Pain is a pain

**canoehead, BSN, RN** · Aug 30, 2017

I HEAR YOU.

I record what the patient says, and then do a FLACC scale which gives a 1-10 based on nursing observations. FLACC is terrible for adults because are stoic, and some are not. Its a quick way to quantify the difference between subjective and objective, and to look back at your notes and know what you were thinking when you gave the med.

I do medicate to the patient's pain score...but oversedating and needing resp support is an issue for some people. I wanted an easy way to quantify behavior, and FLACC helps.

Emergent, RN · Aug 30, 2017

The 10 out of 10 pain scale is really pretty useless.

That's all I have to sayâ€¦

dream'n, BSN, RN · Aug 30, 2017

Nursing is getting mixed signals on pain control. For about 20 years it's all been "pain is what the patient says it is." Now with so many Opioid and Heroin deaths, the FDA and some other healthcare groups are trying to curtail the use of many of the stronger pain medications. Add in patient satisfaction surveys being tied to reimbursement, who the **** knows what to do. You're damned if you do and damned if you don't.

I do agree that the 1-10 score is absolutely useless. I've had too many 10s for a stubbed toe or small laceration and too many 5s for kidney stones and bone cancer pain to believe the scale has any merit

Ruby Vee, BSN · Aug 30, 2017

Sometimes we nurses just need to vent about the problems that tend to reemerge in our everyday livesâ€¦ problems that are potentiated by annoying policies and practices which are often applicable to a few, useful for some, and just plain ridiculous for those certainâ€ individuals. You know the ones I'm talking aboutâ€¦ those patients for whom pain is a 10/10 when they are balled up in tears and somehow still a 10/10 when they are laughing and talking on the telephone...

Just because someone can spout out a number, it doesn't necessarily mean that they have given the proper time or consideration to answer this one simple question accurately at all. But when we try to help them clarify, so your pain hasn't improved at all since I gave you that medicationâ€ (ehemâ€¦ dilaudid) as we think to ourselves seeing how I just woke you up from your seemingly pleasant little nap.â€ And because there are meds still available... and the patient is still somehow A&Ox4â€¦ and they say, No, It's not any betterâ€â€¦ here we come with some more meds (because, heaven forbid, someone is in painâ€ and we don't do anything about it)â€¦ so, once again, here we come an hour later to reassessâ€¦ and still a 10/10...

If pain is what the patient says it is,â€ then exaggerating is what a nurse says it isâ€¦ (On a scale of 0-10, with zero being appears accurateâ€ and ten being not even close,â€ how would you rate this patient? -----where on earth is this question next to the pain scale?)

It's not that this topic hasn't been broached before, but it's an issue that never seems to go away â€“ especially if you work in med-surg. Painâ€¦ sometimes it's just a royal pain in theâ€¦

Disclaimer: I am totally an advocate for ensuring adequate pain control for people who are in pain and need pain management. I believe I may have thought the word "seeking" a total of once (in an incredibly obvious situation) in my entire nursing career. I am just not an advocate for the 0-10 scoring scale on ALL patients... oriented does not always equate to honest and / or accurate self evaluation.

So what is it that bothers you all today? Any thoughts?

The "0 to 10" pain scale is all but useless -- I say that as a patient, as the family of a patient and most especially as a nurse. A behavioral pain scale is somewhat easier -- but some patients are stoic. (Of course those patients are probably the same ones who will be flattened by a Mac truck and still tell you that they're "a little uncomfortable" or that their pain is a 5/10.) Some patients have drama issues or attention-seeking disorders -- they'll tell you that their pain is a 20/10 while playing on their phones and eating a bucket of KFC. So the behavioral pain scale isn't entirely dependable, either.

It helps to know your patient a little. I'd take the drama queen's 20/10 with a whole lump of salt, as with the stoic's 5/10. What really matters is are they having too much pain to participate in their breathing exercise, physical therapy, ambulation or a conversation about how much pain they're having? If yes, seek more medication. If no, then hold off.

But what you really wanted to do is vent, and I'm all in favor of that. I don't mean to step on your vent. I'll even add to it. What really, really ticks me off about all this "Pain is what the patient says it is" is that it's more tied to P-G scores than to helping the patient to be able to participate in recovery. It seems a lot of folks expect to be zoned out on narcs until their discharge. And that makes it difficult for those of us who need a bit more to relieve our pain (narcotic tolerance -- I had my orthopedic surgery AFTER my cancer surgery, and my tolerance had increased) enough to do those grueling PT sessions.

Guest219794 · Aug 31, 2017

I find the 1/10 scale to be useless in helping most patients.

And, I dread the day I have to use it as a patient.

I consider 5/10- 50% of pain possible to feel- to be extreme. When I could barely make it 15 feet from my bed to the bathroom, I would have rated that at 5/10. Far more debilitating than what mot people must be experiencing when they walk in texting and drinking a latte.

So, if I am in a hospital and want pain medicine what number do I give?

I am going to feel like a complete jerk saying by pain is 8/10, which is probably what I will need to get narcotics. The fact that I can even verbalize it means it is less than that.

Anyhow, just wanted to participate in this therad before it degenerates, which should be some time soon.

Been there,done that, ASN, RN · Aug 31, 2017

Sometimes we nurses just need to vent about the problems that tend to reemerge in our everyday livesâ€¦ problems that are potentiated by annoying policies and practices which are often applicable to a few, useful for some, and just plain ridiculous for those certainâ€ individuals. You know the ones I'm talking aboutâ€¦ those patients for whom pain is a 10/10 when they are balled up in tears and somehow still a 10/10 when they are laughing and talking on the telephone...

