Pain scale

[nurseequestrian]

Hey everyone. So my question for you all is when you are giving patients pain medication, do you always follow the parameters given exactly? So for example, say a patient can have Norco. The pain scale listed for it is say 5-7/10 Pain. If the patient states their pain is a 4, would you still give the Norco?

I know I have done this because it depends on each situation. But the other day I overheard a nurse not wanting to give the patient the pain medication because they were 1 point lower than the parameters.

What do you all think? It's honestly not something I have given much thought to, but now I feel like I've been doing it all wrong. Thanks!

[Kitiger, RN]

I know a person who has fibromyalgia, who states that he is never without pain, and that he rates his pain consistently as a 7 to 10. I asked him what his pain was right then, and he said it was 8. I told him a rating of 8 means it is so severe he cannot do most activities, he almost can't think about anything else, and even talking and listening are difficult ... but he was standing there quietly talking, breathing normally, calm, and with a relaxed expression.

He said his pain tolerance is so great that he can function through pain that is an 8. Other people wouldn't be able to function, but he can.

Note: this was not a patient, and he was not drug-seeking.

How would you rate his pain if he were your patient?

[Mavrick, BSN, RN]

Dosing by a subjective, non-verifiable number is stupid. By that practice, a nurse runs the real risk of not medicating appropriately.

I mean there are some who will underreport pain (my pharm prof would say "the bachelor Norwegian farmer type") -- they are determined to remain stoic. So POD#1 after a double knee replacement, pt is gritting his teeth, grimacing, and PT will be here in an hour. Is plain Tylenol appropriate vs an opioid -- ONLY because the pt rated their pain a 2? I've had pts do this but agree to meds after some education, e.g. "you look miserable, and you have PT in an hour. PT can be painful. I'm concerned that without treating your pain, your PT will be less effective -- if you can even do what the PT recommends. If you can't do PT, your healing will be significantly slower."

Conversely, there is the type who if conscious will always rate their pain an 11... is it appropriate to give a mg of Dilaudid when the pt's resp rate is 6 -- ONLY because the pt rated their pain an 11?

If pt care doesn't require critical thinking, if it's appropriate to mindlessly "follow orders," why have licensed nurses?

If my nursing judgment says the order is inappropriate -- say in the 1st example -- and the MD refused to write a reasonable order, I would probably suggest the pt that the opioid can't be given unless they rate it >5.

This post has a multitude of brilliant observations/suggestions, but I can't get past the first line without rolling my eyes to Heaven and uttering out loud "DAMN STRAIGHT"

How stupid do we have to be to mindlessly follow every order?

Would you give 10mg IV of Dilaudid because it was written that way? (When it's obviously a typo????)

The type of thinking required to manage this dilemma may not be taught in nursing school. Be sure and ask your preceptor about this real-world scenario.

We bedside nurses are on the front line and should use our intellect and education to out think a stupid template that some doctors will mindlessly click.

[vanessaem, BSN, RN]

Norco is 4-6/10 at my facility so yes I would.

[youenjoymyself]

I give what I want and fill in a number from the "proper" scale to match it.

I agree for the most part. If I have had the same patient for a day or two, get to know them, their personality and their pain/opiate tolerance, I do the exact same thing.

What I have a hard time doing is, at night, when a patient wakes up from a deep sleep and proceeds to tell me their pain is a 10/10...these folks automatically get bumped down 3-4 notches. I don't question their pain, but I do question the severity.

Diagnosis, age, culture, etc...all play roles. Better judgement, coming sense, critical thinking goes a long way.

[Accolay]

Our facility gives pain meds for "mild pain, give first" (usually tylenol) "moderate pain, give second"(usually oxycodone or dialudid) or "severe pain, give second" Oftentimes there are two "give first" or "give second" PRNs on the list. Or it just goes from mild to severe with no moderate in between. I think they started listing it that way after the Joint Commission said so. Basically, one must work around and use judgement because it's stupid. I supposed I could call the MD to make them change it, but it really feels like a waste of everyone's time. Sometimes it's trial and error. Always ends up with an attempt to make them comfortable. It's totally science too: I start with a low dose and work my way up after allowing enough time for the first one to take affect- 15 min for IV, 30 I think for oral per policy. If they are screaming in pain, then that's not enough. If they are drooling and have trouble waking up, then that's too much pain medication. Trial and error.

Also when working with people who appear to be in pain, but can't really tell you what's going on like head trauma, or slightly confused/sedated intubated patients that are having trouble communicating at you, how would one justify a pain number/med if they can't accurately tell you what their pain level is? I don't ask a lot of my current patient population what their pain numbers are 'cause a lot of them aren't sure what that means. We can say they're restless or their heart rate or blood pressure is up, but also subjective as in: What will your patient's blood pressure be if they are in 7/10 pain?

