Rethinking Pain Assessment - page 5

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   FutureNrse
    Quote from 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:
    I couldn't agree more. Maybe medical professionals should also ask themselves if it's worth the risk when they don't give pain medication. If the person really is an addict and a drug seeker, then you have merely given them one fix. In the scheme of things, is that such a big deal? Wouldn't you rather possibly make a druggie happy than make a true pain patient even more miserable? And if you can manage to give the shot/pill without the eye rolling and dirty looks, we'd really appreciate it.
  2. by   FutureNrse
    Quote from Angie O'Plasty, RN
    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.
    If you've read all of my posts then you know that I have said very plainly that I am not a nurse or a student. I am a social worker. Because of what I've learned here and at a couple other sites, and because of my own experience with chronic pain, I have decided to go into patient advocacy. Yes, I do know quite a lot now because I've had no choice but to learn, and yes I can be quite rabid about this subject because of my own experiences and because the social worker in me just can't stand to see suffering. I am not disaffected, I assure you, and I do have adequate pain management now, it is my past experiences that are a problem, and obviously a problem for many others here as well.
    Last edit by gwenith on Feb 5, '05 : Reason: personal attacks
  3. by   UM Review RN
    Quote from FutureNrse
    You seem to be taking this very personally, is that because you have been guilty of mismanaging pain yourself? Or maybe you've just had a bad day. My statements weren't directed at you so I'm unclear on why you've taken such exception to them.
    I'm a professional. Managing pain is one aspect of my job, and I'm very good at what I do. I come on this board to learn new techniques, schmooze, hear new ideas, and in general, broaden my base of knowledge as a nurse.

    On the other hand, you're making assumptions about healthcare professionals that are insulting and make me question why you say you want to be a nurse. Comments like these:


    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?
    Since you have now clarified your goal as "being a patient advocate," instead of being a "Future Nurse," I have gained an understanding of what kind of information you seek from this BB and I can respond accordingly. Had you said you were a nurse or a nursing student, my response at this point would be very different. Thank you.
  4. by   mwbeah
    RECOGNIZING THE DRUG SEEKER

    Drug seekers often give away their intent, and most are poor actors whose scripts read much the same. An index of suspicion is the best starting point. If something in the patient's history or physical examination does not "feel" right, it probably isn't. The clinician must be attentive to objective findings in the examination that do not match the subjective history.

    Emphasis on a specific medication is a potential red flag: The patient may request it by name before the examination, describe it as the only effective treatment (going so far as to argue pathology with the provider), or claim that it is the only choice to which the patient is not allergic. The drug seeker may claim to have developed a tolerance to the medication and to need increased dosing. He or she may intentionally mispronounce the medication's name to appear innocent.

    The drug-seeking patient may bring along a friend to validate the history and confirm the patient's distress. Even an infant or a grandparent may be used to make the story more believable.

    Attempts to "dupe" can manifest as scams, sympathy seeking, aggression, or outright stealing. Scamming may take the form of a "doctor shopper"--a patient who sees multiple practitioners to obtain adequate supplies of a controlled medication. Doctor shoppers often present to the ED or urgent care clinic after hours with a fictitious scenario, such as rotted teeth, old war wounds, or lower back pain; being from out of town or recently moved to the area; lost, stolen, of ruined prescriptions; or complex insurance problems. (4,6,9,16)

    Sympathy is a ploy often used by patients with a history of a significant medical condition who have developed an addiction to their medication. In theatrical fashion, they give a current history fraught with social and subjective terms rather then objective medical facts. One might complain, "I ran out of my pain medication early because my grandmother has cancer and I gave her some," and another might claim, "I have such terrible back pain that I cannot take care of my children."

    Some drug seekers are overly friendly, striving to win over the prescriber. Others may become noisy, aggressive, or disruptive, hoping the practitioner will do "whatever it takes to get them out." Those who are refused may curse and slander the office and staff in a last-ditch effort to wear down the provider.

