Two days after surgery, Kathy was weaned off theketamine and the Dilaudid PCA was continued. Kathywas very nervous about having the PCA discontinued,and much reassurance was necessary to let her knowthat we would do as much as we could to controlthe pain. When the PCA was discontinued, Kathywas prescribed 5-10 mg Dilaudid every 2 hours asneeded for pain. Parameters on the Dilaudid includedholding the medication if Kathy was oversedated,had a respiratory rate of <10 breaths/min, or hadManagement of Acute on Chronic Pain e271mental status changes. In addition to maximizing theuse of medications, efforts were underway to ensurethat Kathy’s anxiety about moving from intravenouspain medications to oral analgesics was minimized. Everyeffort was made for Kathy to have consistent caregiversto decrease her anxiety. I informed Kathy’shusband about what was happening to help decreasehis anxiety. I let him know that his wife was experiencingdelirium, which had manifested itself as acute confusion,visual hallucinations, and decreased awarenessof safety needs. Despite the increased somnolence, delirium,and fluctuating vital signs, Kathy maintainedthat she was in severe pain whenever we used thepain scale. It became clear that we were going needto rely more on objective signs and symptoms to assessKathy’s pain, because Kathy was not able to accuratelyuse the pain scale to effectively rate her pain. We continuedto use the Duragesic patch, hydromorphonePCA, and adjuvants, such as scheduled acetaminophen,Lyrica, and gabapentin, using the vital signs toguide our care.
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