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?

[typoagain]

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??

So you think that pain meds should be passed out like candy? I have seen parents who want their children kept so drugged up they can't stay awake out of fear that the child might feel any pain.

The child I talked about in my post had a father who actually said that he knew the pain meds were not working because the pt was still awake. My, is it strange that a kid is awake at 6:30 pm?

The bottom line is that I was trained to use WISDOM when giving ALL medications. I am generally quicker than most of my coworkers to give pain meds, but I am sorry, ther are limits.

We have see a lot of babies with reflux and surgery for this is very common. Most of the babies do very well with just Tylenol after the first night. So what do you think I should have said to the mother that wanted demerol for her 21 day old baby who was crying? She thought it was pain, I felt that it was because the baby was still NPO after nearly 48 hours.

[Warpster]

When my old tomcat was dying of cancer 2 years ago, he'd exhibit classic signs of drug seeking around the time his pain medication was due. The rest of the time, he was his old self, even playful.

People in serious pain can and do exhibit this behavior. It can be chalked up to the anixiety of not being in control of their own relief. It's why they want the medication on the dot, so they won't have to experience pain while they wait for somebody to notice they're in trouble. By then, they've been miserable for a very long time, something that should be unacceptable to all of us.

As for the addicts we've all had to deal with in acute care settings, we just have to ask ourselves why they're there. Are they there because they just had an MI or are they there for opiate detox? It's an important question and one which should guide our attitude around med administration.

[aloevera]

I say, if a pain med is ordered, give it......

If a pt. says he is in pain, who am I to question him ????

We all have various thresholds for pain and I do not wish anyone to suffer while under my care....

[AZ Nurse]

you are very correct in saying pain is subjective. behavior is not a good indicator of pain. have you ever cracked your elbow on a door jam? if so, you probably immediately rubbed it to modify your pain. that was a nonpharmacological intervention. sometimes when our patients are laughing, watching tv etc they are using distraction to help their pain.they aren't even conscious of what they are doing. others are just able to tolerate pain without outward s/s. those of us in pain management have changed our plea from "believe the patient's pain report" to "accept the patient's pain report". unless you work in a detox center you aren't going to be addressing an potential addictive issues. instead think of how they may have grown tolerant to the medications from prolonged use or chronic pain managment. maybe the answer isn't to question their pain med requests but to instead ask how we could better manage their pain. would they do better on a long acting medicaiton with breakthrough coverage? do they have a multimodal approach to their pain medication regimen? are we giving them "hi's" and "low's" with the prn dosing? are we being proactive in treating the pain so it doesn't get severe and then need several doses to manage it? all these are good questions to think about and ask the physician. if you still have questions try contacting a pain specialist nurse in your area. you can probably find one from the local chapter of the american society for pain management nursing (www.aspmn.org). pain can be a horrible thing for a patient to deal with if their healthcare providers are constantly questioning the validity of the pain. one last word...i think we have all had the patient who has requested pain medication and by the time we get back to their room they are asleep. please awaken them to give them the medication. believe it or not a patient can fall asleep with a high pain level - pain is exhausting. if you allow them to sleep and they awaken 15 min or 2 hr later....their pain will probably be much worse. good luck with your future pain management.

[Wishinonastar, BSN]

Per typoagain-

"So you think that pain meds should be passed out like candy? I have seen parents who want their children kept so drugged up they can't stay awake out of fear that the child might feel any pain."

~ No, I think you should give pain medication when it is needed, and remember that parents know their child better than you do. Children and animals often suffer because of an inability to express their needs. Once, they operated on babies without anesthesia because it was thought that they did not feel pain.

"The child I talked about in my post had a father who actually said that he knew the pain meds were not working because the pt was still awake. My, is it strange that a kid is awake at 6:30 pm?"

~ Was he awake and crying when he would normally be sleeping?

"The bottom line is that I was trained to use WISDOM when giving ALL medications. I am generally quicker than most of my coworkers to give pain meds, but I am sorry, ther are limits."

