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.