[OldDude]

At the pedi Urgent Care I work at we use the Wong Baker faces for under age 8. I'll show the kids the scale and say, "OK, "0" is if you're smiling and "10" is if you're crying and you're not smiling or crying so you can't use 0 or 10...then we go from there. With few exceptions they rate their pain higher than they obviously are experiencing. I saw a Lego pain scale one time that attached "imminent death" to number 10. For the older kids I'll reference that 10 indicates "imminent death." It's hilarious when the 14 year old indicates a pain scale of "10" as they are looking up from their text messaging. Regardless, we are instructed to record what they say but I just can't help recording my objective observations in the notes...what a waste of time; especially with kids. I can spot a kid in real pain from 100 yards away.

[Here.I.Stand, BSN, RN]

I know a person who has fibromyalgia, who states that he is never without pain, and that he rates his pain consistently as a 7 to 10. I asked him what his pain was right then, and he said it was 8. I told him a rating of 8 means it is so severe he cannot do most activities, he almost can't think about anything else, and even talking and listening are difficult ... but he was standing there quietly talking, breathing normally, calm, and with a relaxed expression.

He said his pain tolerance is so great that he can function through pain that is an 8. Other people wouldn't be able to function, but he can.

Note: this was not a patient, and he was not drug-seeking.

How would you rate his pain if he were your patient?

If I believe it safe to give the med -- such as in this case, I would. I would never want to let someone suffer based on how most would exhibit *acute* pain. If the pt is barely conscious and breathing 6/min, no.

[Irish_Mist, BSN, RN]

This post has a multitude of brilliant observations/suggestions, but I can't get past the first line without rolling my eyes to Heaven and uttering out loud "DAMN STRAIGHT"

How stupid do we have to be to mindlessly follow every order?

Would you give 10mg IV of Dilaudid because it was written that way? (When it's obviously a typo????)

The type of thinking required to manage this dilemma may not be taught in nursing school. Be sure and ask your preceptor about this real-world scenario.

We bedside nurses are on the front line and should use our intellect and education to out think a stupid template that some doctors will mindlessly click.

Mavrick, I just LOVE reading your posts. You are definitely one of my most favorite posters on All Nurses.

I agree with you 1,000%. Critical thinking is taught in nursing school ad nauseum but how many times have we seen our colleagues or even ourselves not utilize our intellect? As Here I Stand said, dosing by a subjective number is stupid. Most people insist their pain is 10 out of 10 either way, or so it seems. Maybe if patients were informed that sometimes, no pain isn't possible, we wouldn't have this disaster on our hands.

[JKL33]

How stupid do we have to be to mindlessly follow every order?

Would you give 10mg IV of Dilaudid because it was written that way? (When it's obviously a typo????)

The type of thinking required to manage this dilemma may not be taught in nursing school. Be sure and ask your preceptor about this real-world scenario.

We bedside nurses are on the front line and should use our intellect and education to out think a stupid template that some doctors will mindlessly click.

Great post, and you are right!

But...I'm gonna tack on the idea that, while no, you woudn't give 10 mg dilaudid as mentioned above, you ALSO wouldn't do something different and just sign it off as written...

[akulahawkRN, ADN, RN, EMT-P]

The pain scale as we're used to is probably close to junk but it's about the best tool we have, though it's easily able to be manipulated by the patient. We just have no way to objectively rate pain because pain is subjective. What one person would describe as severe pain, another might find mildly annoying.

What I do is teach my patients a concept of "tolerable vs. intolerable" pain. I do use the same scale, 0-10. What I teach is that 5 is where pain starts becoming intolerable and that means it starts interfering with sleeping - you can't take a nap with it and with your daily activities begin to be impacted because of it. That's also where we might start seeing outward signs of pain as well. I also teach that we should be aiming for a "3" so that you know that pain is present but it's tolerable and you can tell if it's getting better or worse, blotting out pain completely isn't reasonable because something could become significantly worse before you feel it and then we start chasing the pain dragon's tail... Keeping pain at a tolerable level, but still present, allows the patient to know how far they can go when doing activity because they can feel pain getting worse. When doing rehab, I used to teach patients to go until they feel the pain start to increase after the initial onset. Once that happens, don't go further because it means you're causing damage to yourself and that can slow recovery.

I also realize there's quite a difference in chronic pain vs acute pain. This scale does take into account the tolerance of chronic pain as people do learn to tolerate significant pain. After this teaching, many of my patients will often re-state their pain level. They know they'll still get pain medication and they know the goals and why. They know I'm not going to keep giving medication until their pain is gone. It also allows a way to figure out who is seeking... but it's not a perfect method because it's still very subjective and dependent upon patient cooperation with using this scale appropriately. Mostly I catch the seekers because they know when the next dose of medication can be given and they start asking for it almost right on time.

[Elfriede]

I only have longtime pts. Most of them "painchronists".

I understand the parameters as an "up to...".

In arrangement with my pt, I accompany the medication

with physical measures to keep the dose down.

And yes! - I have the time for that. Even if I have to

steal this time.

The side effects of longterm-analgesic-treatment may be

lethal.

[kp2016]

Be careful. In some facilities when charts are audited giving a medical for pain of 5/10 when the order was for pain 6+ would be considered a medication error. Ridiculous in my opinion but I have seen it happen.