Pain management is very difficult in an age where fear of drug addiction is so rampant. So many of the doctors and nurses with whom I work base their decisions on criteria learned in school and information passed from a previous shift without ever making a careful assessment themselves. Every individual deals with pain differently. Symptoms vary - somnolence, hyperactivity, sundowners, crankiness, nausea, combativeness, depression, suicidal ideation, confusion. There is no easy, consistent way to assess pain in individuals. Patients in pain will often deny pain and describe instead that they feel sick, don't want to eat, won't ambulate, don't want to see family. If orders allow, I will treat for pain and see what happens. I had a patient recently who didn't speak english. He had been given MS 2 mg. prn. His color was grey (he had dark skin, so you had to look closely), his face was tight, he guarded his side, he kept his eyes closed most of the time. I gave him 4 mg. MS (the order was 2 - 4)and an hour later he was talking to me about his kids - in english! He had the energy to try and communicate in a second language when his pain was not so severe. You can't learn about how to treat pain anyplace but at the bedside. And we have to be willing to err on the side of over medicating initially. Watch the blood pressure, pulse, mentation, and respiratory rate. Quit using somnolence as the primary criteria for deciding whether or not to medicate for pain. Quit making decisions on paper and go follow a nurse who knows how to manage pain, such as in hospice or on a surgical floor. Forget statistics and look at individuals. Everyone has a pain scale form, but the best way is to let your staff know that pain management is a priority, to pass on observations and to document in the narrative. I commend you for starting to address this problem. You might want to hire a nurse who specializes in pain management to be responsible for assessing and recommending treatment for your patients who would also be responsible for educating the rest of the staff. Let us know what happens. Good luck.