Rethinking Pain Assessment

  1. 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.
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    About gwenith

    Joined: Jul '02; Posts: 10,261; Likes: 233
    icu nurse


  3. by   Brownms46
    There have been times when I thought a pt. wasn't being truthful in the assessment of their pain. Such as sleeping, or laughing with famiily members or friends. But after going thru a couple of surgeries myself, i have come to realize, that none of that is accurate to make such an assumption.

    Example if you're tired enough, you will go to sleep, and you can wake up with the same pain you went to sleep with. I was able to laugh and talk with people, and be totally ready for them to leave, but never said a word, unless they stayed beyond my ability to control my facial expressions.

    I also know that some people are afraid if they accurately report their pain, they will be given less medication, and end up having more pain. Some people even feel they must justify why and how they're having pain. I always feel bad, when a pt. feels he/she must justify their assessment of their own pain.

    I hope this is close to what you wanted....
  4. by   luvbug
    This is a tough one. At the clinic I work at, we only have 2 doctors and most of our patients are "regulars" because we live in a very small town. It doesn't take long for us to figure out the 'special' patients. However, it is not based solely on the objetive data collected from the nurses. The doctors have a lot to do with it, and the pharmacists even play a small role. With each patient that comes to the clinic, we have to ask them if they are there because of pain. If the answer is yes, we have a list of questions to go through with them, including the ever-popular "on a scale of 1 to 10, with 10 being the worst, how would you rate your pain right now?" I have a hard time with this one, because everyone's pain tolerance is different. If it is being used to eventually see how the individual's pain scale goes, that's one thing, but if used just to see how much pain the average patient is in, it doesn't make sense to me. I personally do agree with the fact that some people exaggerate to get additional medications, and that is what makes it harder for the patient who really is in a significant amount of pain. They don't want to look like they are faking, etc. Anyway, for the most part, I think the whole 1-10 scale is pretty accurate for most adults. Children,though, are more difficult, because they probably have not experienced a lot of pain in their lives, so they have nothing to compare it to.
    I know, I am rambling and not making a lot of sense, or saying all that much pertinent to the question, but I thought I'd share a little aobut how it works in my facility
  5. by   live4today
    When my patients say they are having pain, I simply ask them to describe their pain, rate their pain, tell me where the pain is, and does the pain med ordered for them on a prn or scheduled basis cover their pain even intermittently.

    After gathering these necessary facts, I note their facial expressions, their vital signs tell a lot about whether they are in pain, their body posture, the look in their eyes, are they clinching their teeth or their fists, are they pale, is their face reddened, are they sweating bullets, is their breathing shallow or rapid, are they grumpy and anxious, restless......and so forth.

    It's amazing how much a nurse can assess in such a short amount of time between the patient asking for their pain med and actually giving them their pain med.

    The only ones I have trouble with are the known drug abusers who are drug seekers. I feel like I'm supporting their drug habit by medicating them when I'm doubting they are in pain based on my assessment. They know that pain scale of 1 to 10 quite well too. And of course their pain is always a big fat TEN! :chuckle

    It is a known fact that women experience pain in different areas of their body than men when experiencing a heart attack or chest pain. Women may feel pain in their back, have indigestion really bad, and feel nauseas. Men may...and often do feel...the pain shooting up one arm and around their upper back and into their chest.

    I tell patients anything they may be experiencing that they are not use to feeling is a warning sign to alert a nurse or doctor about.....not to just brush it off as "indigestion" or something minor.

    Hope this helps gwenith.
  6. by   PJMommy
    I think there may be some basic generational differences in how pain is reported also. I don't mean to make a sweeping stereotype but seem to find the elderly "seem" to under-report pain.

    What about geographical differences? I'm out here in the cornfields and, let me tell you, it's pioneer spirit and all that jazz. "Oh yeah, the tractor crushed my legs and yeah it hurts but - how are we going to get this harvest in?"

    No generalizations here.... just food for thought.
  7. by   gwenith
    Thank-you all this is exactly what I was looking for - something beyond the text book.