Just because someone can spout out a number, it doesn't necessarily mean that they have given the proper time or consideration to answer this one simple question accurately at all. But when we try to help them clarify, so your pain hasn't improved at all since I gave you that medicationâ€ (ehemâ€¦ dilaudid) as we think to ourselves seeing how I just woke you up from your seemingly pleasant little nap.â€ And because there are meds still available... and the patient is still somehow A&Ox4â€¦ and they say, No, It's not any betterâ€â€¦ here we come with some more meds (because, heaven forbid, someone is in painâ€ and we don't do anything about it)â€¦ so, once again, here we come an hour later to reassessâ€¦ and still a 10/10...

If pain is what the patient says it is,â€ then exaggerating is what a nurse says it isâ€¦ (On a scale of 0-10, with zero being appears accurateâ€ and ten being not even close,â€ how would you rate this patient? -----where on earth is this question next to the pain scale?)

It's not that this topic hasn't been broached before, but it's an issue that never seems to go away â€“ especially if you work in med-surg. Painâ€¦ sometimes it's just a royal pain in theâ€¦

Disclaimer: I am totally an advocate for ensuring adequate pain control for people who are in pain and need pain management. I believe I may have thought the word "seeking" a total of once (in an incredibly obvious situation) in my entire nursing career. I am just not an advocate for the 0-10 scoring scale on ALL patients... oriented does not always equate to honest and / or accurate self evaluation.

So what is it that bothers you all today? Any thoughts?

Pain is 100% subjective. The prudent nurse looks at the patient and their presenting symptoms.

My father had 10/10 pain. It was neurological pain that narcs could not cover. Took 80 mg of morphine/ hour to get him comfort.

Bottom line.. do whatever it takes to releive pain.

Penelope_Pitstop, BSN, RN · Aug 31, 2017

I am another one who finds the numeric scale to not fit everyone. Some people seem to grasp the concept well and think about what it means before answering. I am not one of those people when I'm a patient.

Pain documentation is especially annoying to me at the moment. We had our state survey and it was found that our pain documentation was sub-par. Thus, we have to document the pain score in several different places, including a narrative. I tend to use a lot of quotes, especially with the chronic pain population, because a 9/10 to someone with chronic back pain could be considered "tolerable" to that person whereas 9/10 acute or new pain (or 9/10 in a typically 3/10 chronic pain patient) is something of concern. Just throwing a number out there out of context is meaningless. (Much like vital signs and lab values often times).

GeminiNurse29 · Aug 31, 2017

In psych, I see too many of the "10/10" BS or with seeking meds out of habit. I'm thinking of one guy in particular who can't sleep and stays up all night despite getting his PRNs of hydroxyzine, Ativan, Tylenol, and mylanta. Literally he will come and ask for all his PRNs and I have to give it to him (unless it's not within the time frame yet). Or the personality disordered patients who tell me they can't sleep Bc of nightmares and want me to give them something. The non-therapeutic nurse in me just wants to roll my eyes and say "tough, it's life." But I have to give them something that the doc prescribed for anxiety or agitation. And don't even get me started on exactly what "agitation" is too...

Guest219794 · Aug 31, 2017

Pain is 100% subjective. The prudent nurse looks at the patient and their presenting symptoms.
My father had 10/10 pain. It was neurological pain that narcs could not cover. Took 80 mg of morphine/ hour to get him comfort.
Bottom line.. do whatever it takes to releive pain.

Pain is 100% subjective.

Treat until subjective complaint is reduced to tolerable.

That is a great principle, applicable with many patients, like your father. Completely impossible in many environments.

If we took that approach in my ER, we would, literally, need to open a new facility for this purpose.

I just had a PT who c/o severe pain. She looked like she might well be in pain. Had objective/subjective S/SX.

HX polysubstance abuse
Multiple negative workups including imaging and specialists
Multiple narcs from multiple providers past several months
4 different ER's past month
Refused any non-narcotic interventions offered

When offered Toradol, claimed an allergy. I checked chart, given Toradol 3 months ago, no reaction. When I explained this, her husband informed me that the toradol given had increased her pain, which IS an allergic reaction. He had Googled it, and expressed that if I was competent, I would have a better understanding of allergies.

I have no idea how much pain she was in. I do know that she does not have endometriosis as claimed. My best guess is that her pain is related to her narcotic use, but of course she could have an, as yet, undiscovered medical problem.

We did not giver her narcotics. It would have been irresponsible to do so, and not in her best interests.

She left angry, initially refusing to let me pull her IV.

Some of this stuff is black and white. Your dad on one end of the spectrum, my patient on the other end. But- there is a massive grey area in between that is challenging and frustrating for nurses to navigate.

allnurses Guide · Aug 31, 2017

If I have orders and the patient is tolerating the dose, I medicate. I don't let myself get into evaluation of whether or not they are manipulating me, because ultimately all it does is make me agitated and curt, which the patient is very sensitive to and now we have an adversarial relationship. I work hard to establish trust..."I am going to give you everything you are ordered to have as long as your blood pressure and level of consciousness stay within safe parameters. I will not withhold for any other reason. I can not bring you narcotics/benzos/etc sooner than they are ordered, but I will do everything I can to get them to you on time". Take away the anxiety in the patient that they are going to have a battle on their hands to get the meds ordered and now the shift is much nicer and the call light less active.

An interesting aside.... my current hospital is taking high dose morphine and Dilaudid OUT of the our ER completely. They will not even be an option at that level of care. Will be interesting to see what that does to the ER visits seeking pain meds.

djh123 · Aug 31, 2017

I don't think the 0-10 scale is 'useless', but at the same time, one person's 5 or 6 is another person's '10', without even factoring in whether they're drug-seeking or not. But most of the time, at least with the patients I've dealt with, 3/4 of them seem to 'get it' and attempt to give me an honest answer.