Pain Scale

5228shamrock · Aug 1, 2017

Thank you KindaBack. I agree100% and you stated my point much better than I did! I was looking for something that is more useful than faces or numbers. Maybe it doesn't exist.

macawake, MSN · Aug 1, 2017

I personally find the whole 1-10 scale to be largely meaningless and I don't accept that "pain is what the patient says it is" because so many people jump straight to 10 (or 15 or 40).

It doesn't really matter what you personally think of pain scales and patients reporting their pain, as long as you don't let your personal biases and anecdotal experiences decide how you treat pain. However if you cross that line where you start deciding how much pain the patient is in and treat according to that, basing your decision on your own personal beliefs rather than what the patient reports, then you're wandering into unacceptable territory.

You say that you don't accept what the patient reports. Who should decide how much pain the patient is experiencing? You?

I don't mind if other nurses accept it as valid but I simply don't, based on years of experience asking the question of thousands of people.

Based on experience? How does the available research on pain and the use of pain scales and knowledge of mechanisms of pain and the different natures of acute and chronic pain, factor into your view on pain and its treatment?

Thank you KindaBack. I agree100% and you stated my point much better than I did! I was looking for something that is more useful than faces or numbers.

Considering the thank you, I have to wonder if you weren't primarily looking for validation when you started this thread.

Are you interested in learning more about pain and how best to treat it?

I'm also not trying to second guess someone else's pain.

I actually believe that you are. You've just told us that you agree with KindaBack who clearly stated that he doesn't believe patients when they report their pain.

Maybe it doesn't exist.

It doesn't. There is no objective test/lab that we can run to accurately measure what another human being is experiencing painwise. It would be great if such a test existed, but it doesn't. That's why we listen to our patients and treat the pain that they report with whatever treatment their provider has prescribed, if their vital signs allow that treatment to be administered.

I've often encountered knowledge deficits combined with a generous dollop of personal bias in my fellow nurses when it comes to treatment of pain. Many seem to think that what they experience and the conclusions they draw from their personal experiences, is an acceptable standard to base their professional decisions on. I don't think it is. Our discipline should be and is, evidence-based. Not subjective nurses' opinion-based.

As part of my training to become a nurse anesthetist, one of my coursebooks (+600 pages) dealt entirely with pain and pain management. That was an excellent book and it offered an insight into just how complex and multi-faceted pain actually is. Unfortunately, it's in Swedish so it won't be of any use to you. But with all the excellent American academic litterature available, I'm sure you can find a good resource if you want to expand and deepen your understanding of neural mechanisms of pain, the psychology of pain, the different presentations and treatment of acute and chronic pain, the difference between pain and nociception, concepts like hyperalgesia and allodynia and of course tolerance and dependence.

To start you off, I'd like to point you to a chapter in one of my favorite books; Rang and Dale's Pharmacology. The chapter is The Nervous System - Analgesic Drugs. In about 20 pages it covers a lot of useful information.

Boomer MS, RN · Aug 1, 2017

Below is an excellent review article of pain:

Physiology and Treatment of Pain

JKL33 · Aug 1, 2017

I've often encountered knowledge deficits combined with a generous dollop of personal bias in my fellow nurses when it comes to treatment of pain. Many seem to think that what they experience and the conclusions they draw from their personal experiences, is an acceptable standard to base their professional decisions on. I don't think it is. Our discipline should be and is, evidence-based. Not subjective nurses' opinion-based.

macawake,

There's a lot of good information in your post, so thank you for that. What I haven't completely understood (in the past nearly 2 decades) is what we are supposed to make of the exact scenario that the OP is presenting. It's as if a problem doesn't exist.

I admit some days I feel like groupthink has taken hold with regard to this problem, specifically within Nursing. Am I to believe that every single nurse, no matter how "evidence-based" or compassionate, is just inappropriately "judging" situations like this? Sincerely...I don't think so. They are being made to feel that the plain-view observations they are making exist only in their own mind because they are "judging". If that were actually true, there would be no need for pain clinics to have contracts and tight policies that they follow.

