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 ICU/Critical Care.

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.

I totally agree with you.

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"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. :)"

I agree with you 100%. That is the reason why I started this thread to begin with. Like I said before, I am a new nurse with a year experience and I kinda had different expectations. I am learning and and I am open to be taught. Maybe it is the over prescriptions that bothers me. I am just afraid of a patient overdosing.

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Specializes in Cardiac Telemetry, ED.
i'm not understanding what you're saying...

leslie

I'm talking about the Double Effect Doctrine.

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I am a new nurse with a year experience and I kinda had different expectations. I am learning and and I am open to be taught. Maybe it is the over prescriptions that bothers me. I am just afraid of a patient overdosing.

I've never seen it happen as long as you give it on schedule and not give into the patient who wants it earlier than the time the next dose is due. I've given so much pain meds to one patient or another to the point I was afraid I was going to kill them but no they are just fine. They go from c/o pain as a level 10 to a level 0, laughing and cutting up with friends as soon as they've received their med.

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Specializes in Ortho, Case Management, blabla.

Working in med-surg, I've found some people can be "hypersensitive" to sensations in their body. This includes pain, pressure, etc. One minute they're complaining that their leg hurts, the next minute they're complaining that their room is too cold, next their tummy is upset. Diversionary tactics help a lot, and family members can be boons in these types of situations. The pt will focus on every little thing that is causing them discomfort. I think it also has to do with "loss of control" issues and whatnot, but I also think that some people just happen to be hypersensitive.

On the flipside, you have the undersensitive, like the 40 year old that had a hip replacement and never took a pain med for the entire 3 day stay. I've never seen anything like it. He said, "I don't do drugs, I won't do em ever" and gritted through the physical therapy and trips to the bathroom. I can only imagine the pain he went through. Despite education regarding pain and constantly offering pain meds, he had made up his mind he didn't want to have anything to do with narcotics, he refused every time. No matter what, he always stated his pain at a 1 out of 10, even though his blood pressure would be elevated and he'd be grimacing while moving around in bed. But he said it was a 1, is refusing pain meds, and is functioning, so what do you ?

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Specializes in Cardiac Telemetry, ED.
I agree with you 100%. That is the reason why I started this thread to begin with. Like I said before, I am a new nurse with a year experience and I kinda had different expectations. I am learning and and I am open to be taught. Maybe it is the over prescriptions that bothers me. I am just afraid of a patient overdosing.

Until you have a lot more experience under your belt, you're not really in an informed position to be second guessing the prescribing physician. Check your drug guide for any medication that you're not familiar with if you're worried that the dose is too high. If you're that concerned, call the physician. Otherwise, if the dosage is within the safe range as outlined in your drug guide, and you can see according to the MAR that the patient has been getting the prescribed dosage and that they have not had any ill effects, then it is reasonable to give the med. If the dosage is higher than what is listed in your drug guide, think about it. Does the patient have a history of chronic pain? If so, it's likely that they need a higher than normal dose to get the same effect as someone who is opiate naive. If their prescribed dosage is lower, it could be because they are on renal dosage, or they are tiny. Use your critical thinking skills. :nurse:

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I'm talking about the Double Effect Doctrine.

for those who truly believe in the pde, it often results in the undertreatment of physical suffering at eol.

it's all about intent, regardless if death comes sooner.

yet many hcp's focus on the likely outcome and terminally ill end up suffering much more than necessary.

a shame.

leslie

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Specializes in Cardiac Telemetry, ED.

I've seen more suffering caused by the family members that don't want to let Grandma go. Once the person is on Comfort Care (our facility's version of hospice), I've never known any nurse, myself included, to be hesitant to increase the gtt rate or do whatever it takes to make the pt. comfortable. It's getting to that point, getting the family on board with CC, that can be like pulling teeth without novacaine. At least, that's been my experience. And yes, it is truly a shame.

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Specializes in Retired OR nurse/Tissue bank technician.
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 had a nursing instructor who had been around since Nightengale. She had found in her experience, both professional and personal, that patients who took regular pain meds (like q4h whether they need it or not) the first 48-72 hours post-op usually needed fewer narcotics and had less pain long-term and usually healed faster.

When I had my wisdom teeth out, I was kept inpatient for two days because of anaesthetic and asthma issues. I asked for meds q4-5h, whether I needed or not the day of surgery and the next day unless I was asleep. When I went home on the third day, I was able to be narcotic-free.

Everyone else I've known who have had their wisdom teeth out had to be on narcotics for at least one week and were unable to eat solid food for about as long, if not longer-I was eating normally and going about my regular routine the day after I got out of hospital.

