Getting a patient to use the numerical pain scale should be easy, right? Pick a number from one to ten with one being just a little bothersome and ten being the worst pain you have ever felt or imagined. Seems pretty straighforward to me.
But my patients sometimes look at me as if I've asked them to add the square roots of their children's birth dates and round to the nearest hundredth.
They stare at me and scrunch up their faces as if this is a scary pop quiz and they don't want to get it wrong. After a ten or fifteen seconds of agonizing, I get answers like, "Not quite a four and a half," or, "sort of a six," or, "somewhere between a two and a seven."
We all know about the 10/10 folks who want every prn measure available the second they can have it. But this other group seems really cowed by the complexity of the question. I've seen the same expression on people who have just been told they have to do a dozen algebra story problems. I feel for them. I really do. Sometimes I have even said, "Don't put yourself into a tizzy over this," and reassured them that they aren't being graded. Not even on a curve.
When I offer the pain faces as an alternative, I'm not sure if the face they pick matches their actual medical discomfort or if they are expressing the psychological intimidation they feel about having to choose the exactly appropriate not-so-smiley face.
It's not a big deal. We work it out and they get the meds they need. I'm just periodically amazed/amused at the overwhelming burden picking a pain face or number seems to put on some patients. Makes me wish I could offer them some light sedation before putting them through the ordeal.
Forgive me: nursing school was a long time ago & I work with non-verbal patients, but....
This thread has clearly demonstrated the myriad of reasons the 0-10 is inadequate. So who said that we had to use a scale? Was it the Joint Commission? Why not ask: none, mild, moderate or severe AND tolerable or not tolerable? Then medicate and ask: better, same or worse? How effing hard is that and why is that not adequate?
Perfect!! (That's what I was trying to say but you said it so much better).
I fear there might be too much common sense in that idea though.
I had shoulder surgery once before I was a nurse. It was outpatient and I was waiting to be able to pee before they would let me leave. When they asked about pain I said 6. It was expected pain to me and it was annoying but not intolerable. The nurse gave me morphine 3 times and it didn't really change how it felt when I moved, but I told her I was fine and didn't need anything else even though it still hurt the same.
For some reason, she called anesthesiology and this dr. comes in. With the nurse in the room, he says, "They tell me you're saying your pain is a 6. You don't look like a 6, you're smiling." I told him I didn't ask anyone to call him, that I was just sitting here waiting to be able to PEE, I didn't ask for any pain medication and I didn't care if I never got any pain medication again, and sooooo sorry to have someone waste your time but I didn't ask you to be here so you can leave now.
He left and wrote for them to push Toradol. Weirdo.
Also, for my verbal/coherent patients my pain rating for someone who looks/acts like they're in pain or has a normally painful condition goes something like --)
"Hey, you hurtin' right now?"
"Yeah."
"Where at?"
Blah blah.
"Is it real bad?"
"Yeah."
Since I'm sooper nurse who has checked the next time said pt can have pain meds (and if they have in the past and how much)...and the pt CAN have pain meds (otherwise I'm all like let's reposition/ice/heat/turn on the tv)
"Aight. You have scheduled pain meds which I saw on your chart that you last took X hrs ago. Now, did these help your pain at all last time they were given?" (If pt seems hesitant or otherwise states no) "I'm asking you this because I don't want your pain to be under-treated. If XYZ pain med isn't helping your pain, I need to let the doctor know."
This puts the onus on the doc to deal with a drug seeker who is upset 'cause they ain't getting 5 mg of dilaudid q2h and not me (Just following orders!) It also helps to identify folks whose pain simply isn't being controlled.
I do have issues with patients who play their PCA button like it's a video game controller. "Hi, it says here that you pushed your button 250 times in the last hour..."
As someone else already said, that is because it is true for some.
I've heard nurses say they won't medicate until the pain is 4/10.
As everyone is saying, this is so completely subjective.
I want my patient as pain-free as possible. Don't give me any "he'll get addicted" crap.
I'm with you. I work on a post op floor, so generally my patients are in pain. I don't care what their number is, if they're hurting, I'll give it to them if it's safe to do so.
I generally go with the mild, moderate, severe and then when I reassess I ask if it's better, how much.
I swear I think some of them think that if they don't give a high enough number we're not going to give them the pain medication.
As others have pointed out this is actually true for many patients. The trendy new way to define prn pain control is that patients only get certain meds and frequencies based on their 0-10 pain score, assuming that pain scores are universal. The fact that the Nursing profession has largely accepted this moronic system is one of the great embarrassments of modern Nursing.