    And yes! I personally have been there with the "sleep" bit. Post - operative with a sternum to symphasis suture line I had an epidural but ws in such severe back pain that I was trying to lie on my suture line!!!! Anything they did sent me to sleep but I would wake almost screaming. I know that they did not believe me and it turns out that the pain I had was from relaxation of my back muscles related to the epidural!!!

    If we are ever to adress the theory/practice gap we have to look at what actually happens as opposed to what should happen. There are wads of research on how pain is undertreated by nurses but there seems to be little research on why. Perhaps it is because we are getting conflicting signals with the non-verbals saying something different to the verbal cues. If we are to truly address this we have to discuss it openly honestly and without finger pointing.

    The responses so far have been fabulous!!
  8. by   angelbear
    Oh I love this one. I have fibromyalgia so I pretty much always have pain. I feel that I am pretty good at rating it but I dont trust that the care provider understands 1-10 the same way I do. For example: to me 1 is a mild and slightly annoying headache or pressure and 10 is full blown labor. My normal pain level is about a 3 for which I take vicuprofen on a regular basis. When it becomes a 4 I will add tylenol a 5 means I am headed for trouble and 6 is probably going to be hard to get back under control. If it is a 7 I am not very rational. I hate going to ER because I know fequent flyers are considered drug seekers and if I go in and say listen I am at a 5.5 toradol is not going to work and if I dont get demoral or dilauded pretty damn quick that isnt going to work either. They look at me like I am a bother. But ya know what I have constant pain so that is my normal state and I know where I am with it and what I need and I dont like to waste time with stuff I know wont work. Ok done with that one. Now as for my observations, I work in a facility for profound mental retarded with multiple physical disabilities most of them are not verbal. We have one guy who when in pain becomes very ornery running all over the building and pounding on things that is how we know he is in pain. Another one chants in sing song fashion. Another one moans real deep and it sounds like a cow is mooing. I have learned alot at this facility about assessing pain in the non traditional ways. Awesome thread if I think of some more is it ok if I continue adding them? Thanks Gwenith
  9. 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.
    young white males- extrememly low tolerence for pain. Very vocal about their pain and wine alot!
    White females- moderate amt of pain
    black males- mod. amt of pain but don't usually ask for pain meds unless offered.

    When I worked in neonatal ICU I found it interesting that premie black females do much better than premie white males. It must be something in the genes that make black females stronger than white males!
  10. by   bagladyrn
    One problem that I have with the pain scale is that it doesn't seem to work well for labor, especially in first time labor. Young girls come in with contractions of early labor, barely palpable and are convinced that their pain is already a "10". Having had no previous experience with severe pain, it's very hard for them to judge. Frequently, I look at their mother, have to bite back a smile and the urge to say "there is no 20!". I do find that explaining to them that getting pain medicine is NOT dependent on the number they give sometimes changes their assessment.
    On the other hand, I've also worked with women who are very stoic and the only sign you get from them may be sweat on the upper lip and sort of a "faraway" expression.
  11. by   pickledpepperRN
    For acute pain I have found elevated BP & heart rate plus restlessness and frequently changing position or conversely an unwillingness to move.
    Chronic pain is much more difficult to assess so I always take my patients word or that of a loved one.

    Angelbear, please tell us more.
  12. by   purplemania
    One of the advantages of being a pedi nurse is you have to learn to make assessments without consideration of patient's verbal input (especially pre-verbal pts). If skin is pale, eyes staring into nothing or closed most of the time, very still or very fidgety---I guess the idea is extremes in behavior. Best of all, give pain med and see what response you get. That should be a clue for that patient.
  13. by   AndyLyn
    Has anyone else noticed that older patients with dementia can sometimes "escape" pain, like neonates, by going to sleep? I had a patient last week in her 80's with dementia, who when awake was in obvious pain (rib fx) but would go to sleep between when I assessed her and when I brought back the pain med (and it wasn't that long!!! I know what you're all thinkin'... )
  14. 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.