non-verbal signs of painlesness

Specialties Emergency

Published

As nurses we are trained to look for and document non-verbal signs of pain.

I frequently have patients who complain of 8-10/10 pain while they are: ambulating without difficulty, no facial grimace, speaking clearly, have vitals WNL, etc. In addition, they might be eating, texting, etc. If you are reading this, and are an ER nurse, you know what I am talking about.

Frequently, these people are not given pain medication. It is important to me that my documentation reflects, in objective terms, how these people presented.

So- the same way that you might use a set phrases to show that a wound has no signs of infection, ie "edges well aproximated, sutures intact, no redness or swelling beyond the margins, no drainage or prurulent odor", I am looking for a list of pertinent negative that show that a pt has no objective signs of pain.

Any thoughts?

hherrn

PS- if you really feel the need to tell me that pain is what the pt says it is, or to relay a story about somebody who had untreated pain, go ahead. But it won't really help me in any way.

Woodenpug, BSN

734 Posts

Specializes in MPCU.

I'm not an EC nurse, but I know what you are talking about.

We need an objective, validated tool to assess drug seeking behavior. Both to protect the patient from a false diagnosis of drug seeking and to get help for the addicted patient.

Until then, I give the meds as ordered and document "patient states 8/10 pain, no other signs or symptoms of pain noted." If I have the time I will be specific as to which pain indicators are missing (ie, VSS, no grimace, no guarding, bright affect...)

A complete list of non-verbal indicators is found in the NIH's comfort scale http://painconsortium.nih.gov/pain_scales/COMFORT_Scale.pdf. Though that scale is not appropriate for a verbal patient.

heron, ASN, RN

4,117 Posts

Specializes in Hospice.

Keep in mind that people with chronic pain frequently do not show the same objective signs as those with acute, never-before-experienced or new onset pain. Documenting whether the pain is chronic or acute affects the interpretation of the rest of your findings re VS, behavior, etc.

Specializes in Critical care.

I deal with this in PACU on a fairly regular basis. For example, a total knee states the pain is an "8" so I give Dilaudid and the patient goes to sleep. Then the patient wakes up and complains of unrelieved pain. I will give additional pain meds only if the patient's respiratory status can tolerate it. If someone is obstructing, desaturating, has a RR

Specializes in ER; HBOT- lots others.

I know what you mean exaclty. I also DO NOT work in an ED, i dont believe that has to be the dept to be relevant- thought i do see your point. we are limited in what we can chart because of our stupid system we use, with the exception of notes and they discourage us from doing those. i agreee with 'woodenpug' stating pt states 8/10pain- no other s/s present; vs stable.

but i do have to plug the chronic pain issue, i have chronic pain, i am usually high, but there are times where i cannot deal and my vs dont generally change.

-H-RN

Specializes in LTC.

By the book "pain is whtever the pt say it is" unless contradicting

Guest219794

2,453 Posts

Today 06:29 PMHazel3Re: non-verbal signs of painlesness

By the book "pain is whtever the pt say it is" unless contradicting

Hazel-

I am curious. Do you actually believe this?

Patient A: c/o pain 10/10, walking with no problem, talking, eating. Maintaining a conversation with her friend between texting. This patient has been in 20 times in the last year, but has never needed hospitalization. All of her complaints are for for pain in various areas. no radiologic or lab tests have ever shown anything wrong. She is obese, smokes, and drinks. Nothing other than IV narcotics will make her rate the paiin lower than 8/10.

Patient B: c/o pain 5/10. Is in the waiting room, hunched forward, facial grimace, pressured speech. Refuses a wheelchair, but has trouble walking. Elevated amylase and lipase. Chief concern is that he needs to show up to a job site tomorrow.

If you subscribe to this bizarre theory that "pain is what the patient says", you would medicate the 10/10 patient first. Bad nurse, no bicuit.

So, clearly as nurses, part of what we need to do is use tools other than pain scale to asses pain. In fact, we are trained in it.

When I have pt A, I do not advocate for narcotics. I do not believe it is the best interests of pt A for me to administer narcotics to her. If I am lucky enough to be working with an MD who is truly looking out for the best interests of the pt, rather than an easy solution, I want my documentaion to support both of our actions.

What do you suppose an emergency department would look like if we actually subscribed to the "pain is what the pt says" theory? That all complaints of pain were treated to the pt's satisfaction? Remember, the people I am talking about, 1; Don't have really busy schedules, and 2; pay nothing for the sevices.

