Rethinking Pain Assessment

[gwenith]

I want to do a little exploration here and get general nursing input from nurses everywhere across all disciplines about assessing pain and in particular non -verbal cues that indicated the patient may have pain.

I don't want this to degenerate into an argument about "If the patient says they have pain we must treat it". That is a "given".

What I am after is the non-verbals such sa posture, pallor, attitude etc of the person in pain that would tell you they have pain.

Are there patterns of pain response particular to chest pain or abdominal pain or male vs female?

I am also looking for indications that might lead you to think that the person is either overreporting their pain or is faking entirely. Asking this part of the question is not a validation for withholding pain medications but a way to work out how and why we are getting a different non-verbal message to the verbal one.

I am not looking for textbook answers here what I am exploring is data that may not or will not be in a text book.

If you like think of this as phenomenological research. Everyone's opinion and experiences are valid and worthy. From your responses I will try to summarise and recap and see if we can take the research up to the next level.

[fab4fan]

Anyone can use sleep as an escape mechanism when in pain. Being able to sleep does not mean that pain is improved or under control; sedation also does not equal pain relief. It is possible to be quite sedated but still in severe pain.

[oramar]

My problem is more with family members who say patient needs pain meds when patient says "NO". I am running into that so much lately. Anyone else have this problem? If the family feels that the patient is concealing pain I am only to glad to quietly do pain teaching. However, I can kneel on someone's chest and shove it down their throat.

[gwenith, BSN, RN]

Originally posted by fab4fan

Anyone can use sleep as an escape mechanism when in pain. Being able to sleep does not mean that pain is improved or under control; sedation also does not equal pain relief. It is possible to be quite sedated but still in severe pain.

I think that the "patient is asleep and therefor not in pain" is an abiding myth in nursing AND medicine. It is one of the things I was hoping to uncover.

Has anyone hit the person with the bradycardia response to acute pain?

P.S. Thank-you for your thoughtful responses!!!!

[live4today, RN]

Originally posted by glascow

This is something I have noticed taking care of post-op open-heart pts. This is very generalized, but usually predictable.

black females- high tolerence for pain. Rarely ask for pain meds. Usually just ask for a tylenol when you are asking them if they need something for pain.....................................................

It must be something in the genes that make black females stronger than white males!

glascow, I must be a very mixed up kind of mutt because sometimes pain tolerance works for me, and sometimes not. If you ever have me for a patient though.......gosh darn it.....JUST BRING ME THE FRIKKIN PAIN MED STAT!!! :chuckle :roll :chuckle

I wonder what gene in me that was that just jumped out here? :chair: :rotfl:

[glascow]

I hope no one thinks I medicate my pts based on the generalized statements I made.

Of course, I would never NOT give pain med based on what I said.

I was just sharing my observations over the past 12 yrs.

Regardless of race or sex, I do a thorough pain assessment on all of my patients and medicate accordingly.

[atownsendrn]

Originally posted by gwenith

[Has anyone hit the person with the bradycardia response to acute pain?

[/b]

Just a few shifts ago I had a man come in the ER with severe (rated 10/10) epigastric and RUQ pain. He was pale and diaphoretic. Really sick looking. Heart rate was 35 in assessment. Needless to say I put him in a room and on a cardiac monitor. To make a long story short - he had gallstones. Once his pain was relieved his heart rate was in the 80's.

I have also had a few women that come in complaining of teeth or jaw pain - and they were having an AMI.

I agree that young white males seem to be the worst whiners.

I also agree with the sleeping issue. But that is a hard one to explain to nurses (especially ER nurses) if they have never been in pain.

One thing I do alway question is the person that comes in complaining of severe abd pain and nausea. But they are out in the waiting room eating Cheetohs and drinking Coke. That one I don't understand.

I realize that pain is perception. But what do you do with people who rate their pain at 25 (on the 0 to 10 scale) everytime they come in.

[gwenith, BSN, RN]

I just saw an intersting article about the manchester pain assessment tool - has anyone used this?

[grizngrit]

My Dad was allergic to Lidocaine. He needed a Hickman placed. Dr had the staff ice his chest for 15 minutes, then Demerol 25 IV prior to placing the line. Dad seemed to go into a trance, yet would answer appropriately; became hypotensive and bradycardic. (BP 70/40, P 50) When told it was over, he was a/o and asked Dr. "Did my BP go up or anything?"

I was amazed--it gives insight into the power of the mind over body.

[Noney]

I've noticed elderly pts that are bedridden and otherwise nonresponsive get restless when in pain.

Dementia pts get mean.

[canoehead, BSN, RN]

If I suspect a patient is not being honest as far as the pain scale goes I ask them questions that I can verify somewhat, like " are you feeling ANY changes after the meds I gave you?" Do you feel lightheaded at all?"

If they are slurring their words and swaying on their feet I can chart obvious changes in mental status that contradict what they are saying. Patients I would call drug seekers frequently deny any effect from the meds when they are obviously stoned. Other patients will say they feel dizzy, or nauseated etc but still their pain is too much for them. Usually after 20+ of morphine I expect people to report some change in how they feel, not necessarily that their pain is better. I also wait until I see very obvious changes in behavior. My personal prejudice is to give as much as I legally can to those who report their responses honestly, until they tell me their pain is relieved.

If someone is not being honest with me I will say " You tell me that you feel absolutely no effect from the medication I gave you but I see that you are acting differently- have you noticed that?" If they say no then I can't depend on them to report accurately on their body responses and have to go with my own assessment. I have had someone get to the point of semiconciousness, all the while reporting that she had ABSOLUTELY no effect from the dilaudid we gave, and when roused and asked about pain level she would mutter "10" and go back to sleep, with apnea periods...

I say their safety and survival, along with my license take priority over a stated 10/10 pain rating. I had to find some way to keep patients from gorking themselves into oblivion, and this is the best way I've come up with so far. Unfortunately drug seekers do exist and some will arrest before admitting they've had their limit.

Honestly, it would be less work for me to just give as much drug as often as the patient wanted-no nasty objective/subjective charting q15min, and gorked patients are happy patients...but there's that nasty breathing issue. If they have no higher goal for themselves than getting a fix I say to each his own, but don't expect me to put my reputation and livlihood on the line to give you momentary pleasure.

[CCL"Babe", BSN, RN]

These past eight months have been a lesson to me. My past history of being an ER nurse had made me very sceptical.

Having been in chronic pain since January when I herniated a diac has given me a totally different view. Yes I can laugh, eat and sleep with pain. Sleep is an escape mechanism for me. I don't take anything for pain, I do though for sleep. I am at the point where I don't want to rarte the pain, talk about the pain or even think about the pain. I am afraid that Iwill always be in pain now for the rest of my life. The surgery worked at first, but I tried to do too much. Sometimes I'll just say I'm not in pain so I don't have to go through the whole rating and describing thing when I'm in PT.

Crossing my fingers I haven't had the 10 scale pain that made walking or moving almost impossible.

I never thought about all the psych implications before this. The depression, fear of addiction, fear of being thought a drug seeker, the fear of not being able to walk in the morning and never knowing when it was going to happen. The fear of losing my job. The effects it has on your marriage. Not being able to even clean yourself after the bathroom and getting UTIs. Not being able to do the things you love, or even grocery shop.

Now I'm even depressing myself more. Enough. You get the idea.

[ceecel.dee, MSN, RN]

Pain is exhausting to deal with! I think most people dealing with pain, deal with fatigue as well, so sleep should be expected. I also agree that it is a temporary escape from the pain.

Great thread!