My hospital uses a pain scale of 1-5 with faces. How effective is this, really? I had a patient tell me she was a 5 (worst pain) and yet she was on the phone laughing with a friend. Of course I documented that she said she was a 5 on the scale, but I also documented what she was doing at the time. And yes, I did make sure she knew that a 5 was the worst pain on the scale.
Why can't we go back to just documenting exactly what their pain level is by what they say, what they are doing, and our assessment? If my notes indicate a 5 (worst pain) and I don't document what is really going on with the patient, then I may be omitting information. Then again, a 5 is an oxymoron to how she is behaving with the laughing.
The 5 may be her worst pain, but the face on the scale says it is unbearable. How reliable are these scales?
Since pain has only been the "5th vital sign" for a couple of years, I am willing to bet that it will be modified to fit reality a few times in the future. [/b]
Exactly!! I don't think memphis was
trying to insult anyone, just stating her
thoughts/feelings. Pain, as several
have stated, is quite subjective. You
definitly learn frequent flying drug seekers methods for obtaining "pain" relief and objective judgement by the nurse, also has it's place in assessing the situation. Maybe the joke Gwenith posted has the right idea, brick therapy!
I said something profound the other night, grin, and just remembered it while thinking about this subject. We were talking about school and how amazed I STILL am that I graduated college with a science degree. I have never been very strong in the science of nursing, but I think I do very well in the art of nursing. I think this pain scale is a good example of blending the art and science....and sometimes we have to be more artistic, as well as artful...
I was not trying to offend anyone, or "lecture" anyone. I am not a stupid child fresh to the world who has no idea that we will encounter patients who are drug-seeking from time to time. I am an adult mother of 3 who has SEEN nurses fail to give pain medication because they didn't think that patient really needed any.
I have been the patient accused of being drug seeking because I had a migraine and went to the ER.
I have also been accused of drug-seeking for my infant after surgery "because I wanted to sleep" (the nurses words)--when my baby was in obvious distress--at least to anyone except the nurses dealing with him.
So don't lecture ME about how naive you think I am.
My point is, you are there (and I will be too) to help the patient. Not to judge why they are asking for pain meds. MAYBE they say it's a 10 when it's really only a 3 because every time they have said their pain is a 3 they got NOTHING for it--not even a tylenol. You aren't going to be making them drug addicts by giving them pain medication, and if they already are addicts, do you think you are going to fix it by denying them pain meds a couple of times?
I am not talking about assessment of pain from the sense of type of pain (burning, cutting, whatever). But how in the world can you say "OH, your pain is really only a 4 even though you think it's a 9 or 10 and it's really stabbing instead of stinging"? Unless you are feeling the pain yourself, you can not know.
Specializes in LTC,Hospice/palliative care,acute care.
Originally posted by memphispanda
I was not trying to offend anyone, or "lecture" anyone. I am not a stupid child fresh to the world who has no idea that we will encounter patients who are drug-seeking from time to time. I am an adult mother of 3 who has SEEN nurses fail to give pain medication because they didn't think that patient really needed any.
.
I have seen elderly confused post ops not given pain meds routinely because they did not lean up and say "Hey,nurse-can you give me something for pain-you see,I fell and broke my hip yesterday" But they are grimacing,restless and combative.Don't get me started on pain control in the elderly-I work in an LTC with 3 staff docs that are lousy with end of life issues and chronic pain...I don't feel that we nurses are morally responsible for the choices the frequent flier drug seekers make....If the docs admit them and write the orders then we give the meds-to all of our patients...without judgements
I was taught that you have to take the patients word for it because you don't know what the worst pain they've ever experienced is. For example, like the joke with the bricks. If the worst they've ever experienced is stubbing their toe, then who are we to say that breaking their arm isn't a 10/10? JMHO
Sorry for going up in flames but I reacted the way I did because Every time we have tried to have a reasoned discussion about pain and pain assessment someone gets on the board and the accusations about undertreatement of pain begins.
It is a verified documented fact that nurses undertreat pain - that is a given but if we are to make progress in this area we must move past that and start to discuss the non-verbal pain cues WHICH AT PRESENT ARE POORLY DESCRIBED so that we can improve our assessment of patients pain.
We need to think about the non-verbal cues so we can assess the non-verbal patients. So that we can properly assist the patient with inappropriate pain behaviour manage thier pain BETTER without being labelled as drug seekers.
This forum would be an ideal place to perform qualitative research on this very subject, and I have thought about doing a modifed grounded theory research into this subject but I am frustrated by how rapidly the topic degenerates into a mud slinging match about how some nusres do not treat pain correctly.
Please - leave that alone and let us discuss the question as it was asked -
"Wat is the relaibility of the pain scale?"
"What factors other than a pain scale can and are used to assess pain."
A paediatric nurse once told me that children - contrary to popular belief often "run" from pain so that instead of lying quietly or crying they are running and crying. Unless I had been told I would never have picked that as pain behaviour. This is just ONE example of a non-verbal cue.
My non-verbal assessment data in relation to cardiac pain included but is not limited to:
Skin - dry or sweaty warm or cold
Pallor - "pink" pale or "white"
Face - what are the face muscles doing? are they drawn around the mouth or is the face relaxed?
Respirations - easy and "eupnoeic" or laboured/ catching as they breathe in? rapid and shallow? or Deep and relaxed
BP - High or low?
Pulse - High or low and remembering there are some who will be a bradycardia with pain esp severe pain
Patient stance - what are thier shoulders doing - hunched or relaxed? Are they favouring one side of the body?
