How do you all like the pain scale???

Forcemaster · Jan 3, 2005

The following is a direct extract from the British National Formulary..

"Opioid analgesics share many side-effects though qualitative and quantitative differences exist. The most common include nausea, vomiting, constipation, and drowsiness. Larger doses produce respiratory depression and hypotension."

Other possible effects that have been documented include: difficulty with micturition, ureteric or biliary spasm, dry mouth, sweating, headache, facial flushing, vertigo, bradycardia, tachycardia, palpitations, postural hypotension, hypothermia, hallucinations, dysphoria, mood changes, dependence, miosis, decreased libido or potency, rashes, urticaria and pruritus.

The entire point of delivering opioid medication is to overide the bodies nervous system and hence to block pain receptors. When you alter the normal function of ANY body system, you effect it's ability to compensate for that change. If you didn't, then every single medication you ever give would be useless as it would be inert. The body will eventually metabolise the medication into a harmless set of chemicals, and hence return the body system affected to its normal function, but this takes time. By logical progression, the more of any medication you administer, two things are set to happen...

1. That the medication will have a larger effect on the affected body system (In the case of Opioid medications, there will be more pain receptor sites blocked)

2. It will take longer for the body to metabolise the medication because there is more of it...

The thing is... that in the higher dose, there will be some of the medication that will not attach to pain receptors, instead it will end up in other body systems and could have an effect there... As in respiratory depression.

Now the body is a remarkable thing and will adjust to a great many pharmacological substances... but this too takes time... Time in which your patient could suffer.

I mean sure... you might have stopped them feeling their chronic long term pain... but the fact that they now have respiratory depression is ok because they will adjust??? What about short term oxygen starvation?

scooterRN52 · Jan 3, 2005

The following is a direct extract from the British National Formulary..
"Opioid analgesics share many side-effects though qualitative and quantitative differences exist. The most common include nausea, vomiting, constipation, and drowsiness. Larger doses produce respiratory depression and hypotension."
Other possible effects that have been documented include: difficulty with micturition, ureteric or biliary spasm, dry mouth, sweating, headache, facial flushing, vertigo, bradycardia, tachycardia, palpitations, postural hypotension, hypothermia, hallucinations, dysphoria, mood changes, dependence, miosis, decreased libido or potency, rashes, urticaria and pruritus.
The entire point of delivering opioid medication is to overide the bodies nervous system and hence to block pain receptors. When you alter the normal function of ANY body system, you effect it's ability to compensate for that change. If you didn't, then every single medication you ever give would be useless as it would be inert. The body will eventually metabolise the medication into a harmless set of chemicals, and hence return the body system affected to its normal function, but this takes time. By logical progression, the more of any medication you administer, two things are set to happen...
1. That the medication will have a larger effect on the affected body system (In the case of Opioid medications, there will be more pain receptor sites blocked)
2. It will take longer for the body to metabolise the medication because there is more of it...
The thing is... that in the higher dose, there will be some of the medication that will not attach to pain receptors, instead it will end up in other body systems and could have an effect there... As in respiratory depression.
Now the body is a remarkable thing and will adjust to a great many pharmacological substances... but this too takes time... Time in which your patient could suffer.
I mean sure... you might have stopped them feeling their chronic long term pain... but the fact that they now have respiratory depression is ok because they will adjust??? What about short term oxygen starvation?

I've been an oncology nurse for about 10 years, your letter is very informative for nurses that don't give many narcotics, but in my experience

I've taken care of cancer patients who take as much as 640 mg. of ms contin

q 12hrs. these are usually pts. that have been thru chemo and surgery. They

also have PRN orders for breakthrough pain such as: mso4 IV, msir, or dilaudid, oxycontin, roxanal, oxyfast. They need pain management.

