Rethinking Pain Assessment

Specialties Pain

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I want to do a little exploration here and get general nursing input from nurses everywhere across all disciplines about assessing pain and in particular non -verbal cues that indicated the patient may have pain.

I don't want this to degenerate into an argument about "If the patient says they have pain we must treat it". That is a "given".

What I am after is the non-verbals such sa posture, pallor, attitude etc of the person in pain that would tell you they have pain.

Are there patterns of pain response particular to chest pain or abdominal pain or male vs female?

I am also looking for indications that might lead you to think that the person is either overreporting their pain or is faking entirely. Asking this part of the question is not a validation for withholding pain medications but a way to work out how and why we are getting a different non-verbal message to the verbal one.

I am not looking for textbook answers here what I am exploring is data that may not or will not be in a text book.

If you like think of this as phenomenological research. Everyone's opinion and experiences are valid and worthy. From your responses I will try to summarise and recap and see if we can take the research up to the next level.

It seems we all have differing attitudes that effect how we act and react to pain.

I am an RN with many years experence, and am currently in the process of doing a paper for my MS in Biomedical Ethics. This paper will be on pain, not because I really wanted to do a paper on it, but at the strong urging from my thesis advisors. (Now I am actually interested in it)!

Anyway, my question is this: Aside from using the standard pain scales, do you think you rate some pain higher than other types of pain. If so, how do you treat them. In other words, do you obtain pain meds for a patient with chest pain, or an acute injury more quickly than you do with say.. a chronic pain pt, or chronic complainer?

Does anyone think how you deal with your own pain, or family members experencing pain directly or indirectly effect how you treat pain in you patients- be honest..

Thanks

For pain that is more acute than chronic, I have observed the following in older teens and not yet elderly adults:

Increasing irritability and short answers to questions when pain increases

Frequent sighing

The need to shut out sensory stimulation- they want the room dark, the door closed, the TV off

Some patients will threaten to leave AMA if "something" is not done to help them

decrease in appetite, little interest in visitors

For elderly patients:

Restlessness, anxiety,

poor appetite, lethargy

they will tell you they feel nervous

Hope these observations help Gwenith.

Pain is a strange thing. I too am a nurse of 26 years, who has been disabled for two years because of failed back syndrome. I have herniated disks from L1 down either to the left or the right. I have had a spinal fusion. I am in pain 24/7. I am on MS Contin 75mg every 8 hours as well as oxycodone every six hours for breakthrough pain. The pain is dulled but never gone. I laugh, enjoy life as much as I can. People tell me if I get up more then I would probably feel better. Unfortunately, I found out that it does not work that way. People tell me that I look great, so therefore I must be pain free. I just see no need to go around with a long face crying all the time. I had two surgeries on my back and it got worse after each time. Now I will just be satisfied to try to live the best I can in constant pain.:crying2: I am also seeing a pain management doctor and he said that there was nothing else that he could.

Specializes in ICU.
Originally posted by Nurse 2

It seems we all have differing attitudes that effect how we act and react to pain.

I am an RN with many years experence, and am currently in the process of doing a paper for my MS in Biomedical Ethics. This paper will be on pain, not because I really wanted to do a paper on it, but at the strong urging from my thesis advisors. (Now I am actually interested in it)!

Anyway, my question is this: Aside from using the standard pain scales, do you think you rate some pain higher than other types of pain. If so, how do you treat them. In other words, do you obtain pain meds for a patient with chest pain, or an acute injury more quickly than you do with say.. a chronic pain pt, or chronic complainer?

Does anyone think how you deal with your own pain, or family members experencing pain directly or indirectly effect how you treat pain in you patients- be honest..

Thanks

To be honest this needs its own thread. The questions are too important to be burried inside this thread although many of the answers to your questions can be found here. I would like to see you start another thread on this topic and then "subscribe" to that thread. Subscribing to a thread causes an Email to be automatically sent to you when someone replies and you can log on to your thread to answer them. If you need help with this contact any moderator and we will be only too glad to be of assistance. My only concern is that you keep this as a discussion and not perform research as per the Terms of Service even though I did say I was researching mine is not for any particular outcome we are really exploring the topic.

This is why I like caring for peds. They do not manipulate or pretend to be hurting or pretend to not be hurting----at least not until they get near adolescent. Signs are pallor, panting and accessory breathing, lying very still, "fear" in their eyes, increased HR and RR. Kids can get hypercapnic from the rapid breathing. Also, the nurse can re-assess within a few minutes of administering meds and determine any changes in the signs/symptoms. If the med helped, you will know. And too, kids PREFER to be up and playing, rather than being zoned out on drugs. So they tend not to ask for meds. But with real pain, they get withdrawn and very still.