~If you deny a patient pain relief you are breaking the law.

"We have see a lot of babies with reflux and surgery for this is very common. Most of the babies do very well with just Tylenol after the first night. So what do you think I should have said to the mother that wanted demerol for her 21 day old baby who was crying? She thought it was pain, I felt that it was because the baby was still NPO after nearly 48 hours."

~ I think you should have recognized her fear, discussed pain management with her and carefully assessed the infant's needs instead of getting an attitude.

[GooeyRN, ADN, BSN, CNA, LPN, RN]

I used to let seeking bother me. I don't anymore. These are adults, their bodies belong to them. It is not my job to detox someone if they do not want that. If the doc prescribes something, their respirations are fine, they are not slurring their words, and it is time for the med and they ask for it, I give it. I give it even if they are asking me to bring it in without them having to ring. Whatever. Their legal buzz is between them and their doctor. I am not getting involved. They know what they are doing.

But OP, yes, I know what you are talking about. We will get the same people in over and over with different complaints and the pain level is always a 10, no matter where the pain is, if it is a headache, a sore foot, an abdominal issue, a toothache, etc. It is always a 10 and it has to be XYZ med given, nothing else "works". The pain is still a 10 even when the medication peaks even though they say they feel somewhat better. The pain is a 10 no matter what, on admission, while full of drugs, and on discharge. They can be scarfing down their greasy McDonalds and saying their abdomen hurts and the pain is a 10. We have some that sometimes forgot what foot/leg/knee it was that hurt. They get their story messed up. They want their med, I give it to them so they are happy and I can get on with caring for others that need me.

[AZ Nurse]

it has to be XYZ med given, nothing else "works".

Just one comment on this portion of your post......if a patient with migraines comes in and says that xyz med is the one that can ward off a headache no one would question this. Or if they are hypertensive and say that xyz medication is the one that has been successful in treating their Bp then no one has a problem. Why then do we encourage patients to be more informed, know their medications, allergies etc and then criticize them when they try to tell us what works. Personally I will puke my toes up with morphine but do well with dilaudid. Should anyone ask me about my pain management I would tell them please no morphine....try dilaudid. I am sure many would raise their eyebrows at that request and probably call me "drug seeking".

[GooeyRN, ADN, BSN, CNA, LPN, RN]

I think with the "must be xyz med" pain can be real and is real, but it does raise my eyebrow when they want that for the migraine, the knee pain, then the tooth ache, etc.

[Wisc.RN]

Oh heavens yes! Lets not use our ability to assess or trust our instincts about our patients.... just FOLLOW THE DOCTORS ORDERS!! We have an obligation and legal responsibility to question ANY order we have doubts about! Narcotics can cause rebound headaches with migraines.. patients do seek drugs from multiple providers to SELL for profit. I take this behavior seriously and so do most providers that I work with in the ED. Patients can be confronted with known inconsistencies in their stories and should be allowed a chance to explain. Is it not in the patients best interest to point out to them behaviors that are harmful? The same as we do with smoking. exercise, losing weight ect. I do believe pain management is very important but its simply gotten out of control! A sore throat or stubbed toe is not going to kill you!

[leslie :-D]

Oh heavens yes! Lets not use our ability to assess or trust our instincts about our patients.... just FOLLOW THE DOCTORS ORDERS!!

instincts are fine, as long as they're not being obscured as judgment.

sometimes it's a fine line.

and if a doctor prescribes narcs for a sore throat or stubbed toe, then shame on him.

leslie

[dina77]

I try to encourage patients that are prone to pain to take their painkillers even if they refuse as it's much easier to control pain before it starts than to treat it once it has taken hold.

[Nursebarebari]

i believe there are patients whose c/o pains are genuine and there are others who are drug seekers. i have no way of differentiating and i can't go by their behaviour of laughing or talking, so i just go by what they tell me and medicate them.