Rethinking Pain Assessment

Specialties Pain

Published

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.

As most of you know, I talk a great deal about the migriane pt being one myself and I ran into a sad situation one month. I was in the ER for another migraine after self treating at home for 3 days. (I wait before going) Well in walks Colonel Sanders (I swear he looked just like him) and he has no clue who I am, no hx, and I think he was deaf. My pressure was 193/103. Res. 25, pulse 112. I was getting dehydrated too. Well he proceeds to order me a whole slew of things that I know will result in nothing seeing as I had already taken them at home and told him so. I asked to be seen by another doctor who knew my case. It was agreed. I was treated and released 20 hours later.

My question..didn't vitals reflect pain in this case?

You know how he explained my VS? He said "Everyone 's pressure goes up a bit when they come to the ER." :uhoh3: I heard of white coat syndrome but come on. No one under the age of 80 should have a pressure of 190/103 :chuckle

I agree too that many older women try to be too brave with my mom being one of them. After her hysterectomy I had to ask the nurse to ingnore my mom's denial of pain and please push her to ask for pain meds. She did relent twice in the end.

You might find this link useful

http://www.massgeneral.org/painrelief/Guidelines/Ten%20Guidelines.htm

Z, I am so glad that you were able to see someone at the ER who knew your history. You were very lucky to get the treatment you needed. Your vitals should have been a clue yes. What is scarier to me is patients who suffer chronic pain- often vitals don't show any change at all. Pain is a tricky thing to deal with. I have been in a great deal of abdominal pain for over a year. After being put on higher and highter doses of meds I finally demanded a referral to an interventional anesth. for a nerve block. It worked wonders. It wore off after about a week though but I am scheduled to go back this week (They think it's due to entrapped nerves from three open abd. surgeries).

On the other side of the coin, I have a home health patient who complains of severe abd. pain. Of course on my first visit I felt an immediate kinship with her because of my history. I stepped back from the personal side of the situation and tried to do an overall assessment. Keep in mind this lady is on Duragesic patch 75 and hydrocodone 10 for breakthrough. She was begging me to call her MD and get him to rx something. She had been to the ER the previous weekend. Upon doing the assessment I asked her how she slept at night. (I know that when I am hurting badly I don't sleep well and pain scenarios even show up in my dreams since I am hurting so) She responded that she slept just fine. When I asked her to pinpoint the site of pain she couldn't really do that. I then began to wonder. I told her the best I could do was to call her MD and get an appt. for the next day. Her response was: "I don't know if I can make that appt." She did go the next day and he got her in with a pain specialist for the next day as a favor. The day after her appt. with the pain MD I went back to see her. I was really hoping that this MD would do a procedure like I had done and not just rx more narcotics. I was wrong. She was on the Duragesic patch and Actiq which she said did nothing. I began thinking she just wanted to be knocked out. When I counted the Actiq she should have used 3 based on the rx. She had already used 10.

Pain mgt docs often have pts sign a contract saying they agree to not get any other meds for pain from other docs. First thing she asked me was: "Should I get these refilled from my regular doctor?" One bottle was for Demerol and the other was for Percocet. I told her no and to just let her pain doctor follow her pain and to call him if it was still unrelieved. "But I don't have his phone number, can you call him?"

I'm trying to be understanding especially since I have had chronic unrelieved pain but I htink this little lady being very manipulative and abusing her meds. How can one be unbiased in a situation like this. Did the doctors get her hooked or is her pain really untreated. Really she is on enough meds to put down a racehorse. I am having a really hard time believing anything she says. What does one do with patients like this?

first i'd like to point out that vs are not always a viable indicator of a pt's pain status. acute pain will increasse the vitals; chronic pain will not.