The numeric rating scale can be helpful as a gauge of intensity over time, but it's certainly not infallible. It is merely one potential tool for assessment. I like that it's less writing to merely put 5/10 vs. "pt states moderate throbbing pain in R knee is still intolerable, and only slightly improved since previous hydromorphone dose" every single time I assess pain.
I absolutely loathe the concept of rigidly basing interventions off of a pain rating--it's far from best practice. Sure, the patient's pain might be 2/10 right now, but the local's just starting to wear off and the 250 mcg of fentanyl he received intra-op will be wearing off soon. It would be prudent to start him on some longer acting pain medication. If I worked at a place that stupidly used such a system I would complain day and night until it got changed or they fired me.
I manage pain very aggressively. My attitude is more to look for reasons to NOT give medication as opposed to reasons to give it. Unless the patient is completely pain free (e.g. had a spinal or a block), drowsy, or having significant problems with breathing or BP I'm going to give at least some pain medication. Even with those I'm going to try to do something for pain (optimal positioning, NSAIDs, start on oral pain meds, ice, etc.). When possible I try to prevent pain rather than chase it around.
Think of pain management like glucose management. You prevent blood glucose from getting out of whack, not just react to it when it does.
I agree with above. I remember a couple years ago at my facility, they weren't going to allow more than one prn pain med to be ordered at a time. Meaning, instead of using my judgment (you know, that comes out of my itty bitty wittle nurses bwain) to decide, ok, let's switch to PO now, we'd have to call the MD. Do you think that idea was killed because someone realized nurses were smart enough to choose between two pain meds and to not give both of them if the respirations were down to 2? Nope, the docs didn't want phone calls.
Pain management is the most ridiculous fiasco we have going in medicine. The BS about it being a "vital sign" (because why not put a subjective number in the middle of objective data?) The BS about they can have dilaudid if it's rated a 9 or a 10 but only tylenol if it's rated 1-8 because it's much much better to base pain control on a made up number than on a nurse's judgment. The fact that people who really hurt can't get sufficient pain relief but a junkie can walk into any ED and walk out with a handful of vicodin. It's only going to get worse folks...
Well, for the record, I medicate for pain. Not for the number. Do I believe you that it is as severe as you say it is? Not always. Am I convinced some drug seekers will say/do/act anything? Yep. But my docs are as in tune with that as I am, and won't prescribe narcs when they aren't called for (at least most of the time). We work together, sometimes ask back and forth about what is the best thing to do in an individual case.
So for the paper pushers at JCAHO there are numbers. For the human in front of me, there is reality and individuality.
Getting a patient to use the numerical pain scale should be easy, right? Pick a number from one to ten with one being just a little bothersome and ten being the worst pain you have ever felt or imagined. Seems pretty straighforward to me.
But my patients sometimes look at me as if I've asked them to add the square roots of their children's birth dates and round to the nearest hundredth.
They stare at me and scrunch up their faces as if this is a scary pop quiz and they don't want to get it wrong. After a ten or fifteen seconds of agonizing, I get answers like, "Not quite a four and a half," or, "sort of a six," or, "somewhere between a two and a seven."
We all know about the 10/10 folks who want every prn measure available the second they can have it. But this other group seems really cowed by the complexity of the question. I've seen the same expression on people who have just been told they have to do a dozen algebra story problems. I feel for them. I really do. Sometimes I have even said, "Don't put yourself into a tizzy over this," and reassured them that they aren't being graded. Not even on a curve.
When I offer the pain faces as an alternative, I'm not sure if the face they pick matches their actual medical discomfort or if they are expressing the psychological intimidation they feel about having to choose the exactly appropriate not-so-smiley face.
It's not a big deal. We work it out and they get the meds they need. I'm just periodically amazed/amused at the overwhelming burden picking a pain face or number seems to put on some patients. Makes me wish I could offer them some light sedation before putting them through the ordeal.
:lol2:! You captured the phenomenon so clearly. I am printing this thread, saving it, and using it for giggles later.
To add, a favorite of mine are those times when I ask a patient to describe the pain...and they look at me like I have asked them to solve the origins of the universe.
I work in peds so I'm in a situation where developmentally, a patient should be able to answer the question, but in reality, they just don't get it. I remind my patients that I cant feel what they feel, so they have to tell me how bad they feel so I can help them. Often what I'll ask them is if their pain is a little, medium, or a lot. A 3-step scale seems to be easier to understand for patients who look at me like I have two heads when I ask them to give me a number. And really, our treatment is based on mild, moderate and severe pain, so I find a "medium" answer is just as helpful as a 4, 5 or 6.
:lol2:! You captured the phenomenon so clearly. I am printing this thread, saving it, and using it for giggles later.
CompleteUnknown
352 Posts
Perfect!! (That's what I was trying to say but you said it so much better).
I fear there might be too much common sense in that idea though.