Deer in the headlights pain assessments

[rn/writer]

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.

[kanzi monkey]

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.

This really made me laugh :)

[dudette10, MSN, RN]

Or, in the spirit of who cares if we have to fill out yet another form, I propose the Misery Scale as an adjunct to the pain scale. My cut finger could 7 on the pain scale but 2 on the misery scale. My migraine could 6 pain/10 misery and my back pain could be 4 pain/7 misery.

So, what do you all think??

A million kudos! I love this! It addresses how much the pain interferes with normal functioning. A sliced finger might hurt a lot, but it is more annoying than anything, i.e. you can function by working around it. For migraines and back pain, they affect movement, social interaction, etc., and while the pain might be less on a scale, the limitations of life can work on the psyche.

It comes down to what pain can you live with and what pain affects your life.

ETA: Based on my husband's personality and enjoyments of life, he handled the pain of broken ribs much more than the pain of a recent tonsillectomy. Eating is one of his life's pleasures, and I've never seen him so frustrated with the pain. When he had broken ribs (about two weeks after they were broken), he was frustrated, too, but he was able to modify his movement enough that he didn't feel as if he was missing out on his life. He could eat, he could get dressed, he could shower, he could play with the kids (they were small at the time), and he was ok.

It comes down to what is important to you, whether the pain interferes with that enjoyment, and your own adaptability.

[dudette10, MSN, RN]

I know this has been addressed before in other threads, but at the risk of hijacking, I want to ask again.

Let's say you have a FF pt who has medically identifiable reasons for chronic 10/10 pain. However, they are already on dilaudid q4, and they still say 10/10 and are on the call bell on the dot.

These are patients who are walking the fine line between drug seeking and drug tolerance. I don't know what to do with them except repositioning for musculoskeletal pain and pushing the drug q4. During report, some of the nurses will refer to the patient as a drug seeker, but I always mention that the patient has a medically verifiable source of the pain and has lived with it for some time.

I have had a couple of patients like this, and I'm at a complete loss as to what to do beyond what I've already done! Maybe I just need to learn that you can't fix everything?

[Pepper The Cat, BSN, RN]

Let me post from my perspetive. I recently had surgery # 9 for an ongoing, chronic condition. I know my body. I started having pain post op in PACU. I told my (student) nurse I was having pain and would like somthing please. She ask me to rate it.

Now - the pain I was currently feeling was probably a 2 or 3. BUT - I knew if I caught the pain NOW if would prevent it from escapalating to a 9 or 10. I also knew if I said 2 or 3, I woudl probably get plain tylenol, rather than the stonger nacroctic that I really wanted because I knew the stronger nacrotic would prevent the greater pain wanting for me in the wings.

so - I told her my pain was a 5 - and got the narcotic.

If I had told her the truth, that my pain was only at a 2 or 3, I would have gotten plain tyelnol or nothing, and in an hour would have had a lot more pain. So - to avoid additional meds, I lied.

This is why I hate the "pain scale" - sometimes it it no about the pain the pt is having right now, but more about how to avoid the pain in the near future/

[beckster_01, BSN, RN]

I usually ask the patient to describe their pain before applying a number to it. For example I ask "what is your pain like right now?" I get responses such as "not bad," "pretty bad," "not as bad as before," or, if the patient knows what I'm getting at they will automatically number it. This way I can get a better idea of how the patient perceives their pain. I also feel that it helps the patient know that I am interested in their pain control, and I am not going to automatically give or withhold pain medication based on a number. Someone may say they have terrible pain, but only give it a 3, and other patients have said their pain level is "alright," and proceed to rate it as a 7. Regardless of the number my patient gives me, if they have any pain at all I will offer them their pain medication and ask them what they feel that they need (tylenol vs. oxy vs. dilaudid). Most of my patients are vascular, with severe ischemic/revascularization/phantom pain, or cardiac who can't move their arms or cough without having pain. I will give them whatever they want/need to do what they need to do to get better.

And, as always, the drug seekers are quite obvious, and a completely different story. But if they have a legitimate reason for being in pain, then I hold no grudges about handing out the narcotics.

