Pain is subjective?

[lena130]

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?

[TopazLover, BSN, RN]

I am a little confused. The original post was related to LTC where pain is expected. What's the problem of treating what people say is their pain? When many people are used to chronic pain they use any distraction to cope, who am I, or any nurse to assume we know better? As for IVDA, they could be in real pain from something that you don't know about. I know previous drug abusers who have had to take meds for pain that is not related to addiction. Unless you are working directly in a detox area under the direction of an addiction specialist I don't think there is any room for these types of thinking.

Drug addicts did not start out to be drug addicts and rarely is it related to pain control. I do see some control issues here, but not about pain. We are not here to judge. We are to treat. Let the addiction specialists deal with assessment of need to decrease meds. Give when ordered, without judgement and you can go home with less feelings of stress.

[GadgetRN71, ASN, RN]

I try not to be judgemental because 90% of the time these patients have been on PO/ IVP narcs and have built up tolerances to them. I'm not there to detox them.

ITA. Even someone who uses drugs recreationally may well be in pain. I feel the same way-it's not my job to judge people or to rehab them.

Also, many people put on a brave face when they're in pain. I have a chronic condition but none of my coworkers know. I grit my teth, and work through it when I'm feeling ill. I may be laughing and smiling on the outside but grimacing on the inside.

It can be frustrating to deal with drug-seekers, but it can be hard to make that distinction between who's for real and who's faking. I try to give people the benefit of the doubt.

[RedhairedNurse, BSN, RN]

It can be frustrating to deal with drug-seekers, but it can be hard to make that distinction between who's for real and who's faking. I try to give people the benefit of the doubt.

I totally agree!

[MadisonsMomRN, BSN, RN]

I try not to be judgemental because 90% of the time these patients have been on PO/ IVP narcs and have built up tolerances to them. I'm not there to detox them.

This is how I feel. I am not the judge of someones pain. If they say they are in pain... I treat them. But I feel narcs are over prescribed or should I say, for too long.

I work in corrections prn and see people come in on all kinds of stuff that docs have prescribed and docs HAVE NOT prescribed. We detox all the time. It doesn't take long to be on a narc to become tolerant. They are designed to be short term. But it never happens that way. Its sad in a way. Its a physical and mental addiction. Even the best of personalities become addicted without even realizing it because their doc prescribed these meds for periods that are just too long. There are other methods of pain relief that are not utilized the way they should be. Narcs are just fast and simple and for short term. (I had a very close family member with stomach problems that just went on and on. The docs kept giving her pain meds. They didn't know what was wrong until much later. It started with Darvocet and progressed to percocet (over a length of time) When they stopped prescribing them to her she got them elsewhere. She was addicted. It was a painful experience for me and other family members because she struggled with this for years)

Don't get me wrong. I treat a persons pain because pain is what the patient says it is. I am sure they are in pain. I just feel strongly about meds being over prescribed but that's another story. :)

[TopazLover, BSN, RN]

Quote from MadisonsMomRN I just feel strongly about meds being over prescribed but that's another story. :)

I know that is true for some however we also know that most elders are UNDERmedicated for pain. Sometimes this is because they are stoic other times it is because they don't want to bother us.

I am sure there is a middle ground somewhere. If we treat pain as the pt. says it is, we at least are trying to get to middle ground.

Working in corrections must give you a whole different view. You do see more of the actual drug addicted population than most of us do. I applaud you. I could not do that type of nursing.

[Virgo_RN, BSN, RN]

I do not dispute that pain is subjective and I do believe that "pain is what the person experiencing it says it is". But what I do not agree with is the idea that drug seeking behavior does not exist, nor do I agree with the holier than thou attitude that if a nurse is frustrated with a patient's behavior around pain medication, then he or she is less than a good nurse.

As a staff nurse in acute care, it can be incredibly frustrating when one patient sucks up all of your time while your other patients are ignored. I remember one surgical patient who went through no less than three Dilaudid PCA syringes in one eight hour period, and still this was not touching his or her pain. We gave them PO meds to supplement as often as was prescribed, and there was an order from the surgeon NOT to call her about this patient's pain issues. We had the patient on the maximum dose of Dilaudid and were giving the maximum dose of PO meds, and all he/she wanted was IM Demerol and Phenergan. They kept demanding that we call the surgeon to get it. Finally, despite the surgeon's order, we called, and found out that the patient had been calling the surgeon's office several times throughout the day. This patient would be laughing and smiling one moment, bouncing their child on their lap, talking on the phone with friends, then as soon as the family walked out the door or s/he hung up the phone, they would begin wailing, chin quivering, crying out in pain. They would go outside to smoke (from the fifth floor), bantering with nurses along the way, then return to bed and begin wailing, chin quivering. The wailing was so loud, everyone on the entire 40 bed unit could hear. Finally we were able to reach an on call doctor who ordered the Demerol/Phenergan, and that was the only thing that stopped the wailing.....until it was time for the next dose, and the wailing would begin right on cue.

