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Nonverbal symptoms of pain

Hospice   (10,965 Views | 7 Replies)

redheadedvixen specializes in Cardiac, Hospice.

1,155 Profile Views; 23 Posts

I have this patient with dementia who doesn't really have the ability to verbally express his pain. In his life before dementia I am told that he was very stoic and would never complain of pain even if he was in agony. I have found him several times moaning and groaning in his bed holding one part of his body or another. His family doesn't want him to take anything stronger than Tylenol, they say he's never been in pain and they don't believe he is now. His DOCTOR says moaning and groaning and holding your body doesn't mean you are in pain. :angryfire I was flabbergasted at this. Our medical director is going to intervene in this but has anyone had problems like this with physicians and families not wanting you to properly address a patients pain? How did you handle it?

As for that doctor.......someday I'd like to be his nurse.... Yes sir I understand you just had an amputation....I have your tylenol right here.......... (oh that's so not nice :devil:)

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marachne specializes in Hospice, Palliative Care, Gero, dementia.

349 Posts; 8,931 Profile Views

There is a well tested and recognized means of assessing pain in persons with dementia called the PainAD. (It is also appropriate for other non-verbal patients)

There is a wonderful website called "How to Try This" that has a number of Assessments and Best Practices in Care of Older Adults. There is both written information and video individuals using the different tools.

Pain Assessment in People with Dementia is here: http://tinyurl.com/dhvz8x

and the video is here: http://links.lww.com/A251

good luck w/the family and the medical director

And yes, grimacing, moaning, guarding are all signs of pain! So are less subtle things, so maybe bringing some information from experts will help your case

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Higgs has 20 years experience and specializes in Med/surg. ED. Palliative. Geront.

109 Posts; 2,368 Profile Views

Educate the family too. Loads of people think analgesia will sedate and put them to sleep. Not to mention kill them sooner...

Edited by Higgs
typo

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Irish_Libra specializes in LTC & hospice.

6 Posts; 912 Profile Views

just to add that educating patients families sometimes entails reminding them that men in the older generations were taught not to show pain & that to do so is a sign of weakness. And that since he is now unable to make decisions for himself regarding his comfort, it is their responsibilty to do so. Remind them how well he cared for them when they needed him to, & ask that they return the favor to him. (do all this with caring, compassion, & understanding... not so bluntly as I put it)

Moaning, facial grimacing, flexing/contracting muscles, clenching fists can all be signs of non-verbal pain indicators.

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jenkayaker specializes in Hospice, QAPI, LTC, RAI-C,med surge/onco.

4 Posts; 955 Profile Views

My hospice uses the FLACC scale. It is very simple & concrete. You could educate your families on determinging their loved ones pain easily. Google it, you will find the criteria sheet. I will try & post ours later.

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tewdles has 31 years experience as a RN and specializes in PICU, NICU, L&D, Public Health, Hospice.

3,156 Posts; 31,062 Profile Views

As Marachne pointed out, the PAINAD is the tool that you need to use in the situation described. It is a tool designed specifically for assessing the pain of the nonverbal adult. It is an excellent point that you should use this tool as a means to educate the family about signs and symptoms of pain. I am sure that they will want this patient adequately medicated when they realize the level of pain that is being demonstrated on a purely honest level. It is entirely possible that if you speak to the primary physician in terms of a PAINAD assessment or even the FLACC assessment (they are very similar) the MD may respond in a more appropriate manner. Many times MDs are looking for that objective input from the nurse when it comes to pain. When I was a young nurse (waaaay back in the day), working in a PICU, I worked with very competent MDs who were too cautious with opioid use in the pediatric population. I had to be very diligent about collecting data that would support my assessment of pain in the critically ill child. The FLACC scale was an important part of that assessment. Otherwise, those docs would look at the intubated, paralyzed, 9 yr old MVA victim and treat the symptoms of his pain without treating the pain! If we are nothing else as nurses, we are the patient advocate. Sounds like you are on a good path, persevere!

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rngolfer53 has 2 years experience.

681 Posts; 5,600 Profile Views

Educate the family too. Loads of people think analgesia will sedate and put them to sleep. Not to mention kill them sooner...

I always do my PainAD assessment with the family, to educate them, get their input--Grandma's brow has been deeply furrowed ever since eldest son bought the Harley-- and let them know I don't just barge in and give pain meds willy-nilly.

Most often, families then understand and agree with your POC, although some need education to correct what they "read on the internet" at http://www.morphineistheinventionofsatan.com.

As to docs, I've only had to do it a couple times, but when a primary physician is hesitant to adequately relieve a Pt's pain, I'll ask them if they are more comfortable if I page our on-call hospice medical director to manage pain. Never had one say "no" to that.

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