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

[Morainey]

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.

[hiddencatRN, BSN, RN]

I feel like I should clarify something. Do I believe that someone can be experiencing severe pain despite no outward signs of it? Absolutely. Do I believe all patients are truly honest about how they feel? Nope. Will I still med treat a patient based on how badly they say they feel? Yes, with the exception that I've had pediatric patients give very low pain numbers while appearing to be in severe pain. They often get interventions based on a higher level of pain than they give.

[Anna Flaxis, BSN, RN]

I feel like I should clarify something. Do I believe that someone can be experiencing severe pain despite no outward signs of it? Absolutely. Do I believe all patients are truly honest about how they feel? Nope. Will I still med treat a patient based on how badly they say they feel? Yes, with the exception that I've had pediatric patients give very low pain numbers while appearing to be in severe pain. They often get interventions based on a higher level of pain than they give.

This is another angle to the picture- the people who under-rate their pain. I can usually tell within two seconds of talking to someone if they are stoic. You can see it clearly; the tension in their bodies, the tightness and lines on their face. You know they are someone that probably doesn't believe in complaining, doesn't like to have anyone do anything for them that they are capable of doing for themselves, and won't take a pill unless absolutely necessary. I can spot it pretty easily because I'm a keen observer, and because I'm a stoic myself. It's a funny little dance, when I ask them about their pain, already acutely aware that they are minimizing, while the family members at the bedside feel obligated to tell me "Oh, Mama never complains, and if she says it's a 4, it's really an 8!". Oh really? Who'da thunk?

[Anna Flaxis, BSN, RN]

If only this was true. This sounds like dayshift propaganda to me... Lol

Wrong. I have not worked one single day shift as a nurse.

[Anna Flaxis, BSN, RN]

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.

I disagree with this.

In my workplace, we have a numeric pain scale assessment tool, which describes objective observations for each category of the pain scale. For example, the 1-3 category states that the person might describe the pain as an annoyance, but doesn't interfere with functioning or sleep. The 4-6 category is where the person finds the pain hard to ignore, and may interfere with functioning and sleep. At 7-9, the person is grimacing, moaning, guarding or splinting, unable to function or sleep, and you will see VS NWNL. At 10, the person is experiencing a medical emergency and may pass out from the pain.

The reason for this is that this is a tool for measuring acute somatic and visceral pain as seen in an emergency setting. It is not intended to be a be all and end all for assessing every different type of pain. It is not intended to assess your normal, chronic pain.

So yes, in my practice, a 10/10 literally DOES mean that you just got your arm ripped off or just got hit in the head with a steel pole, or just got run over by a semi truck, or just shot yourself accidentally while cleaning your gun, or climbed up a telephone pole and touched a live line, or you are experiencing a massive MI, or you have peritonitis from a perforated bowel, etc.

Even someone who experiences chronic pain is going to respond physiologically and emotionally to severe acute pain.

And while it is true that some people are more stoic than others and may not behave in the typical ways that one might expect them to behave according to their stated pain level, there ARE objective measures that go along with the numeric pain scale.

As to the original topic, yes, I do believe someone can be sleeping and experience severe pain within minutes of waking up, particularly someone who has just had surgery.

[xtxrn, ASN, RN]

Good point, Stargazer-

ED type pain isn't the same as neurogenic pain, ortho pain, visceral pain, incisional pain, etc...

[Anna Flaxis, BSN, RN]

It isn't too different. Ortho and incisional pain are both somatic pain. We deal with somatic and visceral pain all the time. What we are not so good at dealing with are neuropathic and sympathetic pain, because those types of pain do not respond well to opiods and NSAIDs, and opiods and NSAIDs are what we've got!

Folks that are dealing with non-nociceptive pain are really poorly served by coming to the ED. This type of pain really needs to be addressed by a single practitioner that you can establish a relationship with.

[xtxrn, ASN, RN]

It isn't too different. Ortho and incisional pain are both somatic pain. We deal with somatic and visceral pain all the time. What we are not so good at dealing with are neuropathic and sympathetic pain, because those types of pain do not respond well to opiods and NSAIDs, and opiods and NSAIDs are what we've got!

Folks that are dealing with non-nociceptive pain are really poorly served by coming to the ED. This type of pain really needs to be addressed by a single practitioner that you can establish a relationship with.

Yep. Got that !!! But I think you guys get the "impact" end of those kinds of pain..... the floors get the pain from trying to fix it (at least after they get to OR). When you see someone, they are still reeling from what happened to get them to you- and all of the manipulation needed to get them stable enough to admit/diagnose/initially treat.... :)

[Anna Flaxis, BSN, RN]

Well, yes, surgery is brutal and post op pain is sort of its own beast, and a good Med/Surg nurse clearly should have a good grasp on managing postoperative pain.

I think if there's a culture on the unit that interferes with effective pain management (which it sounds like there could be in the case of the OP's unit), this can make things really difficult for a green nurse, not to mention the patients.

[Morainey, BSN, RN]

Well, yes, surgery is brutal and post op pain is sort of its own beast, and a good Med/Surg nurse clearly should have a good grasp on managing postoperative pain.

I think if there's a culture on the unit that interferes with effective pain management (which it sounds like there could be in the case of the OP's unit), this can make things really difficult for a green nurse, not to mention the patients.

You nailed it! :)

I gave it some thought and it's true that not all nurses are consistent. The problem I was having was not that I don't believe my patient who says 10/10 is really in that much pain. I think maybe some people read it that way, but I am fresh out of nursing school and naive and trusting, so I believe my patients when they say 10/10. I also try to medicate my patients accordingly for their pain.

However, I am nervous about oversedating a patient. In this case now, I can look back, say, my patient's blood pressure was always this low. She takes all of these different narcotics at home already, because she has chronic pain. And naturally, my little weenie dose of Dilaudid is hardly going to touch her pain. Lesson learned.

[twinkletoes53]

Yes! I have had bilateral total knee replacements and a triple arthrodesis of my right ankle. Right after my surgeries, I could be asleep, then wake up suddenly and attempt to move just a bit---and immediately send my leg into severe, extremely painful spasms. So if you had checked on me at 2300 and I was asleep, please don't be upset if I call you @ 2310 and request pain meds. ASAP. It does happen.

P.S. And don't forget to put up my siderails after you've medicated me. I got out of bed 3 days after my ankle fusion surgery, drugged on Morphine. Apparently I forgot that I couldn't walk, tried to go to the bathroom, and immediately fell. My room was at the end of the hall, my door was closed, and I lay on the floor crying and calling for help for close to an hour before someone came in and found me. And then they asked me "What are you doing on the floor"? Oh gee, well, I got tired of laying in bed and decided I neded a change of scenery.

[Anna Flaxis, BSN, RN]

P.S. And don't forget to put up my siderails after you've medicated me. I got out of bed 3 days after my ankle fusion surgery, drugged on Morphine. Apparently I forgot that I couldn't walk, tried to go to the bathroom, and immediately fell. My room was at the end of the hall, my door was closed, and I lay on the floor crying and calling for help for close to an hour before someone came in and found me. And then they asked me "What are you doing on the floor"? Oh gee, well, I got tired of laying in bed and decided I neded a change of scenery.

Sorry, but if you're so confused from the morphine that you "forgot you couldn't walk" and got out of bed, I don't really trust your perception of time.

[twinkletoes53]

The jolt of hiiting the floor woke me up. i looked @ my watch. took an hour for staff to respond.