[student987]

I am in nursing school but I am also a long time patient. I always have trouble numbering my pain on the pain scale. I have had my head sliced open (from ear to ear across the top of my head) multiple times. That was unbelievably painful. Now other things do not feel as painful compared to that, that does not mean that it is any less painful. I was in absolutely agonizing pain last week but was rating it a 4 because compared to the past pain of the head slice it was a 4 on the scale of 0-10.

[Perpetual Student]

Let me post from my perspetive. I recently had surgery # 9 for an ongoing, chronic condition. I know my body. I started having pain post op in PACU. I told my (student) nurse I was having pain and would like somthing please. She ask me to rate it.

Now - the pain I was currently feeling was probably a 2 or 3. BUT - I knew if I caught the pain NOW if would prevent it from escapalating to a 9 or 10. I also knew if I said 2 or 3, I woudl probably get plain tylenol, rather than the stonger nacroctic that I really wanted because I knew the stronger nacrotic would prevent the greater pain wanting for me in the wings.

so - I told her my pain was a 5 - and got the narcotic.

If I had told her the truth, that my pain was only at a 2 or 3, I would have gotten plain tyelnol or nothing, and in an hour would have had a lot more pain. So - to avoid additional meds, I lied.

This is why I hate the "pain scale" - sometimes it it no about the pain the pt is having right now, but more about how to avoid the pain in the near future/

If you would've told me or any of my hospital's PACU RNs (or any student under my watch who doesn't want me to drag her to the dirty utility room for a come-to-Jesus chat) you had pain you would've received some opiods (and some other drugs to include acetaminophen and an NSAID) unless you were having significant respiratory issues. We are knowledgeable and care about MANAGING pain, not reacting to it. Sadly, you're quite right that many nurses are very ignorant regarding appropriate pain management. Even if you completely denied pain we'd encourage you to take some oral pain meds (e.g. Percocet or Norco, not just acetaminophen, prior to discharge home or transfer to the floor unless we had reason to expect ongoing lack of pain.

These are patients who are walking the fine line between drug seeking and drug tolerance. I don't know what to do with them except repositioning for musculoskeletal pain and pushing the drug q4.

Q4H is a rather long interval between doses. Most patients will have little or no remaining relief from most IV opiods after that much time unless it was one heckuva dose. I would interpret them wanting the drug at 4 hours as seeking adequate pain relief.

[dudette10, MSN, RN]

IV dilaudid q4 for a chronic pain condition isn't enough? How do these people survive at home then?

[Perpetual Student]

IV dilaudid q4 for a chronic pain condition isn't enough? How do these people survive at home then?

Hopefully with longer acting opiods (e.g. OxyContin, MS Contin, methadone) and other treatments, as well as an immediate release medication for breakthrough pain. The duration of IV hydromorphone is around 2-5 hours depending upon dose, tolerance, metabolism, etc. At 4 hours many patients will no longer be having adequate (or perhaps any) relief, and they certainly are no longer having near as much relief as they did at the peak.

ETA:

I also want to mention that if the patients are stating their pain is 10/10 consistently you may want to look at what they're prescribed in the hospital vs. what they take at home. If it's a lower equianalgesic dose it would make sense that they're having inadequate relief and they should receive a more appropriate dose.

[CompleteUnknown]

I often wonder if some of these patients would have done better in the days where most things were given IM (because of the longer duration of action).

[beckster_01, BSN, RN]

For the type of patients you are describing I am a big fan of giving PO pain meds q4hours around the clock. Some nurses I work with won't wake a patient up for pain medication (if you are asleep you aren't in pain). Unfortunately, if you are asleep you can wake up in severe pain, and we wake our patients q4hours for vitals anyways. I hate playing catch up using IV medication. I have many people tell me that IV dilaudid doesn't relieve the pain, it just makes them not care about it. Using only IV medication for pain relief is unacceptable in my book (unless they are NPO)- it encourages dependence/tolerance and just does not last long enough for most patients. A patient with chronic pain will never go home on IV drugs, a priority for them is to work out an adequate pain regimen on po meds BEFORE they get discharged.

[Christy1019, ASN, RN]

I know this has been addressed before in other threads, but at the risk of hijacking, I want to ask again.

Let's say you have a FF pt who has medically identifiable reasons for chronic 10/10 pain. However, they are already on dilaudid q4, and they still say 10/10 and are on the call bell on the dot.