When my friend had outpatient foot surgery, she had waited to take meds until she was in pain and then she couldn't get ahead of the pain. By the time I got to her home, she was in agony. Her pill bottle said 1 Tylenol #3 q4-6h PRN; I gave her two T-3s 3.5h (using the 1/2 hour rule we have up here) after her last dose and sent her to rest. I monitored her breathing and there were no problems; her pain was under control and she was finally able to sleep. When she woke up, I told her to dose one pill q4-6h regardless of pain for 2-3 days, then go q4-6h PRN. If her pain was getting ahead of her despite regular dosing then to use a single extra T-3 and then go back on the normal dosing.

When her MD asked how much narcotic she needed at her first follow up visit, he said she used a fair bit less than most other patients and did she have a high pain tolerance? When she told him the severity of her pain the first day, he said she did the best thing, doing the extra tablet (for some reason, he'd meant to write 1-2, but only wrote 1), then dosing around the clock unless she was asleep for the first couple of days regardless of pain before going to PRN again.

That's usually what I advise friends and loved ones-dose regularly the first 2-3 days, then go to PRN. Med needs are usually lower and pain shorter than only dosing when there's pain.

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Specializes in MED-SURG, LTC.

As nurses, it is not our job to assess iif the patients pain is real or not. It is the physicians job to decide if they are drug seeking or not. Even if you are able to find an easier way to assess objectively we cannot in good faith deny them meds that they are entitled to especially if it is a valid order that is not contraindicated.

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Specializes in telemetry, med-surg, home health, psych.

my job is not to decide whether or not a pt. is in pain......

my job is to help the pt. to alleviate that pain....whether they are telling me they are in pain or I can see it in their face.....I don't have the time or energy to try and guess who is med seeking and who is trully in pain.....

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I'm not a nurse (although by now I assumed I would at least be studying to be one), and I haven't posted in here before, but now felt like the right time.

I am a former Marine, a sort of tough girly girl sort of a person, who used to have an average pain threshold. Thankfully, I never once felt pain during the 8 years I was in the Marines except for 1 sprained ankle.

Fast forward to today - 7 years post-discharge. I now have had chronic daily 5-9/10 pain every single day for the past 6 years for some mystery SI joint pain that has never been diagnosed. In 2004, I was diagnosed with Cystinuria, and have passed hundreds of kidney stones on my own, and have had 6 or 7 ureteroscopy procedures with stent placements.

Now, when I present to the ER with a killer stone I no longer cry or writhe in pain. I haven't in years. My pain threshold is that of Superman. To me, having a high pain threshold means I still feel the same pain (both when it comes to stones and my intolerable SI joint pain), but I just deal with it differently now. I can hold an intelligent conversation, joke about my condition with my doc, and make small-talk with the nurses. Half of the time in the ER, I ask for Zofran (nausea from the blockage) and Toradol instead of a narcotic just because I've been judged by docs on several occasions before the CT scan results come back. Then they throw meds at me like candy.

I'm also allergic to Morphine and I'm too sensitive to Dilaudid to take it as well. Maybe that's also why I just deal with the pain when I can, because I cant take anything that actually dulls my pain properly.

Anyway, there is nothing more unnerving than being judged by someone who can't even pronounce Cystinuria and has to look the condition up online. If I say I'm in pain, I'm in pain.

I had one doc administer demerol in the ER and when I told him it wasn't helping, he said, "I gave you enough to make a horse sleepy," and he proceeded to discharge me before properly bringing my pain down. Perhaps the tolerance had to do with all of the drugs I had been given during my three back-to-back hospitalizations for the stone surgeries and the post-surgery clot/infection? Sigh.

Also, for what it's worth, I'm not dependant on pain meds. In fact, when I receive take-home narcotics, or most pain meds for that matter, I'm non-compliant, because I actually like to know when I'm hurting - then I know when there's something wrong. Know what I mean? Especially when it comes to my mystery joint pain. I prefer to be in tune with my body even if that means putting up with pain that would make most men cry.

So there's my story. I know there are drug seekers out there, but please don't assume right off that everyone asking for drugs is a seeker. That sort of attitude by both docs and nurses has turned me into a person who is embarassed about asking for drugs when I really need them. I know that I'm 32 and should get over myself already, but it's the truth.

Some people fake pain to get drugs. Sometimes I've gone so far as to fake not being in too much pain just to show people how I can tough it out just to get properly treated.

Thanks for listening.

Tammy

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