    The drug-seeking patient may resort to theft. Clinicians should carefully guard prescription pads, name stamps, and DEA numbers--all highly prized items for the patient who is willing to bypass the system altogether. Drug seekers will use the phone and masquerade as pharmacists, insurance agents, or health claims adjusters to obtain a prescriber's DEA number--or a prescription. (9,16)

    The drug seeker's relationship with the medication is clearly much more important than that with the provider. (9) Thus, even when the patient steals, providers must remember not to take drug-seeking behaviors personally.

    THE CONFRONTATION

    Once the drug seeker has been identified, the greatest obstacle for the clinician is to confront him or her. It must be made clear that no means no. (9) The clinician who gives in to pressure once can count on reliving the scene many times.

    At the outset, the patient has all the information, and the provider has little. To regain the advantage, the practitioner must obtain information that either verifies or nullifies the patient's history. Interactions can then be based on facts. Of the many ways to get this information, all take some legwork, but the clinician's decreased anxiety and the potential benefit to the patient are worth it.

    (hope this article helps)
    Mike
  5. by   mwbeah
    What to Ask the Patient

    Three questions asked during the history and physical examination can be useful in determining the legitimacy of a patient's complaint:

    * When was the last time you were seen for this condition?

    * When was the last time you were seen by any health care provider (including EDs, minor emergency centers, clinics)?

    * What was the last medication, including narcotic prescriptions, that you had filled? Where? When?
  6. by   FutureNrse
    The drug-seeking patient may resort to theft. Clinicians should carefully guard prescription pads, name stamps, and DEA numbers--all highly prized items for the patient who is willing to bypass the system altogether. Drug seekers will use the phone and masquerade as pharmacists, insurance agents, or health claims adjusters to obtain a prescriber's DEA number--or a prescription. (9,16)

    I've received prescriptions with the DEA number printed on them. Is this unusual?
  7. by   PA-C in Texas
    Well this is damned if you do, damned if you don't; as I've said before. They may sue you for not adequately treating pain, and they may sue you for contributing to their addiction. So let's just ignore the legal aspects for a moment and concentrate of providing the best medical treatment.

    The logical extension of the argument presented here is that you should continue giving a patient opiods until you max them out. If they say they have pain, you should treat it until it goes away. WRONG. "Pain is what the patient says it is." That's nothing more than a regurgitation of a simplistic cop-out.

    I get to use my judgment to determine what a patient's pain level really is and to decide on the best course of treatment. When a patient is complaining of 10/10 pain, and they are laughing and eating a Snickers (except when you are in the room), it is very appropriate to ask the tough questions. "Why does it seem like you are feeling much better when I pass by your room, but you seem a lot worse when I come in?"

    It is also appropriate to assess the physiological signs that accompany pain when making a decision. If someone is stating 10/10, but their general affect does not suggest distress, their pulse is 72 and their BP is 118/64, something it needs further investigation. If their symptoms seem out of proportion to their diagnosis, they might need more pain medication, but they need a more detailed workup also. I tend to err on the side of treating the pain. In fact, I developed the reputation of being very liberal with regards to narcotics. But my good will and concern is not infinite, and a stupid saying like "pain is what the patient says it is" is not a substitute for good medical judgment.

    So- "Who are you to judge a person's pain?" I'M THE ONE WITH THE DEA NUMBER!

    ---------

    "Sedation does not equal analgesia". That's another little gem, and it never fails that someone spouts that off when giving phenergan with a narcotic is mentioned. But statements like that discourage critical thinking about the topic. It's a tool for the weak minded. I agree that the best evidence today suggests that pain relief is not enhanced by the addition of a sedative. However, I am not fully convinced on the subject. Why? Because pain is incredibly difficult to study. It is difficult to quantify, and we can't even seem to account for it in a qualitative sense. Someone else made the comment that being asleep does not equate to pain relief. That may be, but I am not convinced of it either. Anesthetics and amnestics do have a role in managing pain, or else we wouldn't be giving midazolam for minor oral surgeries and we would be cutting people open while they were awake. If someone is able to sleep well, then that is effectively the same as administering an amnestic- THEY DON'T REMEMBER. Yes, they may wake up in pain. But I woke up in pain after I had my wisdom teeth removed.