I accept the fact that pain is processed very differently from person to person to person. I accept that affective factors and many others are major contributors to how it will be processed. My idea of what I think/feel about someone else's pain can never be the basis for deciding how real or severe or debilitating it is. But what to make of seeming incongruencies (major ones) in what they themselves say about their pain? That's the question. In general, our profession is very preachy about this and it's not helping anyone (including patients) because there are gaps that can be observed from the most neutral of positions. Boomer's (otherwise) excellent article doesn't touch the topic except to imply that pain-based malingering doesn't exist. Continuing education doesn't touch this topic with a 10-ft pole.

I'm of the belief that our current attitude toward all this is not at all compassionate - toward patients. Instead, it is patronizing in one of the worst ways possible.

I'm checking out the text you mentioned on Amazon.

Thanks,

JKL

bgxyrnf, MSN, RN · Aug 1, 2017

It doesn't really matter what you personally think of pain scales and patients reporting their pain, as long as you don't let your personal biases and anecdotal experiences decide how you treat pain. However if you cross that line where you start deciding how much pain the patient is in and treat according to that, basing your decision on your own personal beliefs rather than what the patient reports, then you're wandering into unacceptable territory.

Personally, if the provider places the order and it's safe to give the med, I'll give 'em whatever they want. That doesn't mean that I consider the 1-10 scale a valid pain assessment tool given the repeated and obvious inadequacies.

My complete assessment, which *includes* the patient's self-report but doesn't *rely* upon it, determines the tenacity and aggressiveness with which I advocate for additional analgesics.

We are in the midst of a prescription opioid epidemic that, in my opinion, is partly due to the notion that "pain is the fifth vital sign" and that "pain is what the patient says it is" and I consider it prudent and appropriate to consider other data besides simply the patient's self report in considering appropriate pain management measures.

Been there,done that, ASN, RN · Aug 2, 2017

The visual scale is used for kids and patients with communication barriers. It is only a tool.

Nurses assess pain using observational tools like, facial expressions, vocalisation, restlessness and guarding.

Pain is whatever the patient says it is. It is entirely subjective.

My father had neurological pain. It took 80 mg/ hr. of morphine to give him relief. Cancer patients require more.

Observe closely.. and do whatever it takes to get them comfortable.

macawake, MSN · Aug 2, 2017

I always use the behavior pain scale in addition to the numeric one. They tell me their pain is 10/10 and they need dilaudid, but the behavioral scale rates them about a 3 . . . or the opposite problem. Some folks (including me) tend to rate their 9/10 pain a lot lower than it is because they figure they should be "able to handle it." When they tell me their pain is a 4 and the behavior scale gives me an 8, I talk to the providers about pain control. Unfortunately, the behavior pain scale doesn't help me to rate my OWN pain.

(my bold)

Ruby Vee, what type of patients do you work with? ICU? And when you say behavior pain scale, which one do you mean? The ones I'm familiar with are BPS and CPOT.

Behavioral Pain Scale (BPS) for Pain Assessment in Intubated Patients - MDCalc

Critical Care Pain Observation Tool (CPOT) - MDCalc

The reason I ask is because I'm a bit confused regarding which scale you use. While the two I mentioned are useful tools for ICU patients who aren't able to communicate, they're not as far as I know useful (or validated) for use on the typical population on for example a med-surg floor, where the patients normally won't be intubated/sedated. The BPS looks at three behavioral indicators; facial expression, upper limb movements and compliance with mechanical ventilation (the BPS score is the sum of the three subscales) so it's not relevant to use on for example a patient with preexisting chronic pain who is now POD3 on a med-surg floor (or for OP's patients who seem to be at their place of work).

Perhaps you're referring to some other behavioral pain scale though?

All the research studies on the sensitivity and specificity of the two scales I linked (BPS and CPOT) that I've seen, have had need of invasive mechanical ventilation as an inclusion criteria (but it's entirely possible that I haven't seen/read them all).

For patients who are conscious and able to self-report with for example a Visual Analogue Scale (VAS), self-report is the gold standard.

