Pain assessment: do you believe your pt when...

pistolchick · Nov 11, 2011

I wanted to mention a possibility that may be overlooked. I definitely agree that: patients should be medicated for pain routinely, especially post-op. Patients should be encouraged to take pain medication prophylactically prior to physical therapy. Patients should be discouraged from being "stoic" because pain will impede therapy and healing and is unnecessary and miserable. All that being said, it's important to be aware that routinely giving out PRN pain meds to patients whose pain levels do not "require" them can be risky for the nurse administering. By that I mean, if an order states 650mg apap for pain level of 1-2, 1 percocet for pain level of 3-5 and 2 percocet for pain level of 5-10, and you give them a percocet when the numbers say apap, or you give them 2 percocet when the numbers say 1, and you do this routinely, you could be setting yourself up for investigation for deviation of narcs. This is one of the things they look for. Be aware of your facility's policy on this, and also be aware of what the patient is getting routinely, day to day and shift to shift. If a pattern develops that you are giving more pain meds routinely than anyone else - even though you're doing it with the patient's best interest in mind, and with completely honest intentions - you may be investigated for deviation if anyone sees the red flag. Just be aware.

systoly · Nov 11, 2011

Since I'm a nulligravida, my worst pain experience is associated with post op pain. So yes, you'd get a 8, 9 or 10 the first two days. The important factor for me is pain expectation. Anybody who expects to be pain free either has a fantastic surgeon (and it does make a difference) or needs more education. The same is true for pt.s who believe a bite stick should be the only comfort. I believe discussing expectations and setting realistic goals helps and, imho, should be part of the pain assessment.

kids · Nov 11, 2011

Since I am a new nurse, I a little gun-shy with pain meds (I work nights on an Orthopedic unit). Do you believe a patient who says that they are in 8, 9, 10 out of 10 pain when they were sound asleep five minutes ago?

I believe them because I've experienced it, had I not I would question it.

I don't do well with the demerol and dilaudid (and didn't even in the days before I had chronic pain). Both of them make me sleepy, confused and agitated (because I can't think!) but don't really do much for any pain I've experienced other than knock me out. Put either in my pca and you're going to have a patient who falls asleep withing a couple minutes of hitting the button and is awake, in severe pain, as soon as it wears off enough for me to wake up.

What works fine for the majority isn't always best for the few. I do think it's a very small minority who react this way but that it's worth investigating a little deeper if you have someone who has a pattern of waking up and complaining of severe pain.

For a person experiencing acute pain, I would not expect them to be able to sleep with a pain level of 8, 9, or 10. By definition, that is extreme pain that prevents normal functioning. A 10/10 acute pain would be like having your arm ripped off or being mauled by a bear or being submerged in boiling oil. It's the worst possible pain there can be. It's so severe that you actually pass out. I have seen very few people in 10/10 pain, but the ones I have seen, I will never forget.

This really highlights what I see as a problem the problem with the 1-10 pain scale, what constitutes a 10 is open to the beliefs of the person giving it. The way the 1-10 scale is presented in the region I've practiced (and experienced) is that 10 is the (patient's) worst pain imaginable, not what the person administering the scale imagines.

You've seen people who fit your idea of what 10/10 pain is. Pain is subjective, applying your (the collective you) values to the numbers isn't subjective. I've seen (and been) the person who was totally locked in by extreme pain, it's all they can do to breathe (but not too deeply), it hurts too much to moan, scream or thrash.

I think we have a tendancy to send mixed messages to patients.

If they are calm and quiet when reporting pain, we discount how severe it is because they done 'act' like they hurt.

If they demonstrate behaviors that don't fit what we have self defined as appropriate for any given number on the scale, they are overly dramatic.

Horseshoe, BSN, RN · Nov 11, 2011

so i have a question:
a patient of mine (who was a nurse) told me that if the patient is sleeping, then they are not in pain.
since i am a new nurse, i a little gun-shy with pain meds (i work nights on an orthopedic unit). do you believe a patient who says that they are in 8, 9, 10 out of 10 pain when they were sound asleep five minutes ago?
i try to incorporate the whole picture, such as, are they showing any other signs like grimacing, moaning, grabbing their incision? what was the last time they were medicated? do they have a high tolerance for pain? were they taking a lot of pain meds at home and thus have a high tolerance for opioids? and so on.
let me know what you think... i am scared to death of overmedicating a patient!! i had a scary experience with someone who was taking a lot of dilaudid and now i am really nervous.