    What I would like to see is some polysomnographic data on people who are given sedatives as an adjunct for pain control. We know that the sedatives will effect sleep architecture. Does a painful condition similarly effect it? That is something I would like to find out.
  8. by   leslie :-D
    Quote from PA-C in Texas
    Well this is damned if you do, damned if you don't; as I've said before. They may sue you for not adequately treating pain, and they may sue you for contributing to their addiction. So let's just ignore the legal aspects for a moment and concentrate of providing the best medical treatment.

    The logical extension of the argument presented here is that you should continue giving a patient opiods until you max them out. If they say they have pain, you should treat it until it goes away. WRONG. "Pain is what the patient says it is." That's nothing more than a regurgitation of a simplistic cop-out.

    I get to use my judgment to determine what a patient's pain level really is and to decide on the best course of treatment. When a patient is complaining of 10/10 pain, and they are laughing and eating a Snickers (except when you are in the room), it is very appropriate to ask the tough questions. "Why does it seem like you are feeling much better when I pass by your room, but you seem a lot worse when I come in?"

    It is also appropriate to assess the physiological signs that accompany pain when making a decision. If someone is stating 10/10, but their general affect does not suggest distress, their pulse is 72 and their BP is 118/64, something it needs further investigation. If their symptoms seem out of proportion to their diagnosis, they might need more pain medication, but they need a more detailed workup also. I tend to err on the side of treating the pain. In fact, I developed the reputation of being very liberal with regards to narcotics. But my good will and concern is not infinite, and a stupid saying like "pain is what the patient says it is" is not a substitute for good medical judgment.

    So- "Who are you to judge a person's pain?" I'M THE ONE WITH THE DEA NUMBER!

    ---------

    "Sedation does not equal analgesia". That's another little gem, and it never fails that someone spouts that off when giving phenergan with a narcotic is mentioned. But statements like that discourage critical thinking about the topic. It's a tool for the weak minded. I agree that the best evidence today suggests that pain relief is not enhanced by the addition of a sedative. However, I am not fully convinced on the subject. Why? Because pain is incredibly difficult to study. It is difficult to quantify, and we can't even seem to account for it in a qualitative sense. Someone else made the comment that being asleep does not equate to pain relief. That may be, but I am not convinced of it either. Anesthetics and amnestics do have a role in managing pain, or else we wouldn't be giving midazolam for minor oral surgeries and we would be cutting people open while they were awake. If someone is able to sleep well, then that is effectively the same as administering an amnestic- THEY DON'T REMEMBER. Yes, they may wake up in pain. But I woke up in pain after I had my wisdom teeth removed.

    What I would like to see is some polysomnographic data on people who are given sedatives as an adjunct for pain control. We know that the sedatives will effect sleep architecture. Does a painful condition similarly effect it? That is something I would like to find out.
    first i'd like to point out that vs are not always a viable indicator of a pt's pain status. acute pain will increasse the vitals; chronic pain will not.

    i'm not sure exactly what you're asking in your last paragraph. but what i will tell you is as a hospice nurse, i have seen many patients sleep and be in pain. their faces are not relaxed, brows knitted together, and this is on ativan, xanax or valium. but for effective analgesia to be attained, (i'm talking about my end stage ca pts), you need a narcotic such as morphine, oxycodone, fentanyl, dilaudid which will travel to the appropriate opioid receptors and do what they need to do. and i frequently have a talk with the doctors that prescribe mso4 2 mg. for bone ca.....and i do tell them that i intend to document the poor effect in my nsg notes and how the md did not want to prescribe anything more....that's when they ask what i want for them.
    but back to the original point, yes yes yes, pts can sleep and be in pain. it is not a restful sleep at all.

    leslie
  9. by   z's playa
    As most of you know, I talk a great deal about the migriane pt being one myself and I ran into a sad situation one month. I was in the ER for another migraine after self treating at home for 3 days. (I wait before going) Well in walks Colonel Sanders (I swear he looked just like him) and he has no clue who I am, no hx, and I think he was deaf. My pressure was 193/103. Res. 25, pulse 112. I was getting dehydrated too. Well he proceeds to order me a whole slew of things that I know will result in nothing seeing as I had already taken them at home and told him so. I asked to be seen by another doctor who knew my case. It was agreed. I was treated and released 20 hours later.