I work on a surgical telemetry unit and in a cancer hospital, so every pt. I care for has cancer and has had either, head & neck, thorasic, GI or GU

surgery, the pain med of choice for these pts. are: mso4 Ivp, dilaudid, mso4 pca,

fentanyl/ bupivicaine pcea epidurally. these pts. are monitored every 1, 2 hrs. for all side effects. The most frequent side effect w/ IV mso4 is nausea and

diaphoresis, respiratory depression, the most frequent side effect I see w/ epidural infusions such as: mso4/bupivicaine or fentanyl/ bupivicaine, are:

diaphoresis, urticaria,pruitis, respiratory depression. All patients receiving

IV or epidural infusions of these narcotics have standing orders for:

Narcan, zofran, compazine, and benedryl. The surgical patients go to percocet after 2-3 days when their PCA, or PCEA is discontinued. All patients w/ epidural infusions have a foley catheter inserted, this is not removed until

epidural infusion is stopped for 6 hrs. As an oncology nurse, I always use the pain scale of 0-10, it is used throughout the hospital and accepted by all

the staff. We also have a pain management team that is their specialty, they have an MD, CRNP and several RN's.They are usually consulted for pts. admitted for pain management and medical cases. Pain is the 5th vital sign,

especially in a cancer patient

Forcemaster · Jan 4, 2005

I've been an oncology nurse for about 10 years, your letter is very informative for nurses that don't give many narcotics, but in my experience I've taken care of cancer patients who take as much as 640 mg. of ms contin q 12hrs. these are usually pts. that have been thru chemo and surgery. They also have PRN orders for breakthrough pain such as: mso4 IV, msir, or dilaudid, oxycontin, roxanal, oxyfast. They need pain management.
I work on a surgical telemetry unit and in a cancer hospital, so every pt. I care for has cancer and has had either, head & neck, thorasic, GI or GU
surgery, the pain med of choice for these pts. are: mso4 Ivp, dilaudid, mso4 pca, fentanyl/ bupivicaine pcea epidurally. these pts. are monitored every 1, 2 hrs. for all side effects. The most frequent side effect w/ IV mso4 is nausea and diaphoresis, respiratory depression, the most frequent side effect I see w/ epidural infusions such as: mso4/bupivicaine or fentanyl/ bupivicaine, are:
diaphoresis, urticaria,pruitis, respiratory depression. All patients receiving
IV or epidural infusions of these narcotics have standing orders for:
Narcan, zofran, compazine, and benedryl. The surgical patients go to percocet after 2-3 days when their PCA, or PCEA is discontinued. All patients w/ epidural infusions have a foley catheter inserted, this is not removed until
epidural infusion is stopped for 6 hrs. As an oncology nurse, I always use the pain scale of 0-10, it is used throughout the hospital and accepted by all
the staff. We also have a pain management team that is their specialty, they have an MD, CRNP and several RN's.They are usually consulted for pts. admitted for pain management and medical cases. Pain is the 5th vital sign,
especially in a cancer patient

Im going to split a few hairs now :rotfl:

First off... Isn't pain the 6th Vital Sign?

I always start off with the respiratory rate (a measurement that far too many nurses leave off these days for who know's what reason... but I won't go into here as its off topic...), followed by Pulse, B/p, Temperature and Oxygen Saturations... then pain.

Secondly, without reference to any specific patients details I'm only making an educated guess, but many of the hints in your post allude to patients who are likely to have long term opioid use and have hence likely built up a tolerance because their body has become used to metabolising the drugs... hence they need a larger dose for effect... In essence, they simply have more enzymes designed to metabolise the drug so it has a shorter half life in the body

Thirdly... It may just be me being thick :uhoh21: (and although I'm often the smartest person in the room I can also be the thickest to some extent :rolleyes: ) but I don't get the point of your post... You talk about 'in your experience' mention high tolerance of drugs, a few drug names, a bit about epidural and PCA pain control, then end by talking about pain scales... but you don't follow up on the main point of my post... Which is that the body does not always easily adjust to medications, and that they can have some serious side effects. You do explore some of the side effects you commonly come across, but the point of what your are trying to make eludes me...

Thinking about it, I don't think anyone ever explained the whole Epidural=Urinary Catheter to me... Can you enlighten me to the evidence behind this?