On a general note when it comes to pain. I wouldn't necessarily expect to see any noticable changes in facial expression or vital signs in patients who suffer from chronic pain. That's something I associate primarily with acute pain.

macawake,
There's a lot of good information in your post, so thank you for that. What I haven't completely understood (in the past nearly 2 decades) is what we are supposed to make of the exact scenario that the OP is presenting. It's as if a problem doesn't exist.

I'll try to answer your question to the best of my ability, but it's a BIG question you're asking :)

OP's exact scenario:

And it does happen that people report pain of 10, and say that they can barely comb their hair because their shoulder hurts so bad, and that they can't raise their arm hardly at all- but then they are seen 10 minutes later working, lifting 30 pounds over their head and joking around with their coworkers, with no problems moving their arm. I'm just saying that the two things just don't match and it makes it difficult to know how to proceed with treatment.

It's a bit difficult to come up with the perfect (or even a so-so) answer since I know next to nothing about this patient. The only thing I know is that OP works in occupational health and the scant information included in the above quote.

I don't know what type of pain (acute? chronic? post surgery? injury?) the patient has and I don't know what happened in the ten minutes between the self-report of 10/10 pain and the hoisting of 30 lbs over the head with the help of the recently 10/10 shoulder. But since OP is observing this patient at his/her place of work I guess I'll have to rule out administration of iv Fentanyl or similar, so the rapid improvement does seem quite remarkable. (I have to admit that I've never seen something quite like what OP described, but perhaps that's because I've only worked in acute care hospitals and patients tend to not lift heavy objects over their heads...)

I just realized that I have no idea how to best manage OP's patient.. :dead:

I need more information. The only thing I can say is that, if this was my patient, I'd talk to him/her. I'd tell them that in order to give them the best possible treatment (and treatment doesn't mean medications exclusively), I need to better understand their pain. I'd want to know what aggravates it and what alleviates it. I'd ask them to describe the current pain (when lifting the 30 lbs object) and ask them what the patient him/herself thought had led to what appears to be a significant decrease in pain level in the short amount of time that had passed.

That said, whatever medications the patient is prescribed, no doubt they come with treatment parameters. They are either to be given at specified intervals or prn when the treatment criteria are met. It's not the nurse's job to second-guess the provider who prescribed the treatment (although we are of course free to offer our input/discuss it with the provider and withhold the dose if it's objectively unsafe to administer).

One thing I've never seen is an order that says administer xx mg of drug yy ONLY if you the nurse, believe/are convinced beyond a shadow of a doubt that the patient is experiencing the "required" amount of pain. Seeing as this isn't the standard that has to be met in order to administer a prescribed medication, I think the decision whether to give the med or not, is a lot more uncomplicated than the OP seems to feel.

JKL33, I suspect that the heart of the problem that you're asking me about, is the problem with the "opioid epidemic", rather than OP's specific scenario? I won't pretend that it isn't a problem, because it most definitely is. I don't claim to have all the answers but even if I were to try to outline what I think the "cure" for it would be, that would necessitate a much longer post than I have the energy to write right now (or anyone would have the will to read ).

My main point and the reason for all the posts I make in threads that basically amount to "drug seeking" threads, is that even though we have a societal problem of widespread opioid abuse and addiction that needs to be addressed, there is a very real risk that hospitalized patient's pain is severly undertreated by healthcare professionals, either from lack of knowledge or bias/prejudice.

I apologize for this somewhat rambling post. I've had an intense, exhausting day today and it's 2am over here in Viking land. Attempting to unwind by writing this post probably doesn't qualify as one of my more inspired ideas :)

bgxyrnf, MSN, RN · Aug 2, 2017

Here's an example...

Very early in my career I had a patient whose pain was *always* 10/10... no matter what. She would set her alarm clock to wake her up so that she could ask for more pain medication... from deep, sound sleep to 10/10 pain immediately after the alarm sounded... along with a statement that her roommate was also a 10. Rather than acting immediately upon the self-report, I would wait for 20 minutes or so. Generally, she would be fast asleep again.

I fail to see how anyone could consider the 1-10 scale valid for a patient who simply never has a self-reported pain level that's anything besides a 10... not an 8 or 9, but always a 10... even when she was so sedated that she could hardly get the words out.