    My question..didn't vitals reflect pain in this case?

    You know how he explained my VS? He said "Everyone 's pressure goes up a bit when they come to the ER." I heard of white coat syndrome but come on. No one under the age of 80 should have a pressure of 190/103 :chuckle

    I agree too that many older women try to be too brave with my mom being one of them. After her hysterectomy I had to ask the nurse to ingnore my mom's denial of pain and please push her to ask for pain meds. She did relent twice in the end.
    Last edit by z's playa on Feb 20, '05
  10. by   mwbeah
  11. by   Traveler
    Z, I am so glad that you were able to see someone at the ER who knew your history. You were very lucky to get the treatment you needed. Your vitals should have been a clue yes. What is scarier to me is patients who suffer chronic pain- often vitals don't show any change at all. Pain is a tricky thing to deal with. I have been in a great deal of abdominal pain for over a year. After being put on higher and highter doses of meds I finally demanded a referral to an interventional anesth. for a nerve block. It worked wonders. It wore off after about a week though but I am scheduled to go back this week (They think it's due to entrapped nerves from three open abd. surgeries).

    On the other side of the coin, I have a home health patient who complains of severe abd. pain. Of course on my first visit I felt an immediate kinship with her because of my history. I stepped back from the personal side of the situation and tried to do an overall assessment. Keep in mind this lady is on Duragesic patch 75 and hydrocodone 10 for breakthrough. She was begging me to call her MD and get him to rx something. She had been to the ER the previous weekend. Upon doing the assessment I asked her how she slept at night. (I know that when I am hurting badly I don't sleep well and pain scenarios even show up in my dreams since I am hurting so) She responded that she slept just fine. When I asked her to pinpoint the site of pain she couldn't really do that. I then began to wonder. I told her the best I could do was to call her MD and get an appt. for the next day. Her response was: "I don't know if I can make that appt." She did go the next day and he got her in with a pain specialist for the next day as a favor. The day after her appt. with the pain MD I went back to see her. I was really hoping that this MD would do a procedure like I had done and not just rx more narcotics. I was wrong. She was on the Duragesic patch and Actiq which she said did nothing. I began thinking she just wanted to be knocked out. When I counted the Actiq she should have used 3 based on the rx. She had already used 10.

    Pain mgt docs often have pts sign a contract saying they agree to not get any other meds for pain from other docs. First thing she asked me was: "Should I get these refilled from my regular doctor?" One bottle was for Demerol and the other was for Percocet. I told her no and to just let her pain doctor follow her pain and to call him if it was still unrelieved. "But I don't have his phone number, can you call him?"

    I'm trying to be understanding especially since I have had chronic unrelieved pain but I htink this little lady being very manipulative and abusing her meds. How can one be unbiased in a situation like this. Did the doctors get her hooked or is her pain really untreated. Really she is on enough meds to put down a racehorse. I am having a really hard time believing anything she says. What does one do with patients like this?
  12. by   PA-C in Texas
    Quote from earle58
    first i'd like to point out that vs are not always a viable indicator of a pt's pain status. acute pain will increasse the vitals; chronic pain will not.

    i'm not sure exactly what you're asking in your last paragraph. but what i will tell you is as a hospice nurse, i have seen many patients sleep and be in pain. their faces are not relaxed, brows knitted together, and this is on ativan, xanax or valium. but for effective analgesia to be attained, (i'm talking about my end stage ca pts), you need a narcotic such as morphine, oxycodone, fentanyl, dilaudid which will travel to the appropriate opioid receptors and do what they need to do. and i frequently have a talk with the doctors that prescribe mso4 2 mg. for bone ca.....and i do tell them that i intend to document the poor effect in my nsg notes and how the md did not want to prescribe anything more....that's when they ask what i want for them.
    but back to the original point, yes yes yes, pts can sleep and be in pain. it is not a restful sleep at all.

