pain level of 10 but sleeping

[1996RN]

i have been working in the pacu of a surgery center for a few months now, feel like i've caught on pretty good and am confident in my work. however, recently had one pt who was a lap chole and had pain level of 0, but still gave her 2 lortab and transfered her to the discharge area. apparently during the move, she developed a pain level of 10, but her pain meds hadnt kicked in yet. they refused to take her and transfered her back for me to get her pain under control. as soon as she was back in bed and monitors on, her heartrate was in the 40's, bp 100/60, sleeping. when woken up, states pain as 10. my boss said to give her some meds. i dont feel comfortable with that, especially since my boss is usually the first one to encourage us to kick them out to discharge. if they are awake and talking, get em out. so i told her the pt's hr, bp, sleeping, etc, and she still said to give her meds. ended up giving her meds, she was fine and eventually pain level went to a 4, but still snoozing. how to straddle to line between a fake pain level and what we really know?? what would you have done?

btw, i worked in labor and delivery for 9 yrs and am very familiar with a pain level of '10', even with an epidural and a sleeping pt. but i am used to managing my pt myself without my boss hovering over my shoulder telling me to medicate them.

[SuesquatchRN, BSN, RN]

You can sleep through pain.

I think pain is terribly undermedicated.

[loricatus]

We get standing orders that include IV Fentanyl.

I avoid the pills because of post anesthesia nausea issues and the delayed effect.

Some research studies show that fentanyl works the best within the first 20 minutes post surgery and does not effect the HR and BP as much as Morphine can. After that 20 minute window, pain relief was best acheived by using Toradol IV(according to the research). I have been using these with great success (meaning-able to get most out the door in the time alotted), adding Zofran or phenergan to prevent nausea (if they had not been given prior to entering the PACU).

Now, whether this person is a seeker is more difficult to determine. A look at their med rec sheet may give you clues. If they are on narcotics pre-operatively you may have a seeker or someone going through withdrawal. But, having gallstones is painful and those narcotics may have been recently prescribed-so, an additional look at the history may help. Can never know for sure, so it is best to do what you can to relieve the pain they state they have. You CAN sleep through severe pain because of the exhaustion it causes.

BTW, I have found PACU (surgery center) to be more intense treat em, street em than the ER ever was.

[CaliRN29]

I think it is possible to sleep through the pain but the patient is your patient, not your managers! Our anesthesiologist will "reorient" people to the pain scale and describe pain 10/10 as someone ripping your arm off! I find that the younger people don't have a good grasp on the pain scale ... :)

[cardiacRN2006, ADN, RN]

Fake pain? Wow!

I remember one time when I had such terrible pain, and I was asleep. The best I could do was lie still and try to stay asleep. If you were to look at me, I might have appeared to be resting comfortably. But I was in agony. It was a terrible, terrible night.

And it was indeed, not fake.

How sad..

So your questions was, how to manage fake pain and real pain? The answer is, the same. You medicate. Especially in pacu, that's your job.

BTW, sleeping is a way for pts to cope with pain.

[Southern Fried RN]

Ugh...I hate dealing with that situation and it seems like I hear my co-workers have that same argument with the patients several times a day. "How can your pain be a 10 if you were just sleeping?" It's not worth the argument! If the patient's BP, RR, O2 sats are fine, then I willl medicate. I'm not in the business of discerning a drug seeker or detoxing people, so what do I care?

I will draw the line at someone who is alert, chatty, asking for family/ice chips, and has a 10 pain level. I inform them of their post-op orders for pain meds and send them on their way.

Sometimes a little IV Valium helps for severe pain that is caused by muscle spasms.

[jmgrn65, RN]

Trust me Sleep is an escape from Pain. Just because someone is asleep doesn't mean they aren't in pain, sometimes it is the only way to escape is to sleep. I suffer from Migraines and sometimes that is the only relief I get is to sleep. Of course it isn't easy falling asleep.

[HeartsOpenWide, RN]

Pain is what the patient says it is, its not our place to judge if a patients pain is "fake or not" if the meds are PRN and its OK to give them according to the MAR and the patient states they need pain meds, then give them pain meds. She could have been in a lot of pain but going in and out of sleep because she was just under anesthesia and had surgery...Labor pains and pain from surgery are two different balls of wax. Labor pain is natural for the most part, surgical pain is not (as in getting surgery is not natural, not something our bodies were made to do...)

[care4kids]

"Ugh...I hate dealing with that situation and it seems like I hear my co-workers have that same argument with the patients several times a day. "How can your pain be a 10 if you were just sleeping?" It's not worth the argument! If the patient's BP, RR, O2 sats are fine, then I willl medicate. I'm not in the business of discerning a drug seeker or detoxing people, so what do I care?"

I agree--pain is very subjective and depends on the person. If a patient says they are hurting and meets criteria, it is your job to treat. IV pain meds work quicker than po. If you have already given po, IV fentanyl and continued monitoring is a good idea, because it works quickly and wears off quickly, giving the po meds time to work. In our Pedi PACU, we often load up patients with a combined total of 2mcg/kg fentanyl (in 4 divided doses) within the last hour on our pediatric patients and immediately titrate in morphine in divided doses over about 30 minutes. If they are sleeping and already got adequate fentanyl on board, we will progress straight to morphine. We treat for pain preemptively. The more experienced nurses in your unit may be able to give you some tips on how much pain they think certain surgeries will cause. Pain control is best when you get on top of it and don't have to play catch-up.

I have also found in my 9+years in PACU that some patients won't wake up until you give them adequate pain meds. I have taken care of patients that were so sleepy and staying an extended length of time. When I tried everything to wake them up and then out of desperation looked at their last dose of pain meds and thought--hmm--let's try that! Bingo, 15 minutes later the kid wakes up and asks for a popsickle.

[Alexnursing1]

Pain is subjective. We, as nurses or even bystanders, do not know how the individual is feeling inside. If the patient really is faking, it is not our job to punish, or even judge them. We are to make our patients comfortable and feel at ease, while keeping them safe. If it is safe to give pain medication, and the patient states their pain is a level of 10, we must administer the pain medication. Some people show pain differently, some may sleep, others may scream.

[sharpeimom]

Pain is subjective, so if the patient isn't reacting as you might, that is irrelevant. We show pain in different ways.

When I have severe pain, I read or listen to classical music. I also meditate. It doesn't eliminate it but it will sometimes

lower it from an 8 or 8.5 to a 5, which I can cope with... but only if some moron doesn't keep asking me questions or touching me to see whether or not I respond.

Don't assume!

[azhiker96, BSN, RN]

Pain is subjective so as long as the patient can maintain their O2 sats I'll keep giving meds. I tell them I'll keep working on their pain as long as they keep breathing. That way, when/if they desat I can remind them that breathing is number one and that's why I'm not giving them another dose at this time.

Also, if the pain seems unreasonably high consider other causes. We had one lap chole pt whose pain did not respond to meds. Anesthesia okay'd discharge to med/surg. The patient later became hypotensive and went back to the OR to correct a bleed.