Pain scale - page 3

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... Read More

  1. by   vanessaem
    Norco is 4-6/10 at my facility so yes I would.
  2. by   youenjoymyself
    Quote from Sour Lemon
    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.
  3. by   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?
  4. by   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.
  5. by   Here.I.Stand
    Quote from Kitiger
    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.
  6. by   Irish_Mist
    Quote from Mavrick
    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.
  7. by   JKL33
    Quote from Mavrick

    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...
  8. by   akulahawkRN
    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.
  9. by   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.
  10. by   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.
  11. by   typoagain
    I have to say it depends on the situation.

    I once had a patient who had pain meds ordered Q4 hours PRN for post-op pain. She would set an alarm to go off 3 hours after she got her medication and then you immediately start hitting the call button demanding her pain meds early. After 2 or 3 days the nurses went to the doctor with concerns about her abusing PRN meds. Especially since she never once said her pain was less than 10 out of 10, even two hours after being given the pain meds. She would literally wake up in the middle of the night because her alarm went off and start complaining her pain was 10 out of 10. But if we were in the room when the alarm went off we could reach over and shut it off before she woke up. And she would sleep until her next round of vital signs. One of the other nurses actually tried it. She slept nearly 7 hours.

    The doctor said to just give the pain medications and let him know of any adverse reactions. He also wrote in an order for Narcan.

    About 5:30 a.m. one morning she was on her call light demanding her pain meds. And so I pulled the meds and gave them to her, just like the doctor said to do. Then when I went around at 6:30 to check on her I found her sleeping. But I was unable to arouse her. So I got the charge nurse to come in who also could not arouse her. So she got her dose of Narcan.

    Needless to say she was wide awake in seconds. And she was throwing a wall-eyed fit about how much she hurt.

    You should have seen her face when I told her she could not have any more pain meds and why. I also explained that even if we gave her more medication it would not work until the Narcan was out of her system.

    Fortunately it was the end of my shift and I didn't have to deal with her anymore. When I came back that night she was giving everyone hell. She kept on demanding pain meds. But much to her disgust the doctor had DC'd all narcotics. He discharged her the next day, without any narcotic pain meds. But she did get a referral to a pain specialist. He also informed her that she would need to find another physician.
  12. by   sweet sunshine
    I know JCACO wants pain meds given according to scale which is dumb and could be dangerous. 90 year old, post-op hip replacement never has taken opoids rates pain a "10". Order for sub-q dilaudid, 0.5 mg for pain level 1-3, 1mg for pain 4-6, 1.5mg for pain 7-10. No way in hell im giving 1.5mg as starting dose. But according to scale that's what I should give. Also, pain level might be a lower number in a pt. because you're giving pain meds regularly. It took us a while to get your pain under control and now that it's a 4 I can only give you 5mg, not 10mg. Pain will bump back up out of control.
  13. by   Buckeye.nurse
    We just started using the Defense and Veterans Pain Rating Scale at my hospital. We're still getting used to it, but so far it seems to be much more useful than the old 0-10 rating system. Here's a link...

    Defense & Veterans Pain Rating Scale (DVPRS)

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