Patient Movement - how much are they moving? - If they are pacing/unable to sit still the probability is low that this is cardiac. If the patient is lying still in bed unable to move and obviously ennervated it is probably cardiac
Appetite - good or bad - take it from me the size of the infarct is inversely proportional to appetite but it is an unreliable criteria to say the least.
These are just a few. I use many criteria on an almost subliminal level in assessing pain neither do I use all of them at once. It is this subliminal assessment that tells us whether the pain is congruent with what the patient is reporting. Unless we can bring the subliminal out into the open and analyse it we may never know why we have the "feelings" about the patient that we do. If we are able to say - "He is not showing the pain on his face but everything else - stance vitals are telling me he has severe pain" will we not be better able to ignore the one factor that is incongruent to concentrate on the others that are?
Please let us move past the finger pointing about lack of pain medication - just because someone is usig non-verbal cues does not mean that they automatically disbelieve patients and undertreat pain.
We need to think about the non-verbal cues so we can assess the non-verbal patients. So that we can properly assist the patient with inappropriate pain behaviour manage thier pain BETTER without being labelled as drug seekers.
Very good point. I have the privilege of working with many non-verbal clients on a daily basis. I have become quite familiar with
them and am readily able to pick up on their non-verbal clues. I am able to do this because I work with them on a daily basis. It
is much harder to pick up on a "strangers" non-verbal clues.
I truly believe everyone here can have a civil discussion on this
topic, at least I hope we can, I love learning new approaches!!
Pain is something that is hard to judge and everyone is correct to say you have to take the patient's word for how bad they hurt. I hurt every day of every week, 24/7 r/t herniated disk with nerve damage and intractable pain. I do not cry about it when it is at a ten, because I cannot cry and moan all the time. Most of the time my pain is somewhere between 5 and 10 and that is with pain meds being taken every 8 hours and between times for breakthrough pain (ms contin and oxycodone). When I take the meds I end up sleeping all day or all day and all night. I am never out of pain, but I do try to put on a happy face for the general public. My husband fusses at me about it, because he said don't try to hide it, if you hurt, it is ok to show it. I am sorry for the long post, but just needed to tell my story.
I guess I need to clarify a bit. I work with a variety of doctors in the ER and they all approach pain in different ways. As a nurse, *I* have no control over what the doctor orders, I can only bring things to the doc's attention and act on orders. One doc gives naprosyn to everyone and I have seen her give lortab ONE time to my knowledge, and never have I seen her order morphine. Another doc gives morphine for almost everything and sends almost everyone home with a script for lortab. The others are somewhere in between, but you see the point, I hope.
I was mentioning the report of a 10/10 not as an indictment against the patient, but more of a perception that the patient has of the doctor's response. This is what I meant by an earlier post about the ART of nursing. We take those non verbal cues seriously, in both directions. Being a small town ER, we see the frequent fliers and know who they are and what they are after. I only report the chief complaint and assessment findings, the doc is the one who actually decides what the pt is going to get, and I give it. There are times when I think a patient needs a shot of demerol and the doc orders motrin....and there are times when the other doc orders MS and I think the pt would do better with Toradol, but I am just the nurse, and it isn't my call....BTW, the generous doc has come up with what he calls a BACC pain study "bellyachers and chronic complainers" cocktail of Ativan 2mg, Haldol 2mg and Benedryl 25mg; in varying dosage levels depending on the patient. I have read the study and it is pretty astounding the results he gets without giving a narcotic. He thinks that some of the chronic pain can be dealt with using haldol and other psych meds.
Am going to stop now....pain control is actually one of my favorite subjects, especially when I found out that Pain is an epidemic in this country, BUT the drug Vicodin/Lortab is #4 most prescribed med in the US and the DEA is constantly on the case of doctors that they think are prescribing too many narcs. It is a contradiction that needs to be addressed.
I just remembered some cases when I worked the floor a few years ago. We had a patient who would be admitted for something or other, usually asthma exacerbation where she was forcing an expiratory wheeze on auscultation. She would get an aminophylline drip and the doc ordered Nubain and Phenergan q4h. She would spend 2 weeks in the hospital, and in the first week she would NOT sleep, but drink coffee 24 hours a day and insist on her pain meds on the minute. I would go into her room and she would be sitting on the bed so drugged she couldn't keep her eyes open, slurred speech, etc. But if we tried to hold the med, she would become one of the meanest people you ever met. The doc had to almost literally force her out by cutting out her coffee and then doing a fluid restriction on her. He started ordering NS and Phenergan and told her it was called placebo, which she thought was a new med until a float nurse got her as a patient and when asked what she was getting, told the pt it was normal saline instead of "nacl" pronounced like a word.
I just wanted to share one of my personal nightmares about pain from the jaundiced side, LOL. It is a pretty good example of a drug seeker.....and of the irresponsible doctor who lets it happen.
THEN there are patients who are in obvious pain that we nurses have to almost insist on medicating and giving them the talk about it not being a problem, and not a weakness on their part, etc. The spectrum is amazing, when you think about it.
Pain is such a touchy subject, because pain is so subjective. I believe in medicating well and listening to the patient, but I don't feel comfortable blindly giving pain medicine based only on what the patient gives for a number on a pain scale. Without using the entire assessment process, plus alternatives such as reducing anxiety, we are only partially completing our job if we medicate based solely on the subjective.
Shamrock, BSN, RN
448 Posts
Exactly!! I don't think memphis was
trying to insult anyone, just stating her
thoughts/feelings. Pain, as several
have stated, is quite subjective. You
definitly learn frequent flying drug seekers methods for obtaining "pain" relief and objective judgement by the nurse, also has it's place in assessing the situation. Maybe the joke Gwenith posted has the right idea, brick therapy!
As always in nursing, there is often no
black/white areas, just grey.