Specializes in ICU, CM, Geriatrics, Management.
Originally posted by Nurse 2

It seems we all have differing attitudes that effect how we act and react to pain.

I am an RN with many years experence, and am currently in the process of doing a paper for my MS in Biomedical Ethics. This paper will be on pain, not because I really wanted to do a paper on it, but at the strong urging from my thesis advisors. (Now I am actually interested in it)!

I'd be real interested to hear your thoughts on the ethics of willfully misinforming patients about the pills we've supplied them for their pain. (See previous posts in this thread.)

Specializes in ICU.

Larry no-one has stated that they misinformed patients of the midications I have and do USE a well known psychological effect to improve pain management. We all know that the placebo effect works and lateley there has been talk of the opposite effect - the nocebo effect where the patient gets LESS relief because they do not have faith in what they are taking. What I do is give them a reason to believe that the medication will work and will work well. If it does not work I add on something else.

Sometimes we are our own worst enemies - how often have you said to the patient - "Let's try this" or "Let's see if this works" setting the patient up fo distrust and the nocebo effect.

Does it truly matter if we have utilised a psychological effect to enhance pain relief? There is a vast difference in doing this to "willfully misinforming the patient about the pills you have given them"

From experience I have heard MANY men who would say "OH DARLIN, it's OK.. don't worry".... so yes you HAVE to look to the nonverbal cues.

I use the 1-10 scale to get them to quantify pain, and then obviously I look at the pulse ox readings, colour, looked for subtle SOB, posture, facial grimacing with lips the first to show "tightness" often, any diaphoresis, pulse rate increases, and then we also had to look at people who were talkative and outgoing who suddenly turned quiet or inward - as more men

than women did. If they could easily and effortlessly carry on a

conversation with me, I found they might be more anxious than with chest pain, but that rule didn't always hold either.

When we are REALLY not sure with our chronic CPs, I had a few docs that would go for the NS placebo and see if that "relieved" their pain.

Sometimes what pts DON'T say is louder than what they DO say....

Specializes in ICU, CM, Geriatrics, Management.
Originally posted by gwenith

Larry no-one has stated that they misinformed patients of the midications ..."

Hi, Gwenith. Thought I read a few posts back about someone giving a patient iron pills and stating they got a script from a doc for them.

Moreover, the spirit of what I was getting at also includes the ethics of not telling patients the total truth (please see your post) about their "meds."

Heck, doesn't the fact that people are entrusting us with their health make the above, at least, somewhat questionable and in conflict with universal principles underlying the philosophy of ethics?

I say let's be upfront with those we care for. And if another modality is needed, then let's make the appropriate referral(s).

Specializes in ICU.

Larry let me try to explain again - what I do is when and only when I see in a patients face - the look that says " I have pain and she has only given me Panadol (Tylenol)" and I know that panadol will in all probability ease the pain - I give the patient reason to believe in the drug. I foster confidence in a good outcome.

The placebo effect is so well known in research and is the reason why we do "double blind" trials - it is because the persons ability to believe that they will get better helps them to do so.

Now there is a difference between helping a person believe they will get better to handing them a sugar pill/iron tablet and telling them that will work. I am sorry if I gave the impression that I would ever contemplate that - I would not as not only is it illegal here in Australia to do so but it is unethical and immoral.

When I use the placebo effect I am attempting to utilise a holistic approach and deal with the psychology and beliefs about pain as well as the primary chemical effect. I hope I have made myself clear.

Specializes in ICU, CM, Geriatrics, Management.

G -- Appreciate your clarification.

Can sense by your expanded explanation above, particularly paragraph three, that we're both on the same page on this.

Purplemania, you are correct in saying that peds patients show pain in many ways. I am an adult and have worked with patient's who have had pain issues as a reason for admission. I finally got tired of hearing nurses say that they are just looking for the meds because they are 'addicts' or their behavior is not what is normally conducive to pain. Well, unfortunately I became a chronic nonmalignant pain patient as a result of multiple abdominal surgeries as well as the impossibility of resurgery for the removal of massive adhesions that can be palpated from the surface. A surgery unless life threatening I am not to have any surgery from the neck to the thighs. Adhesion removal could be just that. There is one principle to keep in mind with adults when a patient is an addict they are looking for a high but a pain patient is looking for relief. I have had pain medication and then will walk as a diversion or use guided imagery. I have used conventional as well as alternative medicine in order to control the pain. A recent qualitative and quantitative study was done and it showed that ER nurses estimate the patient's pain to be 1 to 1 1/2 pts lower than the patient's evaluation with the floor nurse having an even larger distance. The closest was critical care which was almost the same. Why is it society or our own disbelief of patients. I know people who can joke and all and it is used as a diversion and then they use other activities to distract until they get some relief. I have been through a pain management clinic using tricyclic antidepressants, and started with Tylenol on a regular schedule. This was about 10 years ago. I am now wearing Duragesic 100 and still have breakthrough pain. I have been assessed abdominally and it can be excruciating. The board certified pain management practice I go to have two physicians and I have seen both before even contemplating the implantation of a pump. They both concluded that it would be the only route left. When you are disabled there are only so many things one can do and a little bit of comfort would be appreciated. I will be turning 50 soon and already faciing a total knee in the next few months. It one looks one will find that Duragesic 100 is over 300mg of morphine orally every 24 hours. I don't want to go this route but after 10+ years there is little time to enjoy even visiting family members that live locally.

