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 Neuro.

I can understand your concern and even empathize with you. However, we are taught that pain is considered the 5th vital sign and it is whatever the patient says it is. Now before you cast me aside, let me remind you why this policy was adopted. Research has shown that adequate pain relief is not universally provided because of the fear of addiction, dependence and legal liability issues. Accepting that pain is whatever the patient says it is allows us to treat a patients pain without the anxiety of deciding if it is needed or required (within dosing restraints). It also stands as a legally-defensible standard of practice that helps to protect all professionals licenses.

As always you are a professional and you should do what you feel is right. Just don't stress too much over this area of practice. The standard was actually meant to help alleviate yours and your patients pain and anxiety.

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?
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When the average nurse becomes more educated about pain and how each individual handles pain and less judgemental about a person's need for the medication (when were we appointed the pain police?) we will really be care providers. I have said this before in other posts, even if the individual is "drug seeking" there is a legitimate need that needs to be met. seek and refer to the appropriate resources while meeting the immediate need. As others have said, some people can carry on with life and still be a pain level of 9 or 10, this does not negate or invalidate their pain. Medicate and educate is the nurse's responsibiity, nowhere (as far as I am aware) is there a nurse practice act that gives the nurse the role of judge), stop the personal bias and judgements, medicate your patients and use your skills as a resource to move the patient to other resources if that is what is needed. We have enough problems with individual nurses not making sure appropriate care is given, i.e., I had major surgery with a PCA pump ordered but noone put the medication on board and I was without pain med for more than 6 hours because the "nurse" did not believe I could be in pain, focus on the care you are to give and stop judging!! Nanacarol

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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.

typo's response: i do give pain meds every day.

but i am sorry, i think that as a nurse who see babies every day i am often more qualified to judge when a baby is in pain then a 16-18 year old new mother who has never had a sick baby before. i always go look at my pt. often i find the baby needs simple basic care such as feeding, changing or burping. have you ever worked on a pedi unit before? did you have any idea how often i am asked to give pedilyte for 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?

typo's response: no, he was not. he was sitting up in bed watching television and playing. i would walking to room and he would be quick to laugh and play. in this exact case the parents would be up and requesting some sort of pain med an average of once an hour for the 3 days they were in the hospital...while the parents were awake. when the parents were asleep the pain was not a problem at all. i could wake the child up at night 6 hours after his last dose of medication and he would deny any pain. five minutes later the mother would be at the desk telling me he was crying because he hurt so much. the first time this happened i went to the room with her. she was away for the child 2-3 minutes. guess what, the child was asleep.

"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.

i pass out pain meds every shift. normally, i pass out meds to every pt at one time or another on the shift. i normally give out meds to a pt every time they are requested. if i have a pt with a major pain issue i try to pass them out before they start to hurt. i do not want my pts in pain.

"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.

typo's response: i got an attitude? where did you get this from? i do not recall seeing you there! so i should calling the doctor to request heave duty pain meds for a 21 day old baby that is rooting and sucking on anything he can get into his mouth and has not eaten in 48 hours? we should risk major damage to undeveloped kidneys and liver when he is showing every sign of being hungry? i had already given him the normal dose of the normal pain medications the doctor had ordered. by the way, i did call the doctor and he agreed with my request to start the baby on clear liquids, from then on the baby was fine. you know, babies do cry when they are hungry.

lady, i do not know where you come from, but maybe you should back up and read my first post before you attack me. my point was that sometimes you get parents of sick kids who make unreasionalbe requests for pain meds. they ask for pain meds that you, the rest of your staff, and even the doctor think are unreasonable or not needed. part of my job is to do what i can to not risk damage to a very young, underdeveloped biological system. i asked for feedback on that situation.

but instead of thoughtful, intellegent feedback for you, i get you standing on your soapbox ranting, accusing me of breaking the law, questioning my judgment, and accusing me of getting an attitude. you want see me to get an attitude, i can not think of a better way for you to do it.

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Specializes in Psychiatric, MICA.
... I have said this before in other posts, even if the individual is "drug seeking" there is a legitimate need that needs to be met. seek and refer to the appropriate resources while meeting the immediate need. ... I had major surgery with a PCA pump ordered but noone put the medication on board and I was without pain med for more than 6 hours because the "nurse" did not believe I could be in pain, focus on the care you are to give and stop judging!! Nanacarol

Good point: there is no need to police med-seeking (addictive) behavior. Or to police over-eating in obese patients, or candy consumption by diabetics.