Now we have a similar policy in my hospital of monitoring a patient on IV or epidural pain relief (whether it's a PCA or background dose) hourly. Now many of my colleagues only assess Vitals, inc. respiratory rate and nausea, during this time and I am trying to bring them around to assessing ALL the major possible side effects not covered by the Vitals... I.e. urticaria and pruitis. Constipation is (hopefully) assessed at least once daily for ALL the patients on my ward as they are all on some form of pain medication with that effect... Standing orders should exist for all patients on the ward, but not always... not a week goes by where I don't harrangue a junior doctor for not prescribing some form of laxative etc. for a patient on Sevredol or Dihydrocodine :stone .

Lastly, I agree with you Scooter. A Pain Scale is a useful tool in the orificenal of Nursing. But (and I say this to everyone out there) a tool is supposed to be used in a specific way at a specific time. I'm sure you have all heard the saying "the right tool for the right job"? Well it applies to pain assessment tools too. There are different tools... the 1-10 scale, the 1-5 scale, the 0-3 scale, the picture scale, or even the nurse asking "Are you in pain? How bad is it? Can you describe it for me?" All are valid methods in assessing pain, all can be recorded in clinical notes. My advice is don't get too hung up over 1 method :nono: when we all know there are patients out there who seem to go out of their way to make our jobs harder by defying convention :chuckle!!!

z's playa · Jan 4, 2005

As far as I know it's the Fifth Vital Sign.

Let me knoe if it's changed? :confused:

scooterRN52 · Jan 5, 2005

Im going to split a few hairs now :rotfl:
First off... Isn't pain the 6th Vital Sign?
I always start off with the respiratory rate (a measurement that far too many nurses leave off these days for who know's what reason... but I won't go into here as its off topic...), followed by Pulse, B/p, Temperature and Oxygen Saturations... then pain.
Secondly, without reference to any specific patients details I'm only making an educated guess, but many of the hints in your post allude to patients who are likely to have long term opioid use and have hence likely built up a tolerance because their body has become used to metabolising the drugs... hence they need a larger dose for effect... In essence, they simply have more enzymes designed to metabolise the drug so it has a shorter half life in the body
Thirdly... It may just be me being thick :uhoh21: (and although I'm often the smartest person in the room I can also be the thickest to some extent ) but I don't get the point of your post... You talk about 'in your experience' mention high tolerance of drugs, a few drug names, a bit about epidural and PCA pain control, then end by talking about pain scales... but you don't follow up on the main point of my post... Which is that the body does not always easily adjust to medications, and that they can have some serious side effects. You do explore some of the side effects you commonly come across, but the point of what your are trying to make eludes me...
Thinking about it, I don't think anyone ever explained the whole Epidural=Urinary Catheter to me... Can you enlighten me to the evidence behind this?
Now we have a similar policy in my hospital of monitoring a patient on IV or epidural pain relief (whether it's a PCA or background dose) hourly. Now many of my colleagues only assess Vitals, inc. respiratory rate and nausea, during this time and I am trying to bring them around to assessing ALL the major possible side effects not covered by the Vitals... I.e. urticaria and pruitis. Constipation is (hopefully) assessed at least once daily for ALL the patients on my ward as they are all on some form of pain medication with that effect... Standing orders should exist for all patients on the ward, but not always... not a week goes by where I don't harrangue a junior doctor for not prescribing some form of laxative etc. for a patient on Sevredol or Dihydrocodine :stone .
Lastly, I agree with you Scooter. A Pain Scale is a useful tool in the orificenal of Nursing. But (and I say this to everyone out there) a tool is supposed to be used in a specific way at a specific time. I'm sure you have all heard the saying "the right tool for the right job"? Well it applies to pain assessment tools too. There are different tools... the 1-10 scale, the 1-5 scale, the 0-3 scale, the picture scale, or even the nurse asking "Are you in pain? How bad is it? Can you describe it for me?" All are valid methods in assessing pain, all can be recorded in clinical notes. My advice is don't get too hung up over 1 method when we all know there are patients out there who seem to go out of their way to make our jobs harder by defying convention :chuckle!!!