i'm not sure exactly what you're asking in your last paragraph. but what i will tell you is as a hospice nurse, i have seen many patients sleep and be in pain. their faces are not relaxed, brows knitted together, and this is on ativan, xanax or valium. but for effective analgesia to be attained, (i'm talking about my end stage ca pts), you need a narcotic such as morphine, oxycodone, fentanyl, dilaudid which will travel to the appropriate opioid receptors and do what they need to do. and i frequently have a talk with the doctors that prescribe mso4 2 mg. for bone ca.....and i do tell them that i intend to document the poor effect in my nsg notes and how the md did not want to prescribe anything more....that's when they ask what i want for them.

but back to the original point, yes yes yes, pts can sleep and be in pain. it is not a restful sleep at all.

leslie

That's what I want to know, and I believe a study that looks at polysomnographic data will be able to more thoroughly characterize the quality of sleep that a patient has when in pain. We also need to remember that this is a partially-induced sleep, and may be different from a person just falling asleep without being sedated. If someone has frequent awakenings or a their sleep levels are disrupted when they are in pain, that would be good to know.

Z, I am so glad that you were able to see someone at the ER who knew your history. You were very lucky to get the treatment you needed. Your vitals should have been a clue yes. What is scarier to me is patients who suffer chronic pain- often vitals don't show any change at all. Pain is a tricky thing to deal with. I have been in a great deal of abdominal pain for over a year. After being put on higher and highter doses of meds I finally demanded a referral to an interventional anesth. for a nerve block. It worked wonders. It wore off after about a week though but I am scheduled to go back this week (They think it's due to entrapped nerves from three open abd. surgeries).

On the other side of the coin, I have a home health patient who complains of severe abd. pain. Of course on my first visit I felt an immediate kinship with her because of my history. I stepped back from the personal side of the situation and tried to do an overall assessment. Keep in mind this lady is on Duragesic patch 75 and hydrocodone 10 for breakthrough. She was begging me to call her MD and get him to rx something. She had been to the ER the previous weekend. Upon doing the assessment I asked her how she slept at night. (I know that when I am hurting badly I don't sleep well and pain scenarios even show up in my dreams since I am hurting so) She responded that she slept just fine. When I asked her to pinpoint the site of pain she couldn't really do that. I then began to wonder. I told her the best I could do was to call her MD and get an appt. for the next day. Her response was: "I don't know if I can make that appt." She did go the next day and he got her in with a pain specialist for the next day as a favor. The day after her appt. with the pain MD I went back to see her. I was really hoping that this MD would do a procedure like I had done and not just rx more narcotics. I was wrong. She was on the Duragesic patch and Actiq which she said did nothing. I began thinking she just wanted to be knocked out. When I counted the Actiq she should have used 3 based on the rx. She had already used 10.

Pain mgt docs often have pts sign a contract saying they agree to not get any other meds for pain from other docs. First thing she asked me was: "Should I get these refilled from my regular doctor?" One bottle was for Demerol and the other was for Percocet. I told her no and to just let her pain doctor follow her pain and to call him if it was still unrelieved. "But I don't have his phone number, can you call him?"

I'm trying to be understanding especially since I have had chronic unrelieved pain but I htink this little lady being very manipulative and abusing her meds. How can one be unbiased in a situation like this. Did the doctors get her hooked or is her pain really untreated. Really she is on enough meds to put down a racehorse. I am having a really hard time believing anything she says. What does one do with patients like this?

Well, apparently there's something going in, since she used 3 times the amount of a med that she was supposed to. The hard part is going to be finding out exactly what the problem is. If I were you, I'd ask her about the pain meds. Ask her why she has taken more than she's supposed to. Her answer might tell you a lot. She may not realise that she took too many, or maybe she didn't understand the directions, or maybe she thinks she should take whatever she wants whenever she wants. Possibly, she's over medicated and not thinking clearly. If that's the case, then maybe her pain doc needs to do a little housecleaning. take away all of the pain meds, and start from square one. Since she's taking so many things, she's not opiate niave, it might be better to put her on a stronger duragesic patch, and only allow something mild for breakthough pain. She can't mess with the dosage on the patch, unless she wears more than one at a time, and if that's an issue then she shouldn't have access to additional patches. Her breakthough meds can be given in small amounts, with a stern warning that they must last her X amount of time because she will not get her next ones early. No excuses, not even the wild ones like dropping them in the toilet. :)

..... 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.

