Pain assessment: do you believe your pt when...

MunoRN, RN · Nov 11, 2011

It's been well established that patients can sleep even with extreme pain. I've experienced it myself, and it's hard to describe but it's not really true sleep, even though it may appear like it.

If you're only medicating when a patient's pain gets to the level of moaning and grabbing their incision then you've failed at providing proper pain control. The policy where I work is to provide post-op patient with prn pain meds as though they were scheduled for the first 48 hours, unless contraindicated based on assessment. In California, attempting to provide prn's as though they were scheduled for the first 24-48 hours is actually the law.

By following the basic principles of pain management you can avoid oversedation but still provide adequate pain control. Adequate pain control not only improves patient comfort, but improves patient outcomes and decreases cumulative opioid use.

wooh, BSN, RN · Nov 11, 2011

I'm not sure about the prns as though they were scheduled being "the law" but I also tend to give prns almost as if they were scheduled for about the first 24 hours post op. Around 18-24 hours I try to transition to PO as if it was scheduled with the IV stuff available for breakthrough (and I like to overlap my last "planned" IV dose with the first PO so that there's not break waiting for the PO to kick in.) Having had a few surgeries, it sucks to wake up when you don't have anything in your system. It's harder to get pain down than to keep it down. If their vitals are stable, it's pretty tough to overdose someone with the standard post-op pain meds. Think of it this way, if I just chopped into your body, twisting and banging on the bones, would you want your last pain med to have been given 8 hours ago?

Know where the oxygen is, know where the narcan is, and know that you're not going to need them all that often because oversedating is harder than standard new grad fears would make it seem. :)

Always_Learning, BSN, RN · Nov 11, 2011

If pain is managed well before it becomes excruciating, you will actually end up using less medication. I enjoy teaching this to patients, because it never ceases to amaze me how many people try to "hold off" until they are writhing in pain because they don't want to overuse narcotics or become dependent. I also explain that we are not giving them meds any more often than the doctor has ordered, and that it is important for their healing that they are able to rest. Sometimes they get a look of relief when you tell them that "toughing it out" is not really the best option.

MunoRN, RN · Nov 11, 2011

You're not required to give prn's as scheduled since it's up to the Nurse to assess for contraindications (such as oversedation), but as the BON's administrative code (which defines how the law is enforced) states they "should" be given "or at least offered."

http://www.rn.ca.gov/pdfs/regulations/npr-b-27.pdf

xtxrn, ASN, RN · Nov 11, 2011

ORTHO patients hurt- a LOT. Bone pain is its own animal. And it's mean.

Neurological pain is also horrendous.

But, bottom line, it's not your job to believe them- it's your job to medicate them per their orders. Chronic pain patients LIVE with constant pain- it's their "normal", so that nifty little 1-10 scale is a joke. And their vital signs will be normal, since they've compensated.

Pain shouldn't get to a 10 while inpatient, unless maintenance drops a boiler on their legs. :cool: Anticipate regular pain meds post-op for at least 24 hours- depending on the type of surgery, other problems, and opiate tolerance. Someone can be tolerant of opiates, and not be addicted.

Do NOT worry about addiction with a post-op patient. In the time you have to deal with them (a few days) they physiologically can not become addicted. Give them the drugs.

Think about some time you had horrible pain- and what if someone kept relief from you.... it is cruelty to do that.

But, I applaud you for asking for opinions about this. Just remember- pain is what the patient says.... I've had someone tell me their pain was a "20" (out of 10) then go romping down the hall to get coffee. She had "real" physical problems. I called and got a "booster" dose of narcs. She got the dose, fell asleep, and woke up feeling better.

Sometimes WE teach patients to be more dramatic to emphasize what they say, when what they say should be enough when they have a busted up body, or lab work/tests that verify some physiological disorders.

xtxrn, ASN, RN · Nov 11, 2011

Duplicate post :confused:

Anna Flaxis, BSN, RN · Nov 11, 2011

First remember that there are distinctive differences between acute pain and chronic pain, and that a history of chronic pain can complicate the management of acute pain.

For a person experiencing acute pain, I would not expect them to be able to sleep with a pain level of 8, 9, or 10. By definition, that is extreme pain that prevents normal functioning. A 10/10 acute pain would be like having your arm ripped off or being mauled by a bear or being submerged in boiling oil. It's the worst possible pain there can be. It's so severe that you actually pass out. I have seen very few people in 10/10 pain, but the ones I have seen, I will never forget. These are people with blood pressures of 285/150 while grimacing and bucking the tube on astronomically high doses of Propofol, needing liberal and frequent doses of Fentanyl. I have seen 10/10 acute pain, and when someone (without a history of chronic pain) is sitting there texting on their cell phone and smiling, telling me their pain is 12/10, forgive me if I have a hard time believing that.

With chronic pain, the body adapts to being in pain over time; there are actual changes to the brain and nervous system that occur, where the person can be at a very high level of pain, but their vitals are WNL and their behavior does not "look painful". What also can happen is that the person A) Develops a tolerance to opiates, requiring larger and larger doses, over time, to achieve the same effect, and B) Develops an extreme sensitivity to pain, where things that might not seem very painful in ordinary circumstances, can be excruciating to the person.