Forcemaster, this message is for you, so that you may understand the pain scale we use at our hospital works very well for cancer pts. The 0-10 scale

w/ 0 being no pain at all and 10 being the worst possible pain you've ever had is very easy for the multi- cultural population of patients we take care of. I work in the philadelphia region and there are many people from different countries in this city! Now for the vital sign issue: I've never heard of the 6th vital sign, the fith v.s. for you and your institution, obviously is oxygen saturation, our 5th v.s. is PAIN, which is much more common than decreased 02 saturation.

The reason I mentioned PCA's and PCEA's is because they are used so frequently in our hospital. PCEA,s are used for surgical cases only, PCA,s

are used for both surgical and medical patients being admitted for pain

management. Pain management of surgical cases and the chronic pain of

medical cases are very different, causing different side effects in each.I am not going to elaborate on either at this time because I don't think it is

neccessary.

To help you understand why foley catheters are inserted during epidural

therapy I will tell you, medication going into the epidural space for several days effects motor impules to skin and skeletal tissue via nerve pathways in the spinal column, it also effects spinal nerves from the spinal cord that effect the autonomic fibers connecting to viceral organs. This is why a foley is needed, reflexes and sensation that occur to allow urination are dulled by the medication.

To monitor these pts. q 1-2 hrs., we check their orientation, level of

consciousness, pain level. respiratory rate, ( oxygen sat decreases w/ decreased R.R.) sometimes these pts. are on contiuous P/ox, check for nausea or emesis. These pts. are always on n/c oxygen therapy.

The RN's on our unit which is a step down w/ telemetry are trained in cardiac monitoring,and ACLS.

Forcemaster · Jan 8, 2005

Forcemaster, this message is for you, so that you may understand the pain scale we use at our hospital works very well for cancer pts. The 0-10 scale
w/ 0 being no pain at all and 10 being the worst possible pain you've ever had is very easy for the multi- cultural population of patients we take care of. I work in the philadelphia region and there are many people from different countries in this city! Now for the vital sign issue: I've never heard of the 6th vital sign, the fith v.s. for you and your institution, obviously is oxygen saturation, our 5th v.s. is PAIN, which is much more common than decreased 02 saturation.
The reason I mentioned PCA's and PCEA's is because they are used so frequently in our hospital. PCEA,s are used for surgical cases only, PCA,s
are used for both surgical and medical patients being admitted for pain
management. Pain management of surgical cases and the chronic pain of
medical cases are very different, causing different side effects in each.I am not going to elaborate on either at this time because I don't think it is
neccessary.
To help you understand why foley catheters are inserted during epidural
therapy I will tell you, medication going into the epidural space for several days effects motor impules to skin and skeletal tissue via nerve pathways in the spinal column, it also effects spinal nerves from the spinal cord that effect the autonomic fibers connecting to viceral organs. This is why a foley is needed, reflexes and sensation that occur to allow urination are dulled by the medication.
To monitor these pts. q 1-2 hrs., we check their orientation, level of
consciousness, pain level. respiratory rate, ( oxygen sat decreases w/ decreased R.R.) sometimes these pts. are on contiuous P/ox, check for nausea or emesis. These pts. are always on n/c oxygen therapy.
The RN's on our unit which is a step down w/ telemetry are trained in cardiac monitoring,and ACLS.

Thanks for clarifying the whole epidural / urinary catheter issue for me :)

Im going to bow to your experience over long term cancer care. Many of the pts I have encountered were in the A&E (that ER for all you 'state-side') for symptom relief (normally pain) and so had large doses of pain meds before being admitted to a specialist ward for long term care, or those on surgical wards who came in for... surprise surprise... surgery :rotfl:, and after they were stable post-surgery they were sent back to the oncology ward...