These are patients who are walking the fine line between drug seeking and drug tolerance. I don't know what to do with them except repositioning for musculoskeletal pain and pushing the drug q4. During report, some of the nurses will refer to the patient as a drug seeker, but I always mention that the patient has a medically verifiable source of the pain and has lived with it for some time.

I have had a couple of patients like this, and I'm at a complete loss as to what to do beyond what I've already done! Maybe I just need to learn that you can't fix everything?

Unfortunately there is no absolute solution to this problem but with time you will develop a stronger objective assessment which can help guide your decision making with what interventions you will perform. Although not every pt with chronic pain who is drug tolerant is also a drug seeker as they are so often mislabeled, there ARE pt's with legitimate chronic pain that have been on narcotic pain meds for a long time and are drug tolerant who are also drug seekers, whether they began misusing pain meds at some point for reasons other than pain and are now "chasing that high" in addition to treating their pain and preventing withdrawal. I've found these patients often are found to have multiple ER visits at different hospitals with multiple prescriptions for same narcotic each month and will pay out of pocket for it b/c insurance won't pay for that many scripts that frequently. they also tend to display manipulative behavior and try to bargain w/you for meds, i.e. "if you give me just one more dose of dilaudid and benadryl iv i'll be good and can go home" vs becoming agitated and uncooperative when offered PO or non narcotic analgesics, or will modify their behavior to what they think the nurse will appeal to whether its giving a long, dramatic sob story ranging from everything that hurts to how their grandma died and they lost all their money at the casino, etc. with hopes that the nurse will feel pity for them, or complimenting and trying to befriend the nurse to get favorable treatment. lastly, i've found a trend that the ones who have also become seekers have a past hx of non compliance with follow up treatment like physical therapy, surgical procedures, or other prescribed medications that they don't take because they say "that doesn't work for me", i.e. muscle relaxers and NSAIDs being refused by pt with chronic back pain, but will take narcotics and request higher doses. i'm not trying to stereotype anyone, just offering my personal experiences with your type of situation, and obviously every patient is different and shouldn't be pre-judged based on their past med hx.

In regards to what you do for those patients that you can't distinguish seeker or tolerant, first you are absolutely correct with non pharmacological interventions first, and as always you document exactly what the pt says his pain is, but still chart YOUR objective pain assessment as well. If there is no order for breakthrough pain meds, make sure to chart that you made the MD aware of the pt's continued pain score and whether he ordered anything else or not, "MD made aware of pt's pain 9/10 after receiving pain meds, no new orders received at this time", that covers your butt if the pt comes back later saying he was ignored etc. also, depending on the cause for the chronic pain, other types of medications in addition to narcotics may be beneficial, such as valium/flexeril/NSAIDs for chronic back pain, Neurontin for neuropathy, benadryl given with iv pain meds to potentiate it's affects, cymbalta is used for chronic pain as well, and sometimes sedatives such as xanax, ativan are given to relieve the anxiety associated with the pain that heightens their perception of their pain. Obviously if the pt isn't on any of these other meds in addition to narcotics at home some physicians may be apprehensive to initiate it as part of their pain mgmt, and i've found many MDs perceived responses to pain meds to be way off base from what see daily with narcotic administration. I've encountered quite a few physicians who actually believe 1-2mg Morphine IVP q4hrs is appropriate dosing for pt with significant pain like kidney stones, etc. and when i tell them the pt is still in severe pain and can tolerate a higher dose such as 4mg they've said "i don't want to snow the patient!" Okay yeah, if its 93y/o granny who weighs 70lbs, 1-2mg might work, but for the average person it's equivalent to taking motrin 800mg lol. Or they will order 4mg morphine every two hrs in the ER b/c the pt is not getting any relief, but flat out refuse to order dilaudid. if ur assessment finds that the pt appears to be in severe pain and the MD is refusing to order anything else despite being approached multiple times, then i make THEM go to the bedside and explain why they won't order anything, but when they have to be the one getting yelled at like we have for the last 3hrs, they often give in to "shut the pt up" or because they don't want to have to go tell the patient no themselves.

Also, i've found that using disposable hot packs to apply to muscle/nerve pain or even just for the comfort of feeling warm and relaxed, generally always helps the pt's level of comfort, as well as multiple pillows for support. Hope that helps!