i had a neck fusion surgery 2 weeks ago. i had chronic pain for almost a decade and the only medicine i ever took for it was advil. in the hospital, i woke up in excruciating pain. yes, 8 or 9 out of 10. it took my breath away and made me feel nauseated. so yes, although five minutes before that i was asleep, i was definitely in pain, needed medication, and was entitled to it without my nurse trying to figure out if it was really possible for me to be in pain five minutes after being sound asleep.

secondly, i guess they are no longer teaching this in nursing school, but it's important for you to know:

people who have chronic pain do not exhibit physical signs of pain such as those you will see in patients with acute pain. their bodies cannot sustain the fight or flight reaction over a period of months or years, so as it relates to vital signs and even other subjective signs of pain (such as grimacing, crying, inability to carry on a conversation, etc.), they will not be there. this does not mean they are not in pain, it does not mean they are faking, and it does not mean that their nurses have the right to withhold ordered pain medication. please take this to heart.

leslie :-D · Nov 11, 2011

I wanted to mention a possibility that may be overlooked. I definitely agree that: patients should be medicated for pain routinely, especially post-op. Patients should be encouraged to take pain medication prophylactically prior to physical therapy. Patients should be discouraged from being "stoic" because pain will impede therapy and healing and is unnecessary and miserable. All that being said, it's important to be aware that routinely giving out PRN pain meds to patients whose pain levels do not "require" them can be risky for the nurse administering. By that I mean, if an order states 650mg apap for pain level of 1-2, 1 percocet for pain level of 3-5 and 2 percocet for pain level of 5-10, and you give them a percocet when the numbers say apap, or you give them 2 percocet when the numbers say 1, and you do this routinely, you could be setting yourself up for investigation for deviation of narcs. This is one of the things they look for. Be aware of your facility's policy on this, and also be aware of what the patient is getting routinely, day to day and shift to shift. If a pattern develops that you are giving more pain meds routinely than anyone else - even though you're doing it with the patient's best interest in mind, and with completely honest intentions - you may be investigated for deviation if anyone sees the red flag. Just be aware.

excellent post.

i give pain meds even when not in pain...

because i want them to stay ahead of it.

and yes, always medicate before pt or other planned mobility exercises.

also very true that you are suspect if you give prn's, more than other nurses on floor.

when i worked nights, i remember this one woman w/advanced vag ca, with lots of clotting/bleeding.

no one (NO ONE) ever bothered to medicate her on nights, because she would just lay there...awake (!!) with a sweet smile on her face.

when i came on board, i had to ask her WHY she was awake...it was pain. :madface:

i gave her the prn's and noted meticulously...

and STILL i was questioned by DON about medicating her.

keep in mind, this is an inpatient hospice unit.

i feel myself getting worked up just thinking about all the bs that happens to well-intentioned nurses, so it's time to sign off.

but again, this post was spot-on, and much appreciated, pistol.

truer words never spoken.

leslie

Jenni811, RN · Nov 11, 2011

No, i don't believe it. I know we are taught pain is what the patient says it is.

But i've had a patient who was CLEARLY CLEARLY a 9 or 10 by the looks, he still was rating it a 7. i mean, it was clear he was in a lot of pain. We were doing everything under the sun for him. anyway...what i don't believe is someone who rates their pain a "9" when they were sleeping a few minutes ago. "I think i need my oxy. Do you mind calling the doctor for 3 oxy? the 2 just didn't do it last time"

i just want to be like "Bull Shi**. You want to see someone with a pain of 10? let me know you!" but that would be wrong on so many levels. So i put a big smile on my face "I'll see what i can do."

If it's a lady and they aren't a complete bit** and i feel i can add some humor, if they rate their pain a 10/10 and they don't look like a 10/10 then i will say "worse than child birth?" then they say "oh no!!! its not worse than child birth" then i'll say "lets rate your pain again" "well i guess about a 4 or so"

Jenni811, RN · Nov 11, 2011

yes- for the students who posted we give pain medications based on what their pain is. but that is in NCLEX land where all your patients are perfect, and everything is just PERFECT! Don't we all wish we could work in NCLEX land?

in real time land, we have patients that will rate their pain a 10/10 after they are maxed out on their narcotics and tylenol for the day. If they are still in pain, and it DOES happen, we will try other things. BUUUUUT im talking about the people who are perfectly fine and act totally normal, no moaning/groaning/rubbing/grimacing or anything and rate it a 10/10. "I need more pain medications!!!!!! its a 10. If i give it a 12 will you give me more pain medication?"

it's hard to take it seriously sometimes. And im not saying i won't medicate, because majority of the time i will just to make them shut up about it. sometimes i wish we could give placebo pills to those patients. I'm convinced it would work on 25% of them.