Thanks for your input.

hherrn

Specializes in Critical care.
By the book "pain is whtever the pt say it is" unless contradicting

The problem comes from the ED frequent flyer who knows we are supposed to treat according to that standard. These people come in complaining of "10/10" abdominal/back/headache pain. Doctors work these patients up for the worst case scenario associated with a real medical emergency--stroke, aortic dissection, etc--because on the OFF chance someone really is having an emergency and that person dies....there's a lawsuit if a test isn't done. I worked in an innercity teaching hospital's ED where this very scenario happened. A known drug-seeking frequent flyer complained of terrible back pain, given her usual IV drug fix and sent out. She turned out to have an aortic dissection and died. It's not a good use of resources every time these drug seekers come in to run every test and scan. It's hard to tell when these people are faking and when it's truly real....think of the little boy who cried wolf.

Also nurses get frustrated with this type of patient because they tend to be rude, demanding and take their time from patients who truly need care. I got burned out in the ED dealing with drug seekers cursing at me for not getting their Dilaudid and turkey sandwich fast enough, meanwhile trying to work on a patient coming in with an acute MI.

shamari

8 Posts

Specializes in Med-Surg.
Today 06:29 PMHazel3Re: non-verbal signs of painlesness

By the book "pain is whtever the pt say it is" unless contradicting

Hazel-

I am curious. Do you actually believe this?

Patient A: c/o pain 10/10, walking with no problem, talking, eating. Maintaining a conversation with her friend between texting. This patient has been in 20 times in the last year, but has never needed hospitalization. All of her complaints are for for pain in various areas. no radiologic or lab tests have ever shown anything wrong. She is obese, smokes, and drinks. Nothing other than IV narcotics will make her rate the paiin lower than 8/10.

Patient B: c/o pain 5/10. Is in the waiting room, hunched forward, facial grimace, pressured speech. Refuses a wheelchair, but has trouble walking. Elevated amylase and lipase. Chief concern is that he needs to show up to a job site tomorrow.

If you subscribe to this bizarre theory that "pain is what the patient says", you would medicate the 10/10 patient first. Bad nurse, no bicuit.

So, clearly as nurses, part of what we need to do is use tools other than pain scale to asses pain. In fact, we are trained in it.

When I have pt A, I do not advocate for narcotics. I do not believe it is the best interests of pt A for me to administer narcotics to her. If I am lucky enough to be working with an MD who is truly looking out for the best interests of the pt, rather than an easy solution, I want my documentaion to support both of our actions.

What do you suppose an emergency department would look like if we actually subscribed to the "pain is what the pt says" theory? That all complaints of pain were treated to the pt's satisfaction? Remember, the people I am talking about, 1; Don't have really busy schedules, and 2; pay nothing for the sevices.

Thanks for your input.

hherrn

Oh my goodness, you hit the nail right on the head. I agree 100 and 2 percent. You go!!!! I couldn't have said it any better.

Knoodsen

95 Posts

Specializes in ER, ICU.

I find many aspects of ER culture to be endlessly entertaining. I understand the frustration related to dealing with the pain issue; it is a big part of our lives. Pain and anxiety are the biggest reasons for ER visits. (If you work nights, as I do, you may be tempted to say, "what about all those fever babies?", but that's more about parental anxiety than baby's fever.) Charting can be fun. I enjoy the challenge of accurately portraying ER people. Quotes are always great. I include their grammar and pronunciation. If they rate the pain "beyond a ten" and have a big smile, then that is exactly what I chart. Also, they do not understand the pain scale so I never again ask them to rate their pain...even on subsequent visits. It can be useful to chart who assisted the Pt with their pain rating. Isn't it charming to watch the family members rate the pain? Anyway, learn to enjoy your charting because you will be doing a lot of it as an ER nurse. You have to be succint and you have to protect your license. You cannot possibly chart "everthing you do". Stable/normal Pt? Get in, get what you need to do done, and get out. Be nice to them. Then, while they marinate, visit every hour or so. Keep them comfy, offer the family coffee. Be nice to them. Then, go chart, "resting quietly. NAD. AOx4, pulse strong and reg, skin warm and dry, resp even and unlabored. No complaints. Awaiting.....". If you sense trouble, then avoid any unnecessary visits to the Pt and document exactly what is done or said. Don't let them intimidate you with that "if you didn't chart it, you didn't do it" stuff. (I can't believe any serious person could believe something so ridiculous.) OK. Next time someone accuses me of being rude, check my charting. There is no chance that I documented that I was rude to them. Therefore, I could not have been rude. There'll be a good chance I documented rudeness on the part of the complaining party.

mwboswell

561 Posts

Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
today 06:29 pmhazel3re: non-verbal signs of painlesness

by the book "pain is whtever the pt say it is" unless contradicting

hazel-

i am curious. do you actually believe this?

the bottom line is thus; neither you, i or anyone can tell anyone how/what you define "pain" as.

