Rethinking Pain Assessment - page 4

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... Read More

  1. by   gwenith
    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.
    Last edit by gwenith on Jan 5, '04
  2. by   purplemania
    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.
  3. by   Havin' A Party!
    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.)
  4. by   gwenith
    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"
  5. by   mags-rn
    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....
  6. by   Havin' A Party!
    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).
  7. by   gwenith
    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.
    Last edit by gwenith on Jan 5, '04
  8. by   Havin' A Party!
    G -- Appreciate your clarification.

    Can sense by your expanded explanation above, particularly paragraph three, that we're both on the same page on this.
  9. by   Enabled
    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
  10. by   beckabeckahi
    Quote from Brownms46
    Example if you're tired enough, you will go to sleep, and you can wake up with the same pain you went to sleep with. I was able to laugh and talk with people, and be totally ready for them to leave, but never said a word, unless they stayed beyond my ability to control my facial expressions.
    I couldn't agree more, I am a person with a grin and bear it attitude and there are many times I have been in great pain and no one knows the difference. For example when I was in labor, instead of yelling and screaming like many do, I was completely quiet and the midwife asked me "Are you SURE your ok?"
    No I wasn't ok, but I wanted to be 'tough" ( and yes I do know this isn't particulary good for my mental health).

    My point is some people (my husband and kids) will get a paper cut and howl in pain. And others will be very ill and continue on with day to day routine. So there absolutely can be a contradiction between what a patient says and what you see.
  11. by   Iamjustme
    This issue seems as though it will never be resolved. I have had chronic pain for the last 2 years, and have dealt with nurses and Dr.s doubting my pain. In the beginning most doc's are sympathetic, but that changes in time. I do feel there is fear with the DEA regulations. I worked in LTC and had residents who had chronic pain and some res. would exp. acute pain for various reasons. As far as my addressing their pain scale I would use numeric scale or faces. Usually thier movements alone would give me the info. needed. When a resident c/o pain I give them their prn which they have been using and what has been effective for them, and reassess in 1 hour. I wish the medical community would quit being judge and jury when it comes to pain issues. I thought pain was subjective and what the pt. states his pain to be. Why is there such a problem with some staff to just give the medication? It is ordered ...so use it if needed. Chronic pain pt.s have to go through the fear of being judged whenever they see a new Dr, or a visit to the ER. Not Fair!! How do you think that makes us feel? Sometimes I feel like just giving up because it is so difficult finding a Dr. who truly believes you. Pleases nurses out there,,,think about this the next time someone wants a pain pill. They hurt...so just give them their pill! I realize there also is the issue of abuse, but does that mean everyone will be looked at as a druggie?????:uhoh21:
  12. by   FutureNrse
    Quote from angelbear
    Oh I love this one. I have fibromyalgia so I pretty much always have pain. I feel that I am pretty good at rating it but I dont trust that the care provider understands 1-10 the same way I do. For example: to me 1 is a mild and slightly annoying headache or pressure and 10 is full blown labor. My normal pain level is about a 3 for which I take vicuprofen on a regular basis. When it becomes a 4 I will add tylenol a 5 means I am headed for trouble and 6 is probably going to be hard to get back under control. If it is a 7 I am not very rational. I hate going to ER because I know fequent flyers are considered drug seekers and if I go in and say listen I am at a 5.5 toradol is not going to work and if I dont get demoral or dilauded pretty damn quick that isnt going to work either. They look at me like I am a bother. But ya know what I have constant pain so that is my normal state and I know where I am with it and what I need and I dont like to waste time with stuff I know wont work. Ok done with that one. Now as for my observations, I work in a facility for profound mental retarded with multiple physical disabilities most of them are not verbal. We have one guy who when in pain becomes very ornery running all over the building and pounding on things that is how we know he is in pain. Another one chants in sing song fashion. Another one moans real deep and it sounds like a cow is mooing. I have learned alot at this facility about assessing pain in the non traditional ways. Awesome thread if I think of some more is it ok if I continue adding them? Thanks Gwenith
    I was told recently that the general attitude at the ED I use is "If you're that informed, you're an addict". That infuriates me. If a patient deals with pain on a daily basis, who better than them to know what will work and what won't? Something has to be done about this for chronic pain patients. I've read a post about patients carrying a card identifying then as cp patients, that contains info essential to thier treatment in the ED. What about having the doc fax a document to the ED that the patient preferrs containing all pertinent info? It would save the nurses, doc and patient much time. It could save the patient unnecessary pain. It would keep them from being labeled a drug seeker and treated poorly.
    For as much as everyone says, pain is what the patient says it is, that does not mean that they are really treated that way. I'm sure everyone will hate to admit it, but there are vindictive docs and nurses, that will make sure that a patient is given a pain med that is not adequate for what they say the pain is. Or offer them a med that they have already clearly stated doesn't work, or makes them ill and then tell them to take it or leave it. For example, Toradol makes me vomit and itch like mad, so if it is offered to me I am not going to take it. Do they think that they are funny when they do this? Do they enjoy having so much control over another persons pain level, and abusing thier power?
  13. by   UM Review RN
    Quote from FutureNrse
    For as much as everyone says, pain is what the patient says it is, that does not mean that they are really treated that way. I'm sure everyone will hate to admit it, but there are vindictive docs and nurses, that will make sure that a patient is given a pain med that is not adequate for what they say the pain is. Or offer them a med that they have already clearly stated doesn't work, or makes them ill and then tell them to take it or leave it. For example, Toradol makes me vomit and itch like mad, so if it is offered to me I am not going to take it. Do they think that they are funny when they do this? Do they enjoy having so much control over another persons pain level, and abusing thier power?
    I doubt it. I think all they're trying to do is address your pain while at the same time, keeping you alive. No one likes to OD a patient, and most patients haven't got a clue about pain meds.

    Obviously, you do. More power to you. Still, you seem to have a great big chip on your shoulder about this issue, since every one of your posts since joining this board are about pain management and your views on it, instead of posts about going to nursing school, as your screen name would imply.

    So I have to ask: are you a nursing student? or a disaffected patient who wants to let us professionals know that you're having inadequate pain management? Because if that's the case, maybe you should be telling your doctors this, not addressing it on a nursing BB. After all, we do not have prescriptive powers, and no matter how cross-eyed the nurses look at you when you need pain meds, we basically can't do more than give you what the doc orders.
    Last edit by UM Review RN on Feb 5, '05

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