    leslie
    That's what I want to know, and I believe a study that looks at polysomnographic data will be able to more thoroughly characterize the quality of sleep that a patient has when in pain. We also need to remember that this is a partially-induced sleep, and may be different from a person just falling asleep without being sedated. If someone has frequent awakenings or a their sleep levels are disrupted when they are in pain, that would be good to know.
  13. by   FutureNrse
    Quote from Traveler
    Z, I am so glad that you were able to see someone at the ER who knew your history. You were very lucky to get the treatment you needed. Your vitals should have been a clue yes. What is scarier to me is patients who suffer chronic pain- often vitals don't show any change at all. Pain is a tricky thing to deal with. I have been in a great deal of abdominal pain for over a year. After being put on higher and highter doses of meds I finally demanded a referral to an interventional anesth. for a nerve block. It worked wonders. It wore off after about a week though but I am scheduled to go back this week (They think it's due to entrapped nerves from three open abd. surgeries).

    On the other side of the coin, I have a home health patient who complains of severe abd. pain. Of course on my first visit I felt an immediate kinship with her because of my history. I stepped back from the personal side of the situation and tried to do an overall assessment. Keep in mind this lady is on Duragesic patch 75 and hydrocodone 10 for breakthrough. She was begging me to call her MD and get him to rx something. She had been to the ER the previous weekend. Upon doing the assessment I asked her how she slept at night. (I know that when I am hurting badly I don't sleep well and pain scenarios even show up in my dreams since I am hurting so) She responded that she slept just fine. When I asked her to pinpoint the site of pain she couldn't really do that. I then began to wonder. I told her the best I could do was to call her MD and get an appt. for the next day. Her response was: "I don't know if I can make that appt." She did go the next day and he got her in with a pain specialist for the next day as a favor. The day after her appt. with the pain MD I went back to see her. I was really hoping that this MD would do a procedure like I had done and not just rx more narcotics. I was wrong. She was on the Duragesic patch and Actiq which she said did nothing. I began thinking she just wanted to be knocked out. When I counted the Actiq she should have used 3 based on the rx. She had already used 10.

    Pain mgt docs often have pts sign a contract saying they agree to not get any other meds for pain from other docs. First thing she asked me was: "Should I get these refilled from my regular doctor?" One bottle was for Demerol and the other was for Percocet. I told her no and to just let her pain doctor follow her pain and to call him if it was still unrelieved. "But I don't have his phone number, can you call him?"

    I'm trying to be understanding especially since I have had chronic unrelieved pain but I htink this little lady being very manipulative and abusing her meds. How can one be unbiased in a situation like this. Did the doctors get her hooked or is her pain really untreated. Really she is on enough meds to put down a racehorse. I am having a really hard time believing anything she says. What does one do with patients like this?
    Well, apparently there's something going in, since she used 3 times the amount of a med that she was supposed to. The hard part is going to be finding out exactly what the problem is. If I were you, I'd ask her about the pain meds. Ask her why she has taken more than she's supposed to. Her answer might tell you a lot. She may not realise that she took too many, or maybe she didn't understand the directions, or maybe she thinks she should take whatever she wants whenever she wants. Possibly, she's over medicated and not thinking clearly. If that's the case, then maybe her pain doc needs to do a little housecleaning. take away all of the pain meds, and start from square one. Since she's taking so many things, she's not opiate niave, it might be better to put her on a stronger duragesic patch, and only allow something mild for breakthough pain. She can't mess with the dosage on the patch, unless she wears more than one at a time, and if that's an issue then she shouldn't have access to additional patches. Her breakthough meds can be given in small amounts, with a stern warning that they must last her X amount of time because she will not get her next ones early. No excuses, not even the wild ones like dropping them in the toilet.

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