Pain is subjective?

Emma Peel · Sep 25, 2008

My mom also had chronic pain from 25 years of rheumatoid arthritis. Mostly what worked for her was never missing a dose on her methotrexate/prednisone schedule. I remember being with her at doctor's appointments where they would ask her how often she had pain and she would say, "Well, I always have some pain. It's just a matter of how much". She would only mention it if she was having a really bad day, but even on a good day she had some pain. She just lived with it.

The pain statistic I remember from school is that less than 3% of pts put on narcs long-term become psychologically addicted. Some of the others have to be weaned because of developing physical tolerance, but 97% don't want to stay on heavy drugs when they no longer have pain. Don't make pts suffer needlessly!

HalfmoonMaggieRN · Sep 25, 2008

The subjective data provided by a pain scale is only part of your assessment. As you mentioned, objective data will allow you to see the larger picture. In noting that some patients' activity and behavior are inconsistent with the pain they're reporting, you have really answered your own question. Documentation of these objective signs is, admittedly, more time-consuming than simply recording a patient's description of pain using a pain scale. You need to document the patient's activity, body posture and whether the musculature is tense or relaxed, the rate of respirations and respiratory quality---regularity, depth, and whether they're labored/unlabored. The volume and quality of the patient's speech will give other caregivers additional information. Document quotations if the patient's words provide a glimpse of the patient's mental and/or emotional status at the time the pain is being reported or pain medication is requested. You can make the documentation process less difficult by doing a periodic observation of the patient for objective signs of his level of comfort, and tallying the results for documentation. For example, you walk past the door of the room every 15 minutes (or whatever interval is practical and/or appropriate for the stability of the data). So, the symptoms of pain are subjective, but the signs of her level of comfort are not. Take advantage of them to draw a more accurate picture of your patient, and you may feel less frustrated about the incongruity of the objective and subjective data you've assessed.

grace90, LPN, LVN · Sep 25, 2008

:deadhorse

Pain is what the patient says it is. Period.

typoagain · Sep 25, 2008

The thing is that I see something close to this yet different-I work in a pedi unit. I recent had a pt that was a 10 yr old who had an appy. He came into the ER complaining of pain for 3 days. This kid gave a textbook perfect description of the symptoms of appendicitis. He's knew all about the symptoms of appendicitis because his father (a former EMT) had told him what was wrong before they ever came into the ER. A fact that he was quite proud of.

All the tests came back normal. but they did the surgery anyway because of the symptoms and constantly complaints of pain. After talking to the surgeon post-op I am convinced that the child had a healthy appendix.

I took care of the child pre- and post-op. I would give him Demerol and the father would be back at my desk within 20-30 minutes complaining that the child was "in so much pain that he is leaning over the side of the bed crying beating on the nightstand." I would then check on the child in 5-10 minutes and he would be looking happy, laughing, and acting fine. Two different times I actually found the child asleep.

The whole time he was on the unit he never rated his pain at less than 10, and his father always said it was even worse.

Now, I do think the child was in some discomfort. But I also think that due to the child's actions and reactions to treatment that the whole mess was being blown so out of proportion that we were unable to accurately assess his pain. And I think that the father was grossly exaggerating the child's discomfort and that he was actively encouraging the child to grossly exaggerate his pain.

So what do you do in a situation like this?

While this is was extreme situation, I often, (sometimes daily,) have to deal with parents who want there kids medicated for pain when I question if they really need it.

Quite often these same people are asking me to sedate their kids so that they will get some sleep.

So what do you do? What do you think I should do?

Wishinonastar, BSN · Sep 25, 2008

I think those of you who are judging are what gives nursing a bad name. Pain is a personal thing. It is what the patient says it is, period. I have seen far more patients suffer needlessly because of paranoid nurses and docs who have an attitude about narcotics than I have ever seen patients who abuse them. Shame on you. I hope when your time comes that you are in pain, and it will, that you will remember these things you said. Ithink more patients should sue for lack of pain relief. Then maybe it would open some eyes. By the time a patient is writhing in pain you cannot relieve it without huge doses of meds. Why don't you go to some inservices on pain management??

CO2emission · Sep 25, 2008

"pain addeth zest unto pleasure and teacheth the luxury of health"

pain is what the patient says it is, nothing more and nothing less.

missjennmb · Sep 25, 2008

As a patient, PRN meds were really hard for me. I hated asking for them, knowing that it was 50/50 if someone would believe me, half feeling that I had to lie about my pain in order to be given something that worked well enough. Pain might be a 5 to me, but tylenol wasn't going to touch it, yet saying I was a 5 got me tylenol. I ended up just saying it was a 7 most of the time in hopes for some real relief. Imagine my panic when I had a serious pain (some sort of kidney infection) and I did not think that anyone would believe me or give me enough pain meds to actually work.

Being in pain and having to "ask" for pain relief every 4 hours really sucks...a lot... its a very humbling thing to have to ask someone else to make you feel better, and then just hope they believe you when you say you are hurting. I hope that I can somehow avoid ending up in LTC where someone makes that choice for me every day, multiple times a day. It terrifies me to be back in that type of situation.