I looked up the patient's history and saw that s/he had regular ED visits for migraines (migraine sufferers, don't jump on me; they run in my family, so I know how migraines are). One particular visit, s/he was angered that a patient with chest pain got to go before him/her. On the very next visit, s/he presented with chest pain and was treated with an EKG, CXR, and Toradol. After that visit, Toradol was listed among her/his allergies (no documentation of an allergic reaction).

Now, I do believe this person was in pain. They had surgery for crying out loud. Of course it's going to hurt. But you cannot tell me that there was not more to it than that. I was there and worked directly with this person, and based upon this experience and others (that haven't been quite as dramatic), I do believe that drug seeking behavior does exist. Having said that, that does not mean that I don't treat their pain as reported to me by them, and that I do not treat them with the same dignity and compassion that I treat all of my patients with. Of course I do. But is it frustrating to deal with, and does it take time away from my other patients who need me too? Absolutely.

Cute story. Recently had a LOL with end stage CHF; DNR but not hospice. She had tylenol for pain, and morphine for SOB. It's 3pm and the CNA comes to me to tell me the LOL is asking for morphine. So I go in there and assess the LOL. She is in no obvious distress. I ask her if she's in pain. No. I ask if she feels SOB. No. I tell her that I can give her more morphine, but not until 4pm. She says ok. At 4pm on the dot, I hear expiratory moaning emanating from LOL's room. I get the morphine and go in there. She denies pain. Her O2 sats are fine, and she is not in respiratory distress. She's just making these noises. She's 90 and she's dying, and if she likes her morphine, who the heck am I to judge?

[leslie :-D]

Cute story. Recently had a LOL with end stage CHF; DNR but not hospice. She had tylenol for pain, and morphine for SOB. It's 3pm and the CNA comes to me to tell me the LOL is asking for morphine. So I go in there and assess the LOL. She is in no obvious distress. I ask her if she's in pain. No. I ask if she feels SOB. No. I tell her that I can give her more morphine, but not until 4pm. She says ok. At 4pm on the dot, I hear expiratory moaning emanating from LOL's room. I get the morphine and go in there. She denies pain. Her O2 sats are fine, and she is not in respiratory distress. She's just making these noises. She's 90 and she's dying, and if she likes her morphine, who the heck am I to judge?

a dying, 90yo lady with end stage chf is only getting prn morphine???

that's a disgrace.

and, she has to fake a symptom in order to get it??

even more disgraceful.

why isn't she on hospice?

at least she wouldn't have to disparage herself in order to get some much deserved medication at end of life.

dang.

leslie

[Virgo_RN, BSN, RN]

It wasn't morphine gtt time yet, Leslie. She wasn't in the active dying phase yet. She was on a Lasix gtt and her lungs were pretty clear. She was kept quite comfortable and was spoiled and doted on by the nurses. Undoubtedly, she would have ended up on a morphine gtt when the time came.

[Virgo_RN, BSN, RN]

Back to the OP.

It sounds like, most likely, you're working with mostly post hip and knee surgery patients. In the immediate postoperative period, we teach patients to take pain medication on a regular schedule, rather than waiting until they begin to feel painful. This is because it is harder to play catch-up with pain than to simply keep on top of it. Plus, pain is expected post-op, and there is no need to grin and bear it.

Once the immediate postop phase has passed, then pain meds can be slowly tapered in frequency and dose, but that process can be highly individual due to the subjective nature of pain.

During rehabilitation from knee or hip surgery, pain control is essential for the person to be able to participate in the rehabilitation process.

So yes, give them their prescribed meds. Anticipate at what time their next dose will be due, and don't expect them to be in a lot of pain at that time. The idea is to keep ahead of the pain, not wait until it's so bad that they need something NOW. As they progress through their rehabilitation process and their tissues begin to heal, their need for pain meds will decrease, but they may already be discharged home from your facility by the time that happens.

As others have pointed out, addiction rates are very low. Most people only take these medications because they need them. Keep in mind that many of these patients probably had to be convinced to take narcotics while in the hospital, and being treated like drug seekers or addicts while in rehab can be quite demeaning.

Remember that they do have to follow up with their physician, and their pain control needs will be reassessed, and any adjustments to their prescriptions will be made by the physician.

As for the hospice patients, give them what they want. So long as you are not hastening their death unnecessarily and are just keeping them comfortable, it is whatever comfortable means to them.

[leslie :-D]

As for the hospice patients, give them what they want. So long as you are not hastening their death and are just keeping them comfortable, it is whatever comfortable means to them.

actually nanc, opioids often do hasten death.

but in hospice, that's perfectly ok/legal/ethical.

our intent is to prevent and relieve suffering.

as long as that is our goal, then hastening death is par for the course.:)

leslie

[Virgo_RN, BSN, RN]

Actually, it's relative. Hastening death unnecessarily vs. as a result of adequate symptom control.

[leslie :-D]

Actually, it's relative. Hastening death unnecessarily vs. as a result of adequate symptom control.

i'm not understanding what you're saying...

leslie