycontin) x 1.5= 15mg(Morphine)
Solution: Morphine Sulfate 15mg PO BID
Remember: That the patient gets this twice per day so the total dose in 24 hours is 30mg.
As you can see if you don’t take into consideration the patient is getting the dose twice per day, you could easily under-medicate them.
Conclusion
So, let’s wrap it up!
Pain management is complex and requires knowledge and skill. If you want to make sure you’re not under-medicating your patients, take the time to get familiar with drug conversions and ask better questions when accessing your patients.
Most importantly, you can’t solely rely on the physician to know what the correct dose is for your patient. You should use your resources such as the pharmacist and your peers to make sure you are providing the best pain management for the patient.
Recommended Articles:
The Truth About Hospice Nurse Certification: Do You Really Need It?
What Successful Hospice Nurses Know That You Don’t!