As a nursing student, I hope to become the kind of nurse that doesn't judge and wants pain relief for her patients, no matter what their background. I know that reality can be different, but that is what I strive to be, and I will remember my own experiences, every time I start to consider judging their pain.

ehooper80 · Sep 25, 2008

I understand the concern some nurses have when they give out a lot of pain medication to patients... and I would imagine in rehab (with all the physical therapy, injuries/surgeries that require rehab), there would be a lot of patients that require some serious pain medication. I work on a neurology med/surg floor in a hospital, but we get a lot of general med/surg overflow patients, who more commonly have prn pain meds.

As a nurse, I DO BELIEVE that pain is subjective... and that it is also the 5th vital sign and assess it like the rest. It is not my place to judge whether a person is in pain, I accept what they say. If they are "laughing and entertaining" in their room, good for them, I'm glad they have the courage to have a positive attitude, and friends/family willing to visit them during their difficult time.

The doctor writes the orders for the medication... evaluating how much medication he/she prescribes is beyond my scope of practice. Doctors often realize things we do not as nurses (an extensive medical history, past usage of medications, metabolic reasons a medicine has a greater/lesser effect on certain individuals). I've seen whopping or frequent doses ordered for cancer patients, history of back disorders, joint/vertebrae disease, on and on.

If I see an order that is so large it shocks me, I will call to inquire, and I've always had a doctor gladly explain why this particular person is on so much medicine.

Also in my experience, the patients that ask for medicine "on the clock" do so because of the nurses that avoid giving them the medicine. If you honestly believe they are a drug seeker, call the doctor and tell them so.

cjcerrn · Sep 25, 2008

After attending a pain seminar a couple of years back, it was pointed out to me that chronic and acute pain are two totally separate entities. Chronic pain suffers undergo pathophysiologic changes that not only changes the type and perception of pain, but due to the changing of the pathways, areas of pain actually increase. But the saddest thing I learned was the fact that many of these chronic pain sufferers would not be in the shape they are in if effective management of pain had taken place at the acute phase.

So when you think about chronic pain, take a good look at yourself in the mirror, and make sure you didn't contribute to that suffering by assuming that they really didn't need that pain med.

CountyRat · Sep 25, 2008

patients with long-term pain should be medicated before their pain becomes distressing. administering narcotics on a fixed schedule is sometimes the best way to treat them. patients who ask for their meds "like clockwork" are sometimes attempting to make their schedule more ridged in order to control pain before it becomes difficult to manage, which is actually a good idea in most cases. other times, they may be acting out their anxiety that the nurses will withhold their medication until they are in agony.

what i am about to suggest is counterintuitive, and might even make some readers angry. all i ask is that you hear me out, and think about the following dispassionately. sometimes patients ask for more narcotics when they are anxious about whether the nurse will administer them, and hit the call button "like clockwork" in response to their anxiety. consider the option of asking the doctor for a fixed rather than prn schedule for narcotics for patients whose condition makes it certain that they will need them. if the doctor agrees, the doctor and nurse should sit down with the patient and explain that, in order to ensure the best care, he or she will receive pain medication exactly on schedule, around the clock, no matter who is nursing them. no need to beg, dramatize, or worry about whether their pain will be treated. this can reassure them, reduce their anxiety, and improve outcomes. doses can be reduced as appropriate, without loosing the patient's confidence that he or she will get the medication they need, so they do not need to dramatize their pain.

this is not the right course for every patient, of course. however, in properly selected cases, it can actually reduce the amount of narcotics the patient needs, without creating conflict between patient and nurse.

drug seeking is not the same thing as drug abuse. when we identify drug-seeking behavior in a patient, our first question should be, "why is he or she seeking drugs?" for some patients, it is because they are drug abusers, and providing them with narcotics may harm their health. however, for many, they are drug seeking because they need the drug, but do not trust their caretakers to help them by giving them a drug that they need to enhance their health. in those cases, questioning the patient's behavior and motives can increase their anxiety, leading to exactly the opposite behavior than we want to encourage! we end up working against ourselves, as well as against the patient's interests.

all i ask is that you think about these ideas, that people seek narcotics for different reasons, and our response as nurses should be the one that is supportive of the best health of each individual patient. that is my only point here.

best wishes to all.

pandora72, BSN, RN · Sep 25, 2008

this is a sore topic for me as i work with a particular nurse that complains everyday that she has a drug seeker of some sort. in my opinion...yes, pain is absolutely subjective. if i had 10 patients in front of me that had pain meds ordered, each one asking for it on the dot, i would rather give all of them what they're asking for even if 9 are seekers rather than miss the one lieing there in misery. i'm not there to treat their addiction and that isn't a problem that's going to be solve in the 12 hours that i have them anyway. furthermore, just because they're addicts doesn't mean they don't feel pain...

darrell · Sep 25, 2008

Pain is simply a nervous signal. Suffering, the meaning we give pain, is subjective.

A person who is med-seeking is suffering, but perhaps not from the pain. Your judgment is important, but remember that you are not the end-all of the decision-making process for that patient. I am an RN in Psychiatry working a Mental Illness/Chemical Addiction (MICA) unit - guess how much my peeps like their Ativan...?

Lotta people think I'm too idealistic, but at 50 years old and with lots of partying memories from my own youth, I think my eyes are wide open when I say that most people did not plan for a stoned life when they were eight. Something went wrong and they adopted chemicals as a coping mechanism.

Personally, I enjoy working with the emotional and behavioral issues more than the physical ones. I understand that not all nurses feel like this. Even so, it may help your own equilibrium to reframe this type of behavior as a symptom of a medial issue rather than just the willful misbehaving of a bad child.

D