The most common pain scales I use are the numeric pain scale, the wong-baker (faces) scale, the flacc scale, and some qualitative scale.
I find that pain scales should not be used alone to assess and determine pain. Having said that - I know that the reality of nursing is different. And the quick "what is your pain on a scale from 0-10" before and after pain medication is often only good to satisfy joint commission standards while not helping with a meaningful clinical practice.
Also, patients have caught up on the fact that unless they say 10/10 or 20/10 they will not get pain medication anytime soon or only tylenol...
There is a lot of misunderstanding how to use the numeric scale. Pain is subjective but if a patient says the pain is 10/10 and after the medication it is 8/10 or 7/10 - that is consider success. It is not so much about the actual number in many cases but more about the reduction. If the patient says 10/10 and you aim to reduce it to 1/10 with narcotics - your patient will be most likely oversedated or requireing narcan ... unless the patient is CMO - in which case we really just want max comfort.
When I do my initial nursing assessment
I use a pain scale that is appropriate but I also use direct observation that is not within a validated scale. My assessment also includes the quality of pain, when the pain is worst/best, how long has the patient had pain problems? how long on a current dose/regimen, prior substance use, current acute illness/reason for admission, how the patient "feels" about the pain/coping, non medication interventions that help or have helped, prior visits to a pain clinic.
The numeric scale alone does not give me enough information.
I also want to know if the patient is satisfied with the current level of pain control and the expectation.
In dementia it can be very difficult to determine pain or no pain as even the observational scales / flacc do not always help. Example: A patient with progressed dementia fell and broke a hip, had to get surgery. Days later the patient is refusing to take any po and is not cooperative with PT/ does not want to get out of bed, is combative. The nurses gave morphine the day of surgery and after surgery a couple of times but on day 3 did not give pain medication regularly anymore or not at all because the patient did not score enough on the flacc scale. She was unable to self-report in any way and did not show any classical signs of pain.
But she had hardly been that agitated before and did not refuse to eat or drink before that much, she has been restless before and wandering - so the nurses think that it is "just her dementia". When I discussed with the primary nurse that hip surgery and PT is painful and that it is likely that this patient has pain but is unable to self report / verbalize and unable to express or understand what is going on.
We asked the MD to order roxanol in concentrated form and the patient received a dose of 5 mg sl 20 min before PT. What a difference ! The patient was working with PT as much as possible with this degree of dementia, and was able to eat and drink once sitting in the chair.
The blood pressure that was high normalized. The pain scales really did not help much - in fact they prevented the nurse from giving pain medication because "she did not score enough."
Another example is the pain assessment with deaf adults, I have written about it before at some point. The first language for deaf people is american sign language. A lot of terms or scales do not make sense for a person who is deaf. The right scale to use is the wong-baker scale. It is also difficult to correlate the quality of the pain. A deaf patient with an epidural abscess, which is very painful, was in despair because the nurses felt that the patient was "drug seeking" and not in pain based on the fact that he was very expressive (gestures, facial expression) when asked about his pain but did not moan that much. They thought that he was "dramatic" and therefor drug seeking. He had chronic pain before the infection in his spine but was not on much pain medication before. He was also perceived as "difficult" and "angry". He had a significant abscess that was pressing on the nerve roots in his back - that usually leads to terrible severe pain. The nurses were surprised that small amounts of oxycodone "did not do anything".
After a pain assessment with the wong baker scale, an "interview" about the pain with an ASL and CDI the patient was started by the MD on appropriate medication and later switched to a fentanyl patch. He was able to get out of bed with the right pain medication, was not sedated and felt better. I handed the patient the faces pain scale to keep at the bedside for better communication and copied the scale for the nurses and did education on pain and communication for deaf patients.
Yes, I use pain scales but not in isolation as it does not provide enough information.