When the person with chronic pain experiences acute pain, the acute pain might be more intense for them that it would be for the person without a history of chronic pain. Also, they may have developed a high tolerance for opiates, so much so, that you could give them enough Dilaudid to kill an elephant, and they're still going to be hurting. They might not "look" painful, because they're always painful. Their VS might be WNL, because they have adapted physiologically.

So, as a general statement, the idea that a sleeping person is not experiencing pain is false. While it may be true for the person experiencing acute pain, the person who suffers from chronic pain has learned to sleep even when experiencing a high level of pain.

I think you are right to look at the whole picture and ask yourself some questions. Look at the patient's history, what they normally take for pain, and talk to them.

Whenever I'm confronted with someone who's experiencing acute on chronic pain and has been on opiates forever and a day, I just level with them. I tell them that I will do my best to get them more comfortable, but that their safety is my primary concern. I tell them "I don't want you to be in pain, but I don't want to kill you, either.". I will give what medications I can safely give, because I don't want them to hurt, but most likely, we're not going to get them pain free; and generally, chronic pain sufferers don't expect to be pain free, ever. I find out what level they are currently at, and ask them what level they would like to be at. If they live at a 6 but they're currently at an 8, I'll try to get them to a 6, but they might have to settle for a 7. I show them that I am involved and invested in their pain control, but that their safety is just as important to me, and that we need to be realistic in our thinking about what we can achieve. Most people who live with chronic pain are very receptive to this, and appreciate my concern for both their pain control AND their safety.

I can have the same kind of conversation with the person experiencing acute pain, but the concept that they will probably not be at a "0" any time soon is not usually a concept they've thought of. Often, the person experiencing acute pain has a belief that being pain free is a reasonable goal, when it is often not. So that's where the conversation usually starts, with clearing up that misconception. Then we go from there and work together to set a goal that seems achievable, and at which they can function and participate in their recovery.

anotherone, BSN, RN · Nov 11, 2011

the whole signs of pain stuff always got to me. because when in extreme pain i don't moan and groan or grab my ankles or flop around in the bed........ frankly, i can't stand it when patients are undermedicated for pain, yelling and screaming at me for more pain meds and the md doesn't want to order more or explain the rationale (esp to the patient) for not doing so(some times there is one).

Anna Flaxis, BSN, RN · Nov 11, 2011

Know where the oxygen is, know where the narcan is, and know that you're not going to need them all that often because oversedating is harder than standard new grad fears would make it seem. :)

That's a good point and very good advice, but don't dismiss the possibility. I've seen respiratory arrests r/t pain meds given *as ordered*. And on noc shift, it's harder to assess for oversedation because patients generally sleep at night, and some sleep pretty hard, hence the rationale for keeping fresh postops on continuous pulse ox overnight.

honeykrown, MSN, NP · Nov 11, 2011

Actually yes i do believe pt can sleep through pain and wake up with 10. Most of the time its the pain that wakes them up and if they say it is 10 i usually believe it cos sometimes i experience that kind of pain. Sometimes they are sleeping fiive minutes ago get up to use the bathroom (which you are not aware of since you were in there 5minutes ago) and then get in bed and start feelign pain. sometimes they sleep to get away from the pain

Morainey, BSN, RN · Nov 11, 2011

I have concerns for a couple of reasons. First of all, I work with some older veteran nurses who only medicate when the patient asks for pain. When I started as a new nurse, I tried to medicate around the clock with PRNs "scheduled" by virtue of the fact that it was an ortho floor, and so many patients were in pain due to their recent surgery.

However, working at night (after orienting on days), I am so much more nervous about oversedating or overmedicating patients. Sometimes I have trouble deciding whether it is better to let 'em sleep or better to wake them up Q4H w/ a pain med. A couple of times I have given people pain med, went to document on their eMAR what their pain was, and when they say "oh not bad, about 1 or 2 out of 10" I was like oh crap, they probably didn't really need to be medicated.

I think mainly, for myself, it is a confidence issue. I am still trying to work out a balance between trusting my judgement. I like to ask other RN's working with me their opinion, but sometimes I get blown off. For instance, I was working with a nurse the other night who I asked this question:

My patient had chronic pain and took Oxycontin at home. When she came up from surgery her BP was crappy (80s/50s) and was begging for pain meds. I was so nervous about giving her Dilaudid because of her BP. Morphine and Toradol didn't help at all, and neither did any PO meds we had. She ended up getting a Dilaudid PCA, but it was a long night of me going in her room and watching her breathing every 20 minutes because I was so scared about crashing her BP and respiratory drive.

I asked the nurse working with me what they thought, and they said if she is begging for pain med, give it (knowing that the BP was low). Then a couple of hours later when the CNA came up to tell me the patient's BP was low (again) they were like... WHY did you give the patient Dilaudid with a BP like that?? And frankly, "But I asked so and so and they said!" is not going to cut it if I had ended up calling a rapid response.

So like I said, I'm a little rattled. I've been reading up on my pain meds, but I am second guessing my every move for the past couple of weeks. I used to trust my judgement. It's not like a patient coded or anything, but I'm still feeling pretty anxious and inexperienced. :uhoh3: