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

Always_Learning, BSN, RN · Nov 11, 2011

Something to keep in mind also is the patient's baseline BP...some run low to begin with and that is their "happy place." Another thing is that you can always ask for something to support pressure (proamatine or somesuch) if the patient is needing lots of pain meds for a longer period of time (such as for ortho patients) and their BP is making you nervous.

hiddencatRN, BSN, RN · Nov 11, 2011

So I have a question:
A patient of mine (who was a nurse) told me that if the patient is sleeping, then they are not in pain.
Since I am a new nurse, I a little gun-shy with pain meds (I work nights on an Orthopedic unit). Do you believe a patient who says that they are in 8, 9, 10 out of 10 pain when they were sound asleep five minutes ago?
I try to incorporate the whole picture, such as, are they showing any other signs like grimacing, moaning, grabbing their incision? What was the last time they were medicated? Do they have a high tolerance for pain? Were they taking a lot of pain meds at home and thus have a high tolerance for opioids? And so on.
Let me know what you think... I am scared to death of overmedicating a patient!! I had a scary experience with someone who was taking a LOT of Dilaudid and now I am really nervous.

Sleeping patients can be in pain, also, if there is a med for pain ordered around the clock, you want to give it to them to keep on top of their pain instead of having to do catch-up later.

I will admit to being skeptical that the patient who is awake who appears to be fine, is eating McDonald's, texting on their phone when I'm trying to ask them assessment questions, etc tells me they are in 10/10 pain. Sure, maybe they are and just cope without outward signs, but yeah, I have doubts. I still communicate their pain level to the doctor and get them meds but I wonder if we should be more descriptive about pain scale levels: 10/10 is "torn apart and eaten alive by a lion pain." How many people experiencing that would be able to ask me why the TV isn't working and will I fix it for them?

Morainey, BSN, RN · Nov 11, 2011

The flip side of the coin is the patient who says they have no pain after surgery. We are supposed to have them flex their knee or hip and then tell us what the pain is.

So if the patient says 0/10, I have no pain. And then when they get up with PT and THEN they have pain, the physical therapist is like, why wasn't this person medicated??? :no:

That being said, when the person says "no, I have no pain, 0/10 even when I bend it all the way," I do attempt to talk them into taking pain medication. Ie, yes I know it doesn't hurt now while you're lying down in bed, but you are going to be getting up out of bed and walking and climbing stairs today, and it's counterproductive to be in pain. And when they say "nope! I think I'm good!" I think to myself, oh crap, PT is going to be coming up to me angrily in about an hour.

xtxrn, ASN, RN · Nov 11, 2011

Sleeping patients can be in pain, also, if there is a med for pain ordered around the clock, you want to give it to them to keep on top of their pain instead of having to do catch-up later.
I will admit to being skeptical that the patient who is awake who appears to be fine, is eating McDonald's, texting on their phone when I'm trying to ask them assessment questions, etc tells me they are in 10/10 pain. Sure, maybe they are and just cope without outward signs, but yeah, I have doubts. I still communicate their pain level to the doctor and get them meds but I wonder if we should be more descriptive about pain scale levels: 10/10 is "torn apart and eaten alive by a lion pain." How many people experiencing that would be able to ask me why the TV isn't working and will I fix it for them?

I think some of it depends on how long they've had the pain, and the type of pain... and those without a history of pain are going to jack up the scores, just because they don't have the frame of reference for anything worse. :) My dad after a lap choley is a good example. The guy never even gets a run of the mill headache. He had an emergency appy about 30 years ago- but doesn't remember much of it, so again, no frame of reference of actual "slice 'm up" surgery. He came home with his 3 bandaids, and CO2 in his shoulder area, and you would have thought someone was ripping off a limb sans anesthesia. To HIM, that was horrible, and as bad as it gets.

Then look at someone with reflex sympathetic dystrophy, a torn ACL, broken femur, or other acute or chronic pain, that many of us have seen drop a grown person to the ground. Their frame of reference is WAY different. And, the differences between neurogenic, orthopedic, visceral, and other pains will make a huge difference in how they are assessed and treated.

I (and many others on this board) haven't had pain free days in years (for me- since 1996). I don't remember the sensation. Yet, I prefer to spend my time with humor and interaction with others. That's for the fibromyalgia (neurotransmitter related pain) and chemo-related pain.....If I've got a bad headache - I'm not likely to move out of bed for hours. Pain is my normal- so that 1-10 scale is a joke. I will give the doc's office some number (usually based on the faces scale- because the numbers mean nothing). When I tore my ACL and medial meniscus on my left leg, I was bed bound for weeks, only getting up to pee and get the delivered food at the front door- I hurt too much to sit at a chair to eat it, so lost about 18 pounds in a couple of months; no help... dad went on vacation....so I had to function at least a little. :)

There will always be the idiots. They still might hurt. And, unless they're in a drug rehab facility, it's not a hospital nurse's job to "fix" them.... maybe the pain IS from detoxing (opiate detox hurts). So give them the meds, and keep them from going into withdrawals...medical hospitals don't know how to handle that--just like the rehab place isn't designed for surgical patients. :up:

Anyhoo, just my experience- professionally and personally. :)

xtxrn, ASN, RN · Nov 11, 2011

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.
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.

You have to wake them for vitals the first couple of nights anyway- so when you ask about pain with vs, ask if they need meds :)

With the PCA, anytime I had concerns about someone's respiratory situation, I got a pulse ox on them.... most of our docs ordered them the first couple of nights anyway. It helps - if they don't like the beep, then too bad. Respiratory depression trumps Press Ganey (and they could mark my wide behind down as much as they wanted to, as long as they went home vertical and not feet first).

You have legit concerns- but some patients have low BPs anyway- had one lady in drug rehab (alcohol only for her) who ran a 60SBP ALL the time. She was a repeat customer (must have had the Groupon, and bought them all for her ).... her BP was ELEVATED at 80SBP. :eek:

Ask for a pulse ox if you're concerned. :up:

Morainey, BSN, RN · Nov 11, 2011

Maybe I'm just overthinking it...

I don't feel like I'm doing horribly at nursing. In fact, I usually feel pretty competent... just wish I could shake this pain med paranoia!!

Thank you all for your answers :)

Chad Collins · Nov 11, 2011

I'm a first year nursing student, they taught us we don't question the patients pain we give the meds as doctor ordered and to practice pain management so the pain never gets out of control.

Morainey, BSN, RN · Nov 11, 2011

I'm a first year nursing student, they taught us we don't question the patients pain we give the meds as doctor ordered and to practice pain management so the pain never gets out of control.

I was taught all those same things too. I'm mainly worried about overmedicating a patient, especially in instances where a patient's blood pressure is low.

wooh, BSN, RN · Nov 11, 2011

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.

True. I check to make sure they're breathing before I give another dose, just in case. :) For me, it's all about the respirations.

ObtundedRN, BSN, RN · Nov 11, 2011

...patients generally sleep at night...

If only this was true. This sounds like dayshift propaganda to me... Lol

wooh, BSN, RN · Nov 11, 2011

If she's on chronic Oxy, her BP is very likely ALWAYS low and she's going to need much higher doses than an opiate naive patient. As for before PT, oh yeah, I will talk someone into it. "So they can make the most of their PT session as it would be a waste to have to wimp out halfway through!" They'll usually go for it after that.

pistolchick · Nov 11, 2011

Sometimes they get a look of relief when you tell them that "toughing it out" is not really the best option.

This is very true. I used to like to tell people, "There is no medal for bravery." I also reminded them, as is true for many orthopedic post-ops, that because physical therapy is going to be part of their daily routine, they must take pain medication in order to tolerate the therapy that they require to get back on their feet (literally). This often made sense to patients, as well.