Pain is subjective?

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I have been a nurse for only one year and I am already questioning the idea/assumption that pain is subjective. I work in the LTC ward where we have subacute patients (including acute rehab and extended care) and hospice patients. I administer vicodin, morphine, oxycodone, tramadol, tylenol #3, etc. at least 8-10 per shift and I work an 8-hour shift. I do have patients that I know without a doubt are really in pain, but 75% of my patients ask for PRN pain medication right on the hour everytime it is due not knowing that I am outside their door and I can hear them laughing and/or carry on an entertaining conversation with another person. Yes, I do believe that pain can be subjective but how am I suppose to assess pain for my drug-seeking/addicted patients? I find it hard to believe that they are telling me that their pain level is 8/10 every single time. Lately, I have been feeling less like a nurse and more like a street drug pusher in a hospital setting. Can anyone relate to what I am saying? Do anybody have any article that suggests I can objectively assess pain?

Specializes in Geri, Pedi, Trauma, OR, Rehab, MH, OP.

This has been an issue from day one for me. I had difficulties, personally, pushing certain meds at certain intervals that just didnt seem right. I have refused the ones that I absolutely could not push morally. It was a mutual concern among the staff and was brought up with the chain of command and dealt with as best as possible. It is not as bad anymore, but the instances are still frequent.

I'm a little relieved to read that there are others that view it like I do, at this point. If I feel objectively that the patient will be in danger if the med is given, I notify the doc and go from there. Usually a change in orders is the result, or I just dont give it. Someone else can, but I'm not going to, but thats only been twice that I have felt the need to make that decision.

For the most part, chart what is subjective and the pain assessment. If its not going to harm them physically, then I give it. I'm not there to detox them. I find it very important though, to make sure you chart that 30 minute post-med administration note. I watch and listen to the patient, THEN I step in and ask them to re-rate their pain. I chart BOTH even if they contradict each other, and notify the doc. If you have a less than cooperative doc on the pts who are possibly seeking, then at least I have charted that certain behavior was noted along with pt statement and physician notified. I feel thats all we can do in that particular setting.

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Specializes in Med Surg, Tele, PH, CM.
I have been a nurse for only one year and I am already questioning the idea/assumption that pain is subjective. I work in the LTC ward where we have subacute patients (including acute rehab and extended care) and hospice patients. I administer vicodin, morphine, oxycodone, tramadol, tylenol #3, etc. at least 8-10 per shift and I work an 8-hour shift. quote]

You have made an accurate assessment on these folks. When I did case management for an insurance company, I always sent my non-compliant patients to SNFs for post-discharge care, especially if there were antibiotics involved. Unfortunatly, most patients today are receive discharge orders from hospitalists who do not know them, and will write any kind of pain med the patient asks for. Any time I received an update from a nurse at the SNF that, in her opinion the patient was abusing pain meds, I contacted the ordering physician and asked him to alter the med order. 95% of the time they agreed. I have so many patients who are addicted to pain meds because of habits that originated in the hospital, then rehab, then ER docs, I can't even count them - rarely from a PCP who sees them regularly.

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Specializes in Med surg, Critical Care, LTC.

This is my take on pain. While I agree, pain is subjective, these are a few things I've noticed in my 17 years.

A person in severe pain cannot tell jokes to staff or friends, usually has no appetite, and their vs are usually WNL. I have had people complain of pain 10/10 and able to do all of the above. I will document something to the effect of "pt c/o pain 10/10, patient observed telling jokes to friends and staff, laughing, vss" Will hold further pain meds at this time.

Patients in a lot of pain will usually show some signs other than just verbally telling you they have severe pain. Some signs are: restlessness, grimacing, guarding, elevated HR & BP, elevated resp rate, diaphoresis.

I've had too many people over the years who just like their drugs, they don't often realize there are other ways to tell if they are truly in severe pain.

I am a strong pain advocate, and I am very liberal with pain medication, but if you can smile and dance the jig while eating a big mac meal, while telling jokes with your mouth full - then sorry, no more pain medication from me - even if you tell me it is 10/10.

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One of the issues I have is when nurses ask the patient to rate the pain on 1-10 and give little guidance. The faces scale previously referenced is a great tool. Without it patients have little way to really be objective about their own pain. Example: DH has been tortured in past, he compares all pain to that experience. When I showed him the faces scale his response was "Wow I was in pain @ a 10. I needed bed rest and could not take care of even basic needs yet I only rated it as an 8 at the most because I compared it to my past."

Nurses need to be sure they are clear when asking for a number. When someone says they have a 10 you can ask, Is this the worst pain you have ever had?" and they can show the face scale to better objectively evaluate pain. The patient may begin to have more trust in getting pain meds without having to say it is a 10 if it is an 7-8, if they know it will be medicated at that level.

This usually is not necessary for every patient but when you see things that lead you to believe the pain is not as bad as the patient says, it sometimes works. Fear of not being medicated sometimes increases the # the patient gives. On the other hand past history may make a patient give a lower number and not get adequate pain control.

Bottom line for me is that nursing is an art as well as a science. We need to use all the tools we possess. Just because we know the pain scale does not mean our patients have the same understanding.

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Specializes in Med surg, Critical Care, LTC.