As a patient I can SO vouch for this! I had had a tubal ligation with bladder and uterine suspension plus appendectomy via a "smiley" incision. I was miserable, especially the afternoon after surgery and the day after. A couple of years later I had an emergency resection of 18" of the mid ileum after releasing myself from local hospital and flying to Mayo with the surgery the next day. Due to the timing I flew to Mayo alone. It was full open abdomen surgery and so much easier recovery!!!! I didn't feel the need to stay awake to comfort my husband sitting there. I had absolutely no recall from entering the OR until the second day after surgery!!! Yet they did have me up to stand and to turn and to cough. I just didn't have to stay awake for them like I would have had to for my family. That recovery was so comfortable, so easy, so quick I would PREFER to NOT have my family or visitors for at least the first two days after any future surgery!! The sad part is that you can't do that to your family. It is too hard on them worrying, etc. It doesn't help even if they sit there quietly and say nothing. Once you know they are there you fight to awaken or to stay awake to reassure them. Maybe I am just an oddball. When I'm hurting or feeling sick I just want to crawl in a hole and bury myself. DON'T BOTHER ME! JUST LEAVE ME ALONE. Or bring me my pain, nausea and/or sleep meds and THEN leave me alone. And I DO love to sleep when I'm in pain or sick.

... You know how he explained my VS? He said "Everyone 's pressure goes up a bit when they come to the ER." I heard of white coat syndrome but come on. No one under the age of 80 should have a pressure of 190/103 :chuckle

I'm just the opposite. I always seem to feel somewhat better when I get to my doctor's office or ER. Then I feel like an orifice for being there!!! Maybe I just unconsciously wait until the worst is past. I even once told my doctor instead of calling for an appointment I was thinking of just driving into his parking lot and sacking out in the car when I felt rotten. Maybe it is because I can be fairly sure that some type of relief will be forthcoming when I get to his office or the ER. Placebo effect???

As a patient I can SO vouch for this! I had had a tubal ligation with bladder and uterine suspension plus appendectomy via a "smiley" incision. I was miserable, especially the afternoon after surgery and the day after. A couple of years later I had an emergency resection of 18" of the mid ileum after releasing myself from local hospital and flying to Mayo with the surgery the next day. Due to the timing I flew to Mayo alone. It was full open abdomen surgery and so much easier recovery!!!! I didn't feel the need to stay awake to comfort my husband sitting there. I had absolutely no recall from entering the OR until the second day after surgery!!! Yet they did have me up to stand and to turn and to cough. I just didn't have to stay awake for them like I would have had to for my family. That recovery was so comfortable, so easy, so quick I would PREFER to NOT have my family or visitors for at least the first two days after any future surgery!! The sad part is that you can't do that to your family. It is too hard on them worrying, etc. It doesn't help even if they sit there quietly and say nothing. Once you know they are there you fight to awaken or to stay awake to reassure them. Maybe I am just an oddball. When I'm hurting or feeling sick I just want to crawl in a hole and bury myself. DON'T BOTHER ME! JUST LEAVE ME ALONE. Or bring me my pain, nausea and/or sleep meds and THEN leave me alone. And I DO love to sleep when I'm in pain or sick.

I wish I could forget my first few hours, following my C4-5,5-6,6-7 lami. I remember being in tyhe preop area, at 5:30AM. The next time, it was 4:00PM and they wanted me to deep breath and cough. I'm like you, give me my medication and let me sleep. I know, I know, deep breathing and coughing are important. :)

Grannynurse :balloons:

Actiq is for cancer pain ONLY and most insurance companies will NOT pay for this med if it is RX'ed for non-cancer pain.

Alan

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