"pain" is subjective. it can be difficult to describe and characterize.

most of us look for the "acute" pain of things like sprained ankle, appendicitis, pid, sore throat etc....

but even then, it is described differently by different people based on their perception of the pain.hherrn

what we need is a better word other than "pain"....

i will typically ask my patient's not how strong their pain is between 1-10 but rather how much it is bothering them.

if they report higher than a 7 or 8 on the 1-10 scale, and they demonstrate some of the behaviors inconsistent with that; i'll ask them - "you say your pain is a 9; but when i come in the room, you are sleeping quietly until i awaken you" - and guess what, when we clarify this sometimes they'll admit it's just a "9" when awake; kind of like being able to sleep through a badheadache.

personally i look at what the triage rn or primary rn has put for the pain scale and note it. our hospital policy is to treat pain to a #4 on 1-10 scale, however, if the pain is higher than that, and i don't believe meds are warranted based on my assessment; then i'll chart something very similar to "pt interview, exam, demeanor and behaviors are inconsistent with verbally reported pain scale". then i'll skip ordering narcotics and try for some other modality instead.

what do you suppose an emergency department would look like if we actually subscribed to the "pain is what the pt says" theory? that all complaints of pain were treated to the pt's satisfaction? hherrn

not true; check your hospital policy - it probably says you have to address/treat pain to a certain number; not necessarialy what the patient determines.

remember, the people i am talking about, 1; don't have really busy schedules, and 2; pay nothing for the sevices. hherrn

...does your stereotype/prejudice really matter at all?

thanks for your input.

hherrn

Guest219794

2,453 Posts

what we need is a better word other than "pain"....

i will typically ask my patient's not how strong their pain is between 1-10 but rather how much it is bothering them.

if they report higher than a 7 or 8 on the 1-10 scale, and they demonstrate some of the behaviors inconsistent with that; i'll ask them - "you say your pain is a 9; but when i come in the room, you are sleeping quietly until i awaken you" - and guess what, when we clarify this sometimes they'll admit it's just a "9" when awake; kind of like being able to sleep through a badheadache.

personally i look at what the triage rn or primary rn has put for the pain scale and note it. our hospital policy is to treat pain to a #4 on 1-10 scale, however, if the pain is higher than that, and i don't believe meds are warranted based on my assessment; then i'll chart something very similar to "pt interview, exam, demeanor and behaviors are inconsistent with verbally reported pain scale". then i'll skip ordering narcotics and try for some other modality instead.

not true; check your hospital policy - it probably says you have to address/treat pain to a certain number; not necessarialy what the patient determines.

...does your stereotype/prejudice really matter at all?

hi-

i appreciate your thoughts on the matter. my point in posting wasn't to vent, or point out a problem in the system. my point was:

- there are often people who come in with a high pain rating, who don't receive any treatment that reduces their pain rating.

- with rare exceptions, when this happens, i agree with, and accept professional responsibility for, the treatment given. if i disagree, and feel that somebody is not being treated correctly, i, a. advocate for them, and b. document with objective findings, their signs, symptoms, and my efforts to address the issue.

- if a pt is discharged with a high pain rating, i make sure that my documentation reflects that i acted responsibly and professionally, and support this with my objective findings. (signs).

- the computer system i am using allows for customized acronyms. for example, i have set it up so that if i type in "ivdc", it reads as "iv discontinued, catheter intact, site asymptomatic, dry sterile dressing applied". it is a handy, time saving feature.

- while i am capable of documenting in narrative form, i was looking for suggestions of a list of signs of painlessness, to support the treatment given to a patient. to document a lack of something, you might provide a list of findings. for example, "no redness, swelling or drainage". this supports my action of applying a dsd, rather than aggressively cleaning the wound, or requesting a dr assess it. i would never write that a wound is not infected. i don't diagnose, i assess.

as far as a policy of treating pain to a certain number: i am not the most experienced nurse, but i have had the opportunity to work in 5 different er's. i haven't encountered it yet. i would be surprised if this was endorsed by experienced er nurses and docs. if you work in a place that uses that policy, and it results in efficient and effective treatment of patients, that's great.

regarding my prejudice: the simple fact is that for the most part, people with jobs who pay all or most of their health care, simply cannot afford to come into the er for minor complaints twice a month. i have a good job, and cigna insurance. my wife recently had a pretty simple er visit- a neb tx and inhaler to go. no labs or xr. it cost us $365 out of pocket. (total bill about $1065) in order for us to pay this $365, we have to give up something significant. whether it is money in our retirement, or some new toys, we are giving up something meaningful to us. a trip to our pcp would have saved us close to $300. we wouldn't dream of going to the er for anything that could be treated by our pcp.

saying that most frequent patients with minor complaints have a lot of free time and pay nothing for the service isn't a matter of prejudice. it is a mathematical fact.

i may have a prejudice, as i do have a belief that i can't support with any objective facts: do you believe that a person with a previously diagnosed chronic problem would come into the er if it meant giving up something significant to them? maybe a month of cable, or a couple weeks of cigarettes? my thought, unsupported by any studies, is that they would not. i think that they would seek a more efficient form of treatment. if this belief constitutes a prejudice then you are right.

hherrn

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