Or another patient who was always a 10 and would actually say, "come on, man, push it fast... it doesn't work if you go slow."

As I said, if the order is there and the patient is awake and breathing, I'll pull it and push it. However, I've seen enough to know that 1-10 is not a terribly reliable measure of pain.

5228shamrock · Aug 2, 2017

Lots of things to think about here, and a really good discussion. It's true, sometimes patients don't get appropriate treatment for their pain. Sometimes patients under report because they feel that they should be able to tolerate it. Sometimes patients tell us everything we need to know as honestly as they can. And sometimes patients just lie and purposely report their pain to be greater than it really is.

MunoRN, RN · Aug 2, 2017

It''s not really possible for a self-reported pain scale to be either accurate or inaccurate, it's not supposed to be a defined measurement system, so long as you're not dosing meds based on the number (which I hope nobody is doing), then it shouldn't really matter. It's only intended to measure changes in self-reported pain levels (it was an 11 and now it's a 10, which means it's improved, etc).

Mandychelle79, ASN, RN · Aug 2, 2017

As a nurse, I medicate per pt rating and my facility uses numeric scale. I tend to increase the scale if I walk in the room, look at the patient and say I can see you're in pain, how bad is it, because I typically get a 6.

As a patient I have found saying I'd rather give birth without an epidural again (I was having a gallbladder attack) was a way to accurately describe the pain because 6 baseline 8 when in a spasm wasn't being understood.

3ringnursing, BSN · Aug 7, 2017

People certainly can have severe pain and still laugh.

After my C-section (which was pretty darned painful) I couldn't stand upright to walk - I had to ambulate bent over from the waist for about a week afterward. I felt like if I stood upright that I was going to tear something internally (I make adhesions after every abdomenal surgery I've had).

Never underestimate how painful a C-section really is after having your belly carved up, organs yanked out and set up on your abdomen, then stuffed back inside and stapled closed. ("You're fine! Just walk it off!"). :yawn:

I was in misery afterward, but couldn't help but laugh while my husband relayed a story to me of what occurred during the delivery: I had been in labor all afternoon but not really progressing, so my husband took an hour off to go grab dinner. He zipped over to our favorite Mexican restaurant and gorged himself, washing it all down with a couple of Mexican beers (for medicinal purposes don't ya know).

Around 3 AM it was decided that I needed a C-section - enough time for all that great Mexican food and beer to amalgamate into stuff of nightmares in his intestines. Due to nerves (and his unfortunate choice of dinner) he got really bad gas - like charnel house effluvia type smelling gas. :wtf:

During the surgery my husband (then a nonmedical career person) was standing up next to my head to one side watching in horror as they cut, ripped and tore into my abdomen. He watched as they levered out my bladder and set it aside up on top my abdomen in their quest for the prize: my uterus and our son inside.

The unfortunate anesthesiologist was seated on a stool behind my head - directly behind my husband, with his face at exactly level with my husband's rear end. This poor man received the brunt force trauma of all nervous gas my husband passed throughout the entire surgery. :dead:

My husband sheepishly told me even he was offended by the stench he was emitting, but he couldn't help it. Nerves will do that to a person. :wideyed:

I was splinting my incision with a pillow laughing in agony, tears rolling down my face while he confessed his tale. I thought I may dehisce right there (I didn't, but it sure hurt bad - in fact I would definitely rate it as an 8/10 easily).

When they brought in my "little bundle of joy" I smiled when I held him in my arms gazing at his sweet tiny rosebud face, and perfectly round head - still in blazing throes of agony.

I was a very thin person pre-pregnancy, so I had really tight abdominal muscles that couldn't just be levered apart like can be done in some women - they had to be cut. It was hypersensitive, burned like hell, and even a light bump from my infant's foot while nursing was misery.

That incision hurt like a dickens for nearly a year while all the nerves regrew, but during the post-op period onward I smiled, laughed and loved ... and suffered simultaneously.

Six weeks later I began work as a new grad RN. I never withheld pain medications from patients - if it was due and they asked for it, then get it they did (with a smile). :)

Pain is a strange and remorseless thing. Unless you've experienced it for yourself it's very difficult to truly understand it's nuances especially in others.