Many times when I have been a patient in the hospital I have had nurses who had the attitiude about pain management. I truly believe that for someone who doesn't have a pain problem doesn't understand the concept. Many times I have not even been asked about a level or where the pain is located, the length of time for staff to respond and yes I am aware of the shortage.

I have reported a hospital ER for not even addressing the issue as well as using a PA-C who did an exam incorrectly. I also blame much of this on a lack of education. This includes physicians who have not worked with patients with this condition. Also, many believe for patient's who have a pump shouldn't have any pain for any other problems. Not true, the pump is to maintain the present chronic pain issue but not an abcessed tooth or a broken ankle. I was given an antagonist in an ER while using the Duragesic. I was unaware at the time that Nubain was. I was then told I was having an anxiety attack or a panic attack when in fact I had been sent into narcotic withdrawal within a few moments. It took Ativan 3 mg IV to atart to bring calm to the withdrawal. No I don't go to ERs al the time for pain management. I have been to an ER 3 times in 4+ years. That is not what I call drug seeking. Having worked in an ER even 20 years ago lists were kept of patients that came in for pain meds and it was routinely circulated with the other hospitals in the area.

My primary has said that if I ever have to go in again to call him first and tell them that I am to have only morphine. Just think about that. How would you respond to a patient who asked for morphine. I bet it would be very slow in coming even if the primary is contacted.

I know someone who had over 30 surgeries and has a pump but she went to an ER and no matter what for those who don't understand the response is "Well, look at all the meds you are on" Not the fact that you have a headache and you blood pressure is conciderably elevated. Society has caused us to believe that individuals needing narcotics must be an addict particularly since we had and still have the street drugs that cause addiction.

Pain also affects other physical and mental health issues. I know of individuals who have all but commited suicide because they felt they could not handle another day as they had no l ife so why stay around. It is truly unfortunate that someone has to go to that extent to get help or even more unfortunate if they suceed in their act.

I have participated in double blind studies as well as help to for a pain assessment form to be completed by the patient. If a patient is in pain that is not relieved even with an increase in meds, pt, massage, guided imagery, chiropractor, etc then they get a pain management consult then if not sooner.

After pounding the corridors for more than 20 years I had painful feet all the time. I thought it was because of the hours. Well it turned out to be neuropathy which has since progressed up my leg leaving some areas dull when touched. One was of diversion was that I returned to school and completed my BSN this month. The pain is definitely affected by weather or fatigue.

My discription of pain is like having a fractured ankle, foot, and all toes at the same time and told to take a baby aspirin. In the course of a day I can use up a full bin of the ice maker.

For me, when I am in pain I tend to talk more at a faster rate or become quite, I will walk if necessary until the med starts working and then I confine it to a certain, If a light switch is close by or I can get someone to shut the lights of and partially close the doors practice guided imagery which I have done for years and can actually smell the floral of the site and hear the brook or as an alternative I use centering prayer and place the pain in the precious hands of the Supreme Healer.

Yes, I have had a placebo and was honest on the "relief or lack of relief" I have had. I have even participated in using new meds to see if something would help me or someone else through a follow up survey. I have even worked with new chronic pain patients that my primary has asked me to speek to. I do have a signed agreement that I would not recommend any specific med or procedure as it is different for each. I also have a signed agreement with the doctor who prescribes my meds. Even with the knowledge I have through all of this I would not even begin to seek another doctor for any meds as I know have a seizure disorder that has become more prominent over the past few years. I also don't use any type of alcohol for fear of increasing or decreasing the effect of any medication.

As nurses it is our responsibility to advocate for the patient. If we begin to question or mistrust what a patient tells us then how can we be effective care givers. By the way a high percentage of patients who are given placebos are not dumb and know that they have been given one. The reason is if it is "effective" the duration is shortened each time and depending on how many times it is "used" on a particular patient the more distrust there is with staff and the physician. Is this the role we are suppose to b

I would recommended that it would be in nursing's best interest to educate oneself on proper pain management. Some sites are AAPM as well as other professional studies etc

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