PMHNP10 · Jan 8, 2005

How do I feel about the pain scale? I don't like it. I'd just rather ask if someone is having pain and do they need pain meds.
steph

I don't like it at all. I know I find myself becoming judgemental at times because I don't believe them. For example, a patient states they have a headache 10/10. My response is, so it's as bad as if someone took a hammer and smashed your arm into 2 peices? Of course their response is yes, which I don't buy because I can't visualize any situation in which a person shatters a body part and is still able to carry on a calm, coherent conversation. It's like I'm trying to have a pissin' contest with the pt; like I'm trying to prove something. Why should a number mean anything to me, because I'm still going to medicate the pt. because they say they hurt. In spite of the judgement I make, I still respond to the pt's needs; I don't doubt that they are experiencing some sort of pain. So all I have managed to do is frustrate myself over a stupid number. Petty.

scooterRN52 · Jan 9, 2005

Thanks for clarifying the whole epidural / urinary catheter issue for me :)
Im going to bow to your experience over long term cancer care. Many of the pts I have encountered were in the A&E (that ER for all you 'state-side') for symptom relief (normally pain) and so had large doses of pain meds before being admitted to a specialist ward for long term care, or those on surgical wards who came in for... surprise surprise... surgery :rotfl:, and after they were stable post-surgery they were sent back to the oncology ward...

You are welcome Forcemaster. :)

FutureNrse · Feb 4, 2005

Tell me about it, I have experienced this many times. Frankly, I see some chronic pain types (usually with a long history of GI complaints) who come in, highly dependent on huge doses of narcotics, totally savvy to the pain scale and able to fully exploit the current climate of acquiesing to every demand made by these patients. Many of these folks appear to have more emotional pain than anything, IMO, and are experts at manipulating the medical establishment to fullfill their unhealthy needs.
I really have no problem giving folks any narcotic that is ordered, and don't feel it's my place to rehab people. But, I dislike the feeling of being manipulated and sometimes end up resenting this type of pt because I feel like the system is forcing me to play along with their charade, even though I realize that they are deeply troubled, suffering people deserving of the same compassion that anyone deserves.
As far as 10/10 pain, I've personally experienced that in the natural childbirth of my 6 children, and it is excruciating in transistion, right before commencing pushing. It's practically unbearable and there is no way that a person can sit calmly while enduring this. Very few people would be able to stoically cope with this type of pain and not present definate signs of it's intensity to others.

I'm glad you made this post. I have so many things to say in response that I hardly know where to start. Okay...I have used that example when trying to make a doctor or nurse understand my pain. I have given birth 4 times, all natural, the last one highly complicated and 17 hours long. As for my current pain due to a back/neck injury from car accident...I spent about 4 years at a steady 8. There are times when the pain flares up even more and can easily be compared to the pain of a natural birth. If I am standing at the start of a flare up, I sit as fast as I can or I am going to fall, plain and simple. This kind of pain can drop a person to the floor, no question.

Now, I've spent 2 hours here tonight reading posts about doctors who hand out meds like candy, and ED's that do everything but ask if you'd like fries with that IV of Dilaudid, and I have to ask.....Where are these docs and ED's? I have never been to one, that's for sure. It took me 4 years to find one doctor who isn't terrified of prescribing pain meds. As for ED's, I've been to many and out of all my trips I only received pain medication one time. On one occasion the ED doc did not even examine me but came straight in giving a speech about the evils of narcotics. I wasn't taking any narcotics at that point, didn't know a thing about them. I had brought copies of my CAT scan results showing my herniated disks and other things but after the way he acted, I was too intimidated to show him or to even ask if maybe he could look at the grapefruit sized lump on the back of my neck. I left, adding humiliated and puzzled to my list of current feelings, just under "agony". Let me add for the record that I respectable looking, have no criminal record, no history of drug abuse and a degree in social services. It's not as if I came in looking like everyones image of a drug seeker.

Maybe the problem is that doctors get into habits, and either give drugs to one and all, or give them to no one without an act of congress. What is wrong with actually taking 5 minutes to asess the situation? Have we stopped training doctors to do that?

One last side note, recently I went to urgent care because of a severe cough, congestion, etc, and I have a history of pneumonia. I just wanted to make sure that I wasn't headed down that road again and expected maybe a scrip for Zythromax, which was what I got, but then the PA that took care of me, blows me away by handing me a second scrip, for Vicodin. I didn't ask for pain meds. I only briefly mentioned that I cough so hard sometimes that it hurts my ribs. I asked him why and he said "You might need them, if the coughing gets worse or whatever" I wanted to scream. Four years I spent trying to get pain management for real pain and this bozo gives me Vicodin for "whatever". I declined the sample pack of Vicodin that he offered me in addition to the scrip.

So, you know the old saying "take two aspirins and call me in the morning"? It can now be replaced with "take all of these Vicodin for "whatever" but don't get addicted".

oneLoneNurse · Feb 4, 2005

I have just experienced some of what I believe you mentioned. I just recently had a root canal done. I told the doc I wanted Percocet. He insisted on ordering Vicodin. Vicodin did not kill the threshold of pain I had with this procedure. I saw him the day after the root canal, again he insisted on ordering Vidodin. Last night I went home and slept 12 hours, not because of percocet, BUT because the clindimycin he gave me to kill the infection has finally kicked in.

I just would have been much happier if he had of ordered percocet for me the first time. And yes, I know I sound like a med seeking nurse, BUT the pain was excruciating for me. Know pain is very subjective. I remember the time I had with the pain, how I couldn't lie down, but kept pacing. It was a very, very hard experience.

FutureNrse · Feb 5, 2005

I have just experienced some of what I believe you mentioned. I just recently had a root canal done. I told the doc I wanted Percocet. He insisted on ordering Vicodin. Vicodin did not kill the threshold of pain I had with this procedure. I saw him the day after the root canal, again he insisted on ordering Vidodin. Last night I went home and slept 12 hours, not because of percocet, BUT because the clindimycin he gave me to kill the infection has finally kicked in.
I just would have been much happier if he had of ordered percocet for me the first time. And yes, I know I sound like a med seeking nurse, BUT the pain was excruciating for me. Know pain is very subjective. I remember the time I had with the pain, how I couldn't lie down, but kept pacing. It was a very, very hard experience.

And such an unnecessary experience! It's awful that you suffered just because he preferred prescribing Vicodin. Medications do not work the same on everyone, that's why we have so many different medications. Everyone with high blood pressure isn't taking the exact same drug, why? Because maybe they had a bad reaction to one, or one wasn't as effective. We have all of these different pain meds for a reason, but if they aren't prescribed they can't do any good.

FutureNrse · Feb 5, 2005

It is usually not very effective with folks who rate their pain as a #10 (and swear its a #10) as they just get off the phone to get up out of bed unassisted and walk unassisted in order to go outside for a smoke just before ordering that big dinner tray because "the food is great and I'm hungry" and smiling as you please. I know I'm exaggerating here, but you get my drift. For these types of patients, their reported level of pain makes it kind of meaningless. However, the rating scale is helpful in assessing post op pain and evaluating effectiveness of pain management. Some folks in chronic pain may never get below a #5. The importance here is making sure that their level of pain doesn't shoot up suddenly out of control because of being in pain at a chronic level (sort of use to the abuse) and haven't asked for the pain med in awhile, especially before/during/after a bout of activity. Folks in chronic pain and post op pain, in my experience, usually do better if "routinely" medicated instead of waiting for the pain to be reported at a #9. I honestly believe that it is easier to keep the patient more pain free if you achieve and maintain their steady state of reduced pain than to put out the fires and ride the roller coaster of pain by only medicating when it begins to hurt "bad"....Ooops, that is not a number, forgive me, let's say #7-10. In the long or short of it, the scales work well in the post op setting.

That was wonderfully written and makes perfect sense. Unfortunately, a lot of doctors don't seem to agree or they wouldn't routinely undermedicate those with chronic pain. Like the doctor who knows his patient has had the same chronic pain for several years, and when the patient reports that the pain is increasing asks for an increase in dosage (the first increase in over 2 years) he decides to raise the dose of Elavil instead. His reason? It will help the pain meds work better. Patient reported several times that Elavil doesn't seem to help anything to help, so what sense does that make? This patients pain was never below a 4 or 5, but had shot up to a steady 7 for several weeks prior to the request. Is the doctor going to wait until the pain is a 10 and then do what to try to knock it down to a reasonable level again? Your way makes a lot more sense, keep the pain down or if possible keep it all the way gone.