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 ub-Acute/LTC, Home Health, L&D, Peds.

My sister recently had a tumor the size of a softball removed from her colon. I was with my sister through both of her natural delivery pregnancies and I know how she deals with pain. She is very quiet and basically meditates to "Go out of herself" as she describes it to deal with severe pain. Well, after surgery I spoke with my mother who was there with her and my mother told me my sister was in severe pain. I spoke to the nurse and the nurse said to me "Your sister is sleeping and I am not going to wake her up to give her pain medication" When my sister is in severe pain it is difficult for her to deal with anything but concentrating and so yes it may seem like she was sleeping but I told the nurse she is not sleeping and I told her how she deals with her pain. Assuming the nurse would medicate her I hung up and called back later. I found out that no indeed the nurse had not medicated her and my sister had been laying there for hours in agonizing pain! So I got in the car with my 2 little boys and drove the 2 1/2-3 hour drive to get there and dealt with the nurse myself. Believe me as soon as I got there the nurse got the doctor on the phone and they got the appropriate dose and timing (not PRN) and my sister was not pain free but she could tolerate it for the rest of her post op stay. The doctor came in the next morning and apologized for my sister not having adequate pain control the day before. I was really angry that the nurse didn't try to assess my sister more thoroughly than just see she had her eyes closed and assume "Oh if she is sleeping she can't be in pain". I know you are a new nurse and you have a lot to learn in the real world but I think a pain seminar would be a great investment. You can not think you know or assume what another person's pain level is no matter the circumstances. You really have to believe what the patient is telling you. We are not there to judge our patients but to assist in treating them. If the doctor has written the order for pain medication then that is between the patient and the doctor.

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Specializes in ub-Acute/LTC, Home Health, L&D, Peds.
Yep, been there and done that MANY times. It ticks me off that docs will prescribe Dilaudid or Morphine q1h. OMG, Im in their room more than anyone elses. But I try to look at it other ways too. When I was in the hospital (after colectomy and hysterectomy) I was asking for my pain medicine on the dot when it was due. I was truely hurting. I am now in constant chronic pain but you wouldnt know it by looking at me. I laugh and talk at work, while deep down my abdomen is churning. And for those who are terminal, who am I to say anything. And for those who have been on it for years, who am I to say anything. Its hard these days to tell the true pain from the drug seekers, but sometimes there are those that you just KNOW are drug seeking. It also angers me when docs order strong narcs for pt's with a minor dx and with hx of drug abuse...knowing this will send them spiraling down that pathway again once discharged. The other day I had a patient who had been imprisoned 4 times for drug abuse. He was prescribed Dilauded 4 mg every 2 hours! He would come to the nurses station asking for it, then leave and smoke. I asked him at 12:15 if there was anything else I could do for him, his response?...."just bring me my pain med at 2:00". I finally blew. I told him that he cant PLAN to be hurting 2 hours later.

I would love to know how "you just know" when somone is a drug seeker? :banghead:

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Specializes in Cardiac Telemetry, ED.

I find it helpful to educate my patients on the Verbal Pain Scale, and what the numbers represent. Once a person realizes that 8/10 pain means that the pain is interfering with their ability to perform the most basic of functions, such as going to the bathroom or talking on the phone, they might revise their number to reflect more accurately how the pain is affecting them. I like to use the little laminated card we have hanging in each room, which looks not exactly like this, but is similar.

http://www.anes.ucla.edu/pain/FacesScale.jpg

My facility has a pain protocol with standing orders for everything from Tylenol to Dilaudid, where we base our decisions on what medications to use upon the patient's stated pain level, and the efficacy of the pain meds given. If their pain level is low, they might just get some Tylenol. If it's in the mid range, they'll get the Vicodin or Percocet, with oxycodone for breakthrough pain. If it's medium high, they'll get Norco or Lortab, and if it's high, they can have IV push meds. I let people know that while the IVP meds work faster, the pills work longer.

I've only had to refuse to medicate one patient, when her RR was 6-8 and she was nodding off between loudly demanding more pain medication (IVP Dilaudid). I explained to her that I did believe that she was in pain, but that I did not want to send her into respiratory arrest, so she would have to wait for the next dose. Of course she wasn't happy about that, but I wasn't about to OD her.

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when/if a patient says s/he is in pain, then it's your responsibililty to medication him or her. it's not our jobs to assss if it is real pain or fake pain just to get the high. its simple: pt wants the med/pt stable to receive the med/pt gets the med and is happy/we go about our merry day. either way, it usually puts them to sleep for a few hours, so that's a lttile bit of relief:)

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Specializes in Acute Care, Rehab, Palliative.

Where I work we educate pts to take their pain meds regularly to keep ahead of the pain.It is not our place to question them asking for pain meds. Most of the time the pts discomfort is what thry say it is. Pain scale of 8/10 for some people would not interfere with ADLs. Everyone deals with it differently. I handle a fiar bit of palliative care at work and they get their morphine regularly to keep them comfortable, pts are not always able to give you a pain scale score.

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Specializes in 2 years as CNA.

I am glad to see so many nurses that realize that pain is subjective. Unfortunately I have seen far too many people feel that patients are just drug seekers. My mother suffers terribly from chronic pain and is even on disability now. She was a LVN for over 30 years and had to stop due to her pain. I have seen her fight with doctors to get the proper treatment she needs. She has been to many specialists and now a new pain clinic. I am very scared because I face the exact same symptoms that she has but not as bad as her yet.

