Pain scale

[nurseequestrian]

Hey everyone. So my question for you all is when you are giving patients pain medication, do you always follow the parameters given exactly? So for example, say a patient can have Norco. The pain scale listed for it is say 5-7/10 Pain. If the patient states their pain is a 4, would you still give the Norco?

I know I have done this because it depends on each situation. But the other day I overheard a nurse not wanting to give the patient the pain medication because they were 1 point lower than the parameters.

What do you all think? It's honestly not something I have given much thought to, but now I feel like I've been doing it all wrong. Thanks!

[Sour Lemon]

I give what I want and fill in a number from the "proper" scale to match it.

[Davey Do]

Amen!! The "pain scale" is likely the dumbest thing ever introduced into the medical field.

I don't know about that Old Dude;

Here's a revised pain scale that I think isn't quite as dumb:

[ATTACH=CONFIG]25647[/ATTACH]

[Davey Do]

I give what I want and fill in a number from the "proper" scale to match it.

Yepper!

[OldDude]

I don't know about that Old Dude;

Here's a revised pain scale that I think isn't quite as dumb:

[ATTACH=CONFIG]25647[/ATTACH]

Now THAT could be useful!!

[OldDude]

I give what I want and fill in a number from the "proper" scale to match it.

This method also applies to skinning a cat.

[Davey Do]

Now THAT could be useful!!

Yeah. Allie Brosh saw the old pain scale this way:

[ATTACH=CONFIG]25648[/ATTACH]

0: Haha! I'm not wearing any pants!

2: Awesome! Someone just offered me a free hot dog!

4: Huh. I never knew that about giraffes.

6: I'm sorry about your cat, but can we talk about something else now? I'm bored.

8: The ice cream I bought barely has any cookie dough chunks in it. This is not what I expected and I am disappointed.

10:You hurt my feelings and now I'm crying!

[JKL33]

Someone mentioned that most of these pain scales come from EMR templates. And that's very true at where I work. I'm not saying that the pain scale is not important, just that it seems to get easy for providers to just pick one So they can move on in the order.

Also, when I give pain medication outside the parameters there is a reason. I work on an oncology floor and we are always doing pain management. When we find a schedule of pain medication that is finally controlling their pain and they are not having any respiratory or BP complications, then I'm going to stick with the schedule we found works for that patient. I'm not going to not give them a dose because their pain is finally controlled. The pain medication will wear off and I'm going to be the reason they are in excruciating pain again. And when this happens that we are on a pain management schedule but the parameters are still listed, the provider is aware that we are doing a schedule. Or for example pre medicating someone before PT. Their pain might be low right now but it will be high soon. Also, for those of you worried about the legal consequences, I feel this is something that could be argued in court. And if I'm carefully monitoring the patient for any side effects, I don't believe any patient would "sue" me for helping to control their pain. As nurses we do have critical thinking skills and I think we get so worried about the very slim possibility of legal consequences for everything little thing we do that we forget to use those critical thinking skills. Now I'm also not saying that we should practice outside our scope or we shouldn't be aware of legal ramifications.

Clarification of my POV: My question is, if you are (correctly) going to do all of that and you have an understanding with the physician, why not take one more step and write it out as a verbal/telephone order? What would be the reason not to do that?

The docs don't care about this crap. They will give you the order you need to serve the patient properly in situations like these. I'm pretty sure I can say I have never been chastised by a physician about the way I administered pain medications or handled a patient's pain. Additionally, they didn't choose the EMRs or build the templates and except for a few rotten apples they don't get their jollies by picking apart others' charting and decision-making. Issues like some of the the junk that gets built in to the EMRs are a PITheirA too.

Legal issues also aren't the primary concern. Your actions as you wrote them certainly are defensible in court. The issue is that having something that someone may interpret as an order and another as a guidline, which is part of the order notation itself, is a situation wide open for others to critique and use to cause various sized unnecessary headaches (which may be as minor as a write-up all the way to an accusation of improper handling of a controlled substance - which is their latest hot-button issue).

Suit yourself, but there's no good reason not to seek the orders you actually need rather than some of the suggested work-arounds...

[Davey Do]

Suit yourself, but there's no good reason not to seek the orders you actually need rather than some of the suggested work-arounds...

I like the way you talk.

I want to hear that again:

work-arounds...

Thank you.

[Irish_Mist, BSN, RN]

Amen!! The "pain scale" is likely the dumbest thing ever introduced into the medical field.

I agree. I hate the pain scale with a passion. Half the time, patients will say 9 or 10 and it factors in with unrealistic expectations of having no pain despite having a painful acute condition or being post op. Also, it contributes to the entitlement of having dilaudid q2h on the dot. *eye roll*

I want to manage my patients' pain but I want better resources and tools to do so.

[nursej22, MSN, RN]

Yeah. Allie Brosh saw the old pain scale this way:

[ATTACH=CONFIG]25648[/ATTACH]

0: Haha! I'm not wearing any pants!

2: Awesome! Someone just offered me a free hot dog!

4: Huh. I never knew that about giraffes.

6: I'm sorry about your cat, but can we talk about something else now? I'm bored.

8: The ice cream I bought barely has any cookie dough chunks in it. This is not what I expected and I am disappointed.

10:You hurt my feelings and now I'm crying!

I miss her!

[ICU56]

If I question what the patient is self reporting then I'll administer the medication deemed appropriate based on my observation of the patient. I'll then document that patient reports pain of 4/10, on assessment patient displayed such and such nonverbal indicators of moderate pain, was medicated with Norco per MD order.

[MunoRN, RN]

I assume (yes I know) that if nurseequestrian is asking about how nurses handle orders in an EMR that she does not have an understanding with a physician. Even if the Doc is okay with you giving meds outside of their orders if you are documenting pain as a 4 and giving a med ordered for pain 5-7/10 they should still be changing their orders. If something goes wrong or a patient complains its going to be easy for the doc to blame the nurse rather than actually take responsibility.

Like many situations we face, it comes down to which decision can better falls into "reasonable and prudent" practice. I feel much more comfortable with the potential of having to defend a decision that I can argue was reasonable and prudent, rather than having to defend a decision that was neither reasonable nor prudent, but was instead a literal translation of something that most likely was not intended to be read that way.

There is no basis to believe that patients' self-report pain scale ratings can be converted into a specific dose that works from one patient to another, in fact we know that this not a reasonable understanding. One patient's 10/10 pain may completely resolve with 325mg Tylenol, anther's 5/10 pain may only come down to 4/10 after 10mg of oxycodone.

I've have never, ever, come across an ordering provider that wanted templated dosing-by-the-numbers to be utilized, and many don't even know it ends up being part of the order. So if you're utilizing an interpretation that you have reason to believe was most likely not the intent of the ordering provider, then you are operating outside your scope as an RN.