Horseshoe, BSN, RN · Nov 11, 2011

anyway...what i don't believe is someone who rates their pain a "9" when they were sleeping a few minutes ago. "I think i need my oxy. Do you mind calling the doctor for 3 oxy? the 2 just didn't do it last time"
i just want to be like "Bull Shi**. You want to see someone with a pain of 10? let me know you!" but that would be wrong on so many levels. So i put a big smile on my face "I'll see what i can do."
If it's a lady and they aren't a complete bit** and i feel i can add some humor, if they rate their pain a 10/10 and they don't look like a 10/10 then i will say "worse than child birth?" then they say "oh no!!! its not worse than child birth" then i'll say "lets rate your pain again" "well i guess about a 4 or so"

I find this post offensive. I rated my pain an 8 five minutes after being sound asleep. See below. It was real, it was excruciating, and you would have no right to decide you knew better than I what my pain level was.

I had a neck fusion surgery 2 weeks ago. I had chronic pain for almost a decade and the only medicine I ever took for it was Advil. In the hospital, I woke up in excruciating pain. Yes, 8 or 9 out of 10. It took my breath away and made me feel nauseated. So YES, although five minutes before that I was asleep, I was definitely in pain, needed medication, and was entitled to it without my nurse trying to figure out if it was really possible for me to be in pain five minutes after being sound asleep.

xtxrn, ASN, RN · Nov 11, 2011

Something else to consider is that BP can drop if the pain triggers autonomic reactions. Ever had menstrual cramps bad enough to cause presyncopal, or actual syncopal reactions? :down:

I "look" fine. I hurt a LOT. Yet, I wait to call the doc, because I don't want to be judged BY THE NURSES who relay the info to the doc.... Once I get the "all clear" re: the chemo clearing out, and I go back to "regular" fibromyalgia and orthopedic pain, I'll likely go back to the pain management doc. I could go now- but don't want more than one doc prescribing pain meds at a time.

Pain effects my ability to carry out "normal" activities- yet I have to get them done at some point (I recently found Walmart's delivery of their products, which will save me a good day and a half of pain that effects how steady my gait is).... for those who are looking for "proof" for YOUR sake, is that good enough for you? Or should I curl up in a ball on the bed, and not move?? It wouldn't do me any good.:)

How does trying to judge someone else's pain help them or you? If they are medically stable enough to medicate, give the xxxx meds, and get over yourself. JMHO. Or, God forbid- remember this someday when you start falling apart..... anybody who doesn't realize just how many nurses on this forum are in constant pain will understand it themselves one day- by then who knows how many patients will have been put through the wringer for no valid reason. None of us anticipated physical deterioration - but it happens ALL the time.... nurses have physically taxing jobs- especially early on. That takes a toll.

If you're not working drug rehab, you do not have the right to tell someone else if they need pain meds or not-- you're not in their skin. Even junkies get narcs if they have medical procedures in rehab. BTDT. I'm glad I worked someplace that treated the HUMAN without cruelty. The stats re: prescription drug abuse/deaths are a concern- but they aren't the vast majority of the population. Someone in pain won't take pain meds if they don't hurt. There is no "high"- just relief. And being made to "beg" for that is simply inhumane. :twocents: :)

Jenni811, RN · Nov 11, 2011

I find this post offensive. I rated my pain an 8 five minutes after being sound asleep. See below. It was real, it was excruciating, and you would have no right to decide you knew better than I what my pain level was.

That is your opinion, and that is mine. By my post "offending you" its not going to change my views. Ill treat their pain as they say it is, but that does not mean i believe it.as long as im treating the pain as they say it is, why should it matter if i believe the patient or not?

and just an FYI...i would never ever actually speak that way to a patient.

sapphire18 · Nov 11, 2011

I had a relatively minor outpatient surgery 2 years ago, and even just from that I would wake up and as soon as I was conscious would be in excruciating pain. Even if I do have my own personal doubts about a pt's pain level, it wouldn't affect how I treated them. I ALWAYS give the pt the benefit of the doubt because you just never can know for sure what they are experiencing. I also do agree that some nurses' treatment of pts in pain encourage what is then seen as "dramatic" behavior by those same nurses- pain is SUBJECTIVE and yes objective s/s are useful when the patient cannot communicate ie. they are intubated and sedated; it is not our place to judge what amount of pain WE think the patient is in.

OCNRN63, RN · Nov 12, 2011

I'm a first year nursing student, they taught us we don't question the patients pain we give the meds as doctor ordered and to practice pain management so the pain never gets out of control.

"When Worlds Collide": nursing school v actual practice.