It is infuriating to me that I have to see her suffer at times. She just now got into see one of the top rheumotologists in our area and is finally getting on a good treatment plan and physical therapy. But all throughout the past 15 years she has suffered when she should not have had too. People need to realize that someone who is in pain does not get addicted to pain medication.

And why does it matter anyway? So, what if someone is a drug seeker, it is not your place to decide that fact. This country is so drug obsessed anyway how could you blame anyone? I just believe that is between the person and their family and doctor. Nurses should not feel that they are the "drug" police. During this day and age no person should ever have to suffer. It just blows my mind to think that there are nurses out there who think they know when someone is seeking drugs. Trust me when you are in pain you are wanting relief and you WANT the drugs!!!!

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As I am taught in nursing school:

Pain is what the patient says it is.

Do an assessment using the pain scale, assess vitals, and document.:nurse:

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I think that sometimes the patients ask for the pain meds on the dot because they are afraid that if they go past that time, the previous dose will wear off, and they really will be in pain.

I have had a couple of surgeries, and I tried to tough it out and not take pain meds until I was really hurting badly. At that point, you take the meds, then wait for it to kick in. Not pleasant. I think most ppl just take them to prevent pain, not alleviate it. Plus, the Dr. told them to get pain meds every x hours. They see it just like taking antibiotics.The thinking is, If Dr. Smith says I need it every 2 hours, then I better do that.

That said, I realize there are drug seekers. They have to live with their very unhappy/unstable lives. Plus, if they are addicted, coming off would make them fell pretty lousy. I say treat them for what they are there for, then reccommend a rehab facility if you are that concerned.

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there are pts who will seek their meds when truly in pain.

there are pts who will seek their meds because they love their meds.

and then there are pts who will request their meds to keep ahead of the pain. (as they've been taught?)

2 out of 3 are valid reasons.

i'll take my chances.

leslie

I think sometimes all 3 reasons are valid.

Sometimes I look at the person's life (what little I know about it) and think, so what if they love their meds?? I don't walk in their shoes.

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Specializes in Cardiac Telemetry, ED.
Where I work we educate pts to take their pain meds regularly to keep ahead of the pain.It is not our place to question them asking for pain meds. Most of the time the pts discomfort is what thry say it is. Pain scale of 8/10 for some people would not interfere with ADLs. Everyone deals with it differently. I handle a fiar bit of palliative care at work and they get their morphine regularly to keep them comfortable, pts are not always able to give you a pain scale score.

Oh, I agree. Sometimes I really hate the pain scale. There are times where I feel I'm badgering some poor little old lady for a number (thank you, Joint Commission!). Patients can't always give a number. I was simply pointing out in my post that educating your patients on the pain scale can assist them in evaluating their own pain and assigning a number that reflects what they are experiencing, and if there is a protocol in place with standing orders, you can use that number to assist you in selecting an appropriate medication. This works well for the vast majority of patients that I work with.

However, the pain scale doesn't always fit, and people don't always fit the pain scale. That's where that thing called "nursing judgment" comes into play; learning to recognize those situations and act appropriately. :nurse:

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Sometimes the way the MD order is written makes the situation worse. When an order is written q4-6 hr prn. Nurses tend to interpret this as pt. receives never unless asking for it. It is our responsibility to be ahead of the pain. We can offer less medication more often. Give Tylenol regularly (barring liver dysfunction) and you might just avoid heavier narcs.

Once a pharmacist told me she hated the prn orders because it seemed that prn meant Patient Receives Never. Many people have had previous experiences where this has happened. Don't judge people too critically, if they are breathing well and say they need pain meds, just do it and chalk it up to good care.

Most elders have earned lots of arthritis by living long and creating a better world for the next generation. Give them a break.:twocents:

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Specializes in ub-Acute/LTC, Home Health, L&D, Peds.
I am glad to see so many nurses that realize that pain is subjective. Unfortunately I have seen far too many people feel that patients are just drug seekers. My mother suffers terribly from chronic pain and is even on disability now. She was a LVN for over 30 years and had to stop due to her pain. I have seen her fight with doctors to get the proper treatment she needs. She has been to many specialists and now a new pain clinic. I am very scared because I face the exact same symptoms that she has but not as bad as her yet.

It is infuriating to me that I have to see her suffer at times. She just now got into see one of the top rheumotologists in our area and is finally getting on a good treatment plan and physical therapy. But all throughout the past 15 years she has suffered when she should not have had too. People need to realize that someone who is in pain does not get addicted to pain medication.

And why does it matter anyway? So, what if someone is a drug seeker, it is not your place to decide that fact. This country is so drug obsessed anyway how could you blame anyone? I just believe that is between the person and their family and doctor. Nurses should not feel that they are the "drug" police. During this day and age no person should ever have to suffer. It just blows my mind to think that there are nurses out there who think they know when someone is seeking drugs. Trust me when you are in pain you are wanting relief and you WANT the drugs!!!!

:yeah::yeah::yeah::yeah::yeah::yeah:I couldn't have said it better myself!! Any nurse that thinks otherwise really should attend a pain seminar!!

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