Why not teach, instead? Teaching is not about supplying information and walking away - it's about walking with a student while trying to point out healthier paths. If it's not my strong suit, I will refer. Judging and enforcing would seem to me sure ways to destroy any chance at rapport.

D

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The general response to medicating pain is that pain is what the patient says it is and as a nurse ypu medicate and educate and advocate, not judge. You are right, there are those who abuse, including parents, still as a nurse you are to educate and advocate, not judge. nanacarol

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Specializes in Psychiatric, MICA.
The general response to medicating pain is that pain is what the patient says it is and as a nurse ypu medicate and educate and advocate, not judge. You are right, there are those who abuse, including parents, still as a nurse you are to educate and advocate, not judge. nanacarol

Agreed. I would say certainly advocate for a child, but without judgment. The offending parent may also need empathy. Doing the right thing doesn't need to be accompanied by righteousness.

D

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The general response to medicating pain is that pain is what the patient says it is and as a nurse ypu medicate and educate and advocate, not judge. You are right, there are those who abuse, including parents, still as a nurse you are to educate and advocate, not judge. nanacarol

it amazes me the judgment out there.

who ever decided that nurses should play God, is beyond me.

and frankly, even God wouldn't judge with such severity.

dang.

the orders are there.

give it, damn it.

and let it go.

we all know obnoxious, demanding pts and have stories to share.

still...

the orders are there.

who the heck are we to decide how to manage one's pain?

if they want it every 3h a/o, even if they're not in pain, then what's the big deal?

maybe they want to stay ahead of the pain?

maybe they fear any forthcoming pain?

hey, maybe they even enjoy the buzz that helps them deal with being imprisoned in a hospital.

just give it...and let it go.

life is too darned short to be sweating the small stuff.

leslie:twocents:

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Specializes in Psychiatric, MICA.

life is too darned short to be sweating the small stuff.

leslie:twocents:

Yeppers. I work in a MICA unit and addictive behavior - including med-seeking - is the norm. The system works so that the orders taper the availability over time until the person is stabilized and moved on. If I am suspicious about a person's pain or anxiety levels, I can take it up with the treatment team and an objective decision is reached. No need to make a personal crusade out of people using meds as a coping mechanism.

D

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Specializes in Cardiac Telemetry, ED.

I think most of us have been taught that "Pain is what the person experiencing it says it is, and exists when they say it does.".

What bothers me is all the finger wagging at those who have questions regarding the subjective nature of pain, and whether drug seeking really exists, and what their role as a nurse is in situations such as that.

As nurses, we are taught to think critically, yet when it comes to pain, when we do so, we get a bunch of judgment and finger wagging from our fellow nurses.

As so many of us like to point out, we are not a bunch of automatons simply carrying out doctor's orders. We are required to think about the rationale for the things we are doing, question orders that don't make sense or are inappropriate, and advocate for the patients in our care.

So why, when a nurse questions pain management strategies, do we all feel the need to jump up on our moral high horses and look down?

Having said all of this, I do agree that A) Patients have a right to pain control and B) We should place a high level of importance on all reports of pain.

But, just as some advocate education without judgment for our patients, I would like to advocate the same for our colleagues.

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As nurses, we are taught to think critically, yet when it comes to pain, when we do so, we get a bunch of judgment and finger wagging from our fellow nurses.

this is the statement i take issue with.

are we really using "critical" thinking skills when wanting to withhold?

only time "critical thinking" is necessary is when resps, bp, loc are dangerously altered (in regards to pain meds).

other than that, when an a&o pt wants his meds, how do we use our critical capacity in determining what someone's pain is?

because they're laughing, they're not in pain?

that's not critical thinking, but a purely subjective assessment.

and if nurses can bestow moral judgment on their pts, then human nature dictates that same judgment could be applied to colleagues as well.

i for one, don't vicariously defend all my colleagues, just because.

as with my pts, everyone needs to be addressed as the individual they are.

leslie

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Specializes in ER,ICU,L+D,OR.

The easiest way is to remember that pain is always a subjective measurement. Some people are very stoic, some are very dramatic. Just assume they are telling you the truth. Life and work is so much easier that way. Why get gray haired jousting at the pain evaluation windmill. If they c/o pain and they have meds due, why get passive agressive and withhold them. If they dont have anything ordered, notify the MD and document it.

Let the MDs address the issue if that is their plan of care.

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Specializes in Cardiac Telemetry, ED.

are we really using "critical" thinking skills when wanting to withhold?

I didn't say anything about wanting to withhold. Neither did the OP. Did you not read my entire post?

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