Everybodys pain tolerance is diffferent. What one could consider the worst pain in the world, another might consider a 4 or 5 on a 1-10 pain scale.
Subjective information is important. However if there is any doubt to whether they are in obviously more or less pain, you must document any objective information.
Things have to correlate, common sense prevails. Here are some examples.
case #1 - Pt: the pain is terrible.....I need something it's a 10/10.
Objective info: You see this patient crying and restless, sweating, pulse 120, resps at 24-36......crying and moaning......do I chart all that? Not usually......but she clearly needs more pain meds, for releif.
case #2 - Patient: The pain is a 3/10 scale.
Objective info: You see crying, maoning, increased pulse and respirations with some diaphoresis, and they are pale. Clearly this needs to be documented, and get an order for pain medication, or give it if you have an order already. Then re-evaluate after a period of time.
case #3 - Pt: the pain is a 10/10........or as we hear so often on a 1 - 10 scale how bad is the pain? They say "12". Always quote the number they tell you.
Objective info: The patient is talking to their friend at the bedside, occasionally laughing and smiling. No crying, no moaning, skin color is good, pulse at 62, resps at 14. Most likely they don't need pain meds at this time. the doctor and/or (in the future JCAHO) or her attorney may want to know why they were not informed, or why nothing was done for the pain? Documenting your objective info........will save your butt! This person clearly is not a 10 or 12, or whatever they claim the pain to be.
Just a few tips........and .....if it's not documented, it didn't happen, or wasn't observed. The last thing anybody wants to hear (because it wasn't charted), "Well I don't know......but if they didn't get anything I am sure their was a good reason for it.