Rethinking Pain Assessment

fab4fan · Aug 11, 2003

Originally posted by canoehead
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.

Sedation does not equal pain relief.

**canoehead, BSN, RN** · Aug 12, 2003

I agree fab4- but if they tell me that they don't feel ANY effect from the med when I can see a definite change, then I start to doubt their honesty. I absolutely agree that a person can be acting loopy or sedated and still be in extreme pain. People I consider drug seekers tend to minimize the effects they feel so they can get more and stronger meds.

gwenith, BSN, RN · Aug 12, 2003

Sigh! I will admit to sometimes using the placebo effect. I will give panadol (acetaminophen) and tell them that because it works on different pain receptors it will work where stronger drugs don't and it has a synergistic effect on most medications so that it makes the effect stronger - Okay not ENTIRELY truthful but sounds so good and believable that they do believe. Even if it is not correct and it is just the placebo effect giving the pain relief then - does it really matter so long as they get relief?

Next question - how many use non-pharmaceutical methods for pain relief and what do you use?

**canoehead, BSN, RN** · Aug 12, 2003

I use heat, cold, position change, pillows, sometimes elderly do well with a cup of tea and a cracker. But with severe pain I like to give the quick fix- IV drugs- and then go for the TLC afterwards.

Irwin0111 · Aug 12, 2003

We are all connected with one another in anyway for whatever that is. I have my full belief that even for the things we feel I mean everything we feel inside out the spirit in us will always make its way to be obvious in all attempt even in the slightest form of emotion. Because,it somehow reveals the truth.be it on the good side or the bad and as the spirit in us dwells in the good, on how one inevitably make show the way he feels if say he is feeling good/happy is lettiing the infectious nature of that emotion to reach out to others in its will to edify or just share others the benefit of that particular emotion. that would mean exactly the same to those that are bad. but in attempt to caught others aware in such spirit desire for others help that in turn makes one ackowledge the basic fact about life that we are all connected in such a way.

letting yourself understand the nature of us. Will help us how we deal about everything.As i say,you will always tell it right if one is really feeling pain even in the most silent of moments.

Am I getting it right? i dont know? Studies will add better into that .

ywee

:cool:

purplemania, BSN, RN · Aug 12, 2003

Brady in kids is always a red flag. Their normal tendency is to be tachy. If they WERE tachy, then went brady on me I would be very nervous. Of course, at 60 beats/min we start CPR if a small child. Maybe the body is overcompensating. This is why rest (with or without sleep) is so impt. to people in pain. Conversation is a stimulant to a degree. Visitors need to be educated to this.

luv-my-dal · Aug 12, 2003

Great thread.....

I believe that, yes, we must believe what the patient tells us. Who are we to say how each individual should/will react with pain? We each feel pain differently and with individual reaction to each episode....

Could you imagine how much more stress that would add to us if we had to "judge" everyone on what we thought their pain was and if it was "adequate" to the situation?

Anyway....I obviously do not have the answer you are looking for as I have recited probably what others have thought also....

I am going to thoroughly read through the posts and see what others have to say....

I really like these "thought provoking" beyond-the- text-book threads! Thanks Gwenith :)

CCU NRS · Dec 24, 2003

Originally posted by 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.

I do not have time to read the entire thread but am very intrigued by you research and wish to participate.

I assess a Pt on entering the room by looking at and speaking directly to them. My first assessment of pain in their actions ie swiftness of movement, grimace, facial droop, favoring or guarding, sounuds that are made with movement from creak crack groan to rub wheeze whistle. I speak clearly and assess hearing by changing pitch and volume as seems appropriate. I then listen to Heart, lungs, bowels abdomen and while finishing ask do you have any pain or probelms right now? I listen to thier description of any pain they wish to report and ask question such does bother you all the time or just when you are doing certain things? I ask what brings it on or starts it? I assess any area appropriately, ie abd. I will press and assess if pain is rebound or tenderness etc. I will also watch for facial expressions and othr subjective sign during this assessment, writhing, pulling away, grimace etc. I will then (except with "life Threatening situations") assess VS I look at my monitor last unless there is something coronary obviously going on because with generallized pain I am not a GIANT fan of VS being a big indication. Yes some will have big changes and all will likely have some changes but with chornic pain I feel that people that live in large amounts of pain daily the system begins to regulate if that system is capable, if not then the Pt will be presenting with a life threatening situation R/T long term chronic pain that has broken down the healthy system. This is my usual assessment process hop it helps.

CCU NRS · Dec 24, 2003

Originally posted by gwenith
Sigh! I will admit to sometimes using the placebo effect. I will give panadol (acetaminophen) and tell them that because it works on different pain receptors it will work where stronger drugs don't and it has a synergistic effect on most medications so that it makes the effect stronger - Okay not ENTIRELY truthful but sounds so good and believable that they do believe. Even if it is not correct and it is just the placebo effect giving the pain relief then - does it really matter so long as they get relief?

Next question - how many use non-pharmaceutical methods for pain relief and what do you use?

I admit I had a brother that was a quadriplegic and he was beleived to be a drug seeker. I tried my own little experiment to satisfy my self. He had continual abd pain. I brought some Iron pills to him one day and told I had something new I wanted him to try for his pain. I told him a Docotr had written me a trial script for it and it was a brand new medicine that was a snythetic morphine derivitive. I called it FeS04. I was saddened by his response he became pain free, I gave it to him a few times and tried to be sure it was working. He told me everytime that it really helped. I finally told him that it was just iron and that I thought maybe he wanted it to work well and it did. he was furious at me and I tried to tell him this was a good thing he could finally beat his problem he was just sour at me and never really had the epiphinany I had hoped he would. He was my brother so I loved him even more.

renerian, BSN, RN · Dec 24, 2003

I know when I have had severe pain I rock. I sit and rock back and forth.

renerian

gwenith, BSN, RN · Dec 24, 2003

Thank-you for reawakening this thread - I will get back to it after christmas and look at some of the replies - summarise and see what we can do about consolidating some of the information.

BarbPick · Dec 24, 2003

personally, in the days when endometriosis was a severe problem, my usual normal blood pressure would go sky high when I was in pain.

When I was a student Nurse a drug called APC's (asprin phenacitin and caffeine) were standard medication. The FDA took phenacitin off the market due to renal problems. They would knock out a headache in 10 minutes. They always came in pink tablets or green. My instructor taught us to us a little spin to it when giving them, telling the patient they were strong pain pills and putting up the side rails for safety and telling them to call the nurse if they needed to get up. It worked like a charm, and the patient usually went to sleep.