Yes, I'm in pain!

[nkochrn]

I just awoke and opened my eyes for only a split second to barely be able to make out the face of my recovery nurse. I feel so weak and powerless right now, the anesthesia must not have worn off yet. She just asked me if I want to see the gallstones I had removed; of course I want to see them, I'm a nurse and that's what we do.

The only thing I really want to do right now though is die, this crushing pain in my chest is so unbearable. I want to tell this nurse so badly, but I just can't find the strength to open my mouth.

I just had my gallbladder removed and this pain feels just like the worst gallbladder attack I had a couple weeks ago. The nurse does finally ask if I'm in pain and I shake my head yes, but I don't open my eyes because I just can't. I'm sure she thinks I'm fine because I'm resting, but this is the worst pain I've ever had in my life.

I finally get moved to a room on the floor where my husband and 1 month old son are waiting for me. I'm more awake now and able to voice my complaint of crushing chest pain.

The nurse quickly gives me 3 mg of morphine which never really does anything to make me feel better.

Once at home I'm able to take my Percocet and finally I am pain free and able to relax. It seemed like that pain would never go away. I am no sissy when it comes to pain, I gave birth 1 month prior to this with no epidural, no spinal analgesic, and no IV pain meds. My drug free natural lady partsl delivery was a breeze compared to the pain I had after surgery.

I returned to work about a month later and as I took over care of a patient in recovery the nurse told me, "she wakes up every few minutes and says she has pain but she goes right back to sleep."

I quickly let this nurse know that just because the patient is sleeping does not mean they are without pain. As soon as the patient was all settled in and checked the orders for some pain medicine. Next time you begin to document that the patient is sleeping and without c/o's, please reconsider if you truly know what the patient' s pain level is.

[*LadyJane*]

Some patients may be trying to practice self-hypnosis, or trying to escape into a painless part of their mind. I have done this when a patient, post surgery. A nurse came up, put her hand on my forearm without saying anything, to see if I was awake, I opened my eyes and looked at her, so she asked me how I was doing. I said, a lot of pain! She was puzzled because I was so still. (I was so still, because I was trying not to breathe because it hurt so bad to breathe), and was excruciating to move in the slightest, so I was perfectly still.

She would have thought I was resting quietly, except she put her hand on my arm, and asked me. Thank god she did. She called the doc, and got the PCA order turned up. God bless her!

[wannabecnl]

Thank you for this post! It is a good reminder for anyone, but as a newbie in the PACU, I'm especially grateful for the guidance. Yesterday I had a patient who was a good example of how there are closed eyes and then there are closed eyes, if you know what I mean. This lady came out looking drowsy; she was arousable, but otherwise never opened her eyes. She wasn't wrinkling her forehead or making any noise, but she did look stressed somehow. Her pain went from 4 to 5; I gave 2 of morphine to see if we could reverse that trend. The pain went to a 7. 4 more of morphine, and then her face (eyes still closed) changed completely. No more stress in her eyes when she looked at me, no more edge to the set of her mouth. We got her pain down to a 2 or 3. It went back up again after an hour, but by then she was on a PCA pump, which I think will work great for her.

Anyway, the differences in her features between her two expressions were subtle, but taken all together, the change was remarkable. It had almost nothing to do with sleep or eyes being closed. Most of my patients in pain don't fall asleep, but the exceptions need pain control, too. Thanks again for this reminder.

BTW, I'm finding facial expression to be more helpful than pain score for some patients; this woman's 4 looked a lot worse than other people's 6 or 7, and at 7 I was expecting her to say 10! This is why I advocate the use of comfort goals--asking the patient what number they'd like to try to get to, knowing that 0 is not always possible. There's some really good literature out there, and it's in the ASPAN pain management guidelines. But I digress...

[echoRNC711, BSN]

My mindset is to look for reasons to not give pain meds, not reasons to give them. Those reasons are rather exceptional--completely unresponsive, denies pain completely (even then I'll give something PO before transferring the patient and continue to reassess), respiratory rate less than 8 or otherwise completely inadequate such as with sleep apnea, maybe BP if it's really lousy but I'd just treat the pain then correct the BP most times

Respiratory rate of 8??? Is that a typo? Am I misreading this...you would give pain meds to someone with RR of 9?

[Perpetual Student]

Yeah, I would assuming they're complaining of significant pain or showing signs thereof. I'd give a smaller dose (perhaps 25 mcg of fentanyl) at increased intervals (10-15 minutes) until the patient reported relief or became too sedated. I would also be sure to give meds like ketorolac or acetaminophen. I'd coach in deep breathing to ensure adequate ventilation, of course. And would let the patient recover and be breathing adequately without coaching prior to transfer. To be clear, the quoted statement was with the immediate post-operative patient in mind who is still sedated due to agents other than opiods and who is being closely cared for in the PACU.

Sometimes these patients end up with a protracted PACU stay, but I believe that's better than just saying "tough luck buddy" and shipping them to the floor with uncontrolled pain. I would certainly agree that in other contexts it would probably (but not always) be inappropriate to administer opiods to someone whose respiratory rate is 9.