What I say to patients is this, "Zero is no pain, ten is the worst pain you can imagine. What is your pain right now on this zero to ten scale".

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Specializes in ER, PACU, Med-Surg, Hospice, LTC.

I love these quotes:

" But pain can be mysterious. Everyone experiences it--and yet you can't see pain, measure its intensity, or even reliably describe it. How people experience discomfort is as varied and subjective as how they experience beauty or happiness. The person who hurts is essentially alone with his anguish, which is part of what makes pain even more painful."

" Still, it can be difficult to convince others--doctors, co-workers, family members--that one's pain is "legitimate." Sufferers often complain that they're told, "It's all in your head." Physiologically, notes Dr. Tenzer, this is correct: "Pain is all in your head." As the center of the nervous system, the brain receives and sends pain signals to and from the rest of the body. We now know that these signals can get amplified or distorted, activating pathways not originally involved in the injury and causing pain to persist long after the injury occurred. Some sufferers also may have lower levels of endorphins, our body's natural painkillers, or a heightened sensitivity to pain."

Taken from here: PARADE

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That's where DH's problem was, torture is not a 10, but it was the worst he could imagine, so even face scale pain of 10 was below what he has been through. He could not give an objective # without more guidance. Most people will not have this kind of experience but I just bring it up as an example of how our continued use of the 1-10 scale can allow us to forget the other criteria that are involved in any number.

The OP was concerned because people did not act as if in pain. Many posts since have shown how different people react to pain. I still recall my cat purring while she was having kittens. I know she was very uncomfortable at that time. It broadened my vision of how we act in pain.

I deal with people in pain. By definition these will be seeking drugs. It is not our job to tease out which are abusers seeking to relieve other kinds of pain.

I do hear the posts about the deversion of medications while under our care. This is an issue that needs to be bumped up the chain of command. It cannot prevent us from treating the vast majority of our patients who really need the meds.

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Specializes in ICU, Paeds ICU, Correctional, Education.

The question is..is pain subjective? No it's not but pain behaviours are and many are standing in judgement by measuring pain by pain behaviours. I guess most are talking about the narcotics/drugs of addiction and placing big value statements on the use of these. These drugs are excellent for managing pain but pain is not a pure sensation. These drugs also treat "pain" by being dissociative...they take people away from unpleasantness. So if you are going to measure pain on a scale of no pain to excruciating agony then you are being subjective. What about the profilaxis that allows patients to move, exercise, accept adjunct therapies and tolerate hospitalisation? When you arrive and say, "score your pain", that is a snapshot in time..... you need to have a look at what else is going on.:specs:

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The question is..is pain subjective? No it's not but pain behaviours are and many are standing in judgement by measuring pain by pain behaviours.

Pain is always subjective. And is your observance of a patient's behavior objective or subjective...

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hi.. i know i am just a novice nurse. i have just been working for 8 months. but maybe i cud give you a relevant idea. We, nurses, should also experiment and explore our fields. We know more about our patients than their physicians that's why we should assess them well. Yeah, We all know that pain is subjective data. but there's a way to know if the patient really experiencing pain or just a mind thing. We can give placebo meds. it will show you what your patient really feels.

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hi.. i know i am just a novice nurse. i have just been working for 8 months. but maybe i cud give you a relevant idea. We, nurses, should also experiment and explore our fields. We know more about our patients than their physicians that's why we should assess them well. Yeah, We all know that pain is subjective data. but there's a way to know if the patient really experiencing pain or just a mind thing. We can give placebo meds. it will show you what your patient really feels.

!! So assuming the pain IS real, what is the patient supposed to do while the placebo is "working"?? Egaads, that is a very scary thought, I have to say. Plus, on a more intellectual level there very well may be *some* effect of the placebo, just based on the power of the mind. Obviously it would not counter intense pain, but the mind has a very expansive power, which imo is a large part of why pain is subjective in the first place.

Pain is definitely subjective. I can recall two incidences where I felt what, to me, was "intense pain". A large IV being put into my hand prior to surgery, and my kidney infection. Two incidences where I *should* have felt intense pain but did not... unmedicated home birth of my two daughters. It was painful but not even close to level 10. People look at me like I am insane when I tell them that I would do it again in a heartbeat (well not the raising of them and 9 mos of weight gain, but the birth anyways :D) Because of my state of mind, my excitement, my "out of bodyness", not being messed with, in my "safe surroundings" of my home, whatever... I never hit the point of not being able to tolerate the pain any longer. The hospital was 2 minutes away and I could have gone at any time and chose not to, and never wavered.

Pain is definitely subjective, and its not just "patient A has better pain tolerance" but so many factors are in play. If they are used to dealing with pain, if they are afraid, cultural considerations, and I'm sure the list is eons long.

On an off note... I am still a student and studying pain this week at nursing school, and this thread is just fantastic because it really brings the whole thing to life for me. Thank you all who have posted, on every side of the issue :heartbeat

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Well, there where the sense of a nurse will take over.. Based on what i have experienced, those patients who exaggerated the pain were also the one who really don't feel the pain(not every patients). If you really had a good assessment, you will know when the patient is acting and when it is real. :D If you knew that the patient is only acting, you can do the placebo thing.

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