Rate Your Pain

[Joe V]

Pain is very personal and subjective. It's difficult to assess just how much pain a patient is experiencing. There is no blood test or X-ray or other diagnostic study to measure pain. Nurses and other healthcare providers often utilize different types of tools such as rating pain on a numeric scale or pointing to the face that best describes how the patient feels when in pain. But, in the end, pain is still subjective and many factors can affect just how useful these tools can be. How often do you utilize these pain rating scales? Which ones? How valuable are these to you as a Nurse? Tell us your stories.

Visit Nursing Toons / Memes for more cartoons!

[mmc51264, BSN, MSN, RN]

I use the faces for people that tend to rate their pain numbers very differently than what their body language says. I work in ortho, so I ask that question 100 times a day! It does get old. I hate it worse when I go to the doctor and they as me.

[NurseSpeedy, ADN, LPN, RN]

I also do not like the number scale. The question to rate on a scale of 0-10 has often got me a look from the patient as if to say, "Um, it hurts bad enough to want whatever you have to make it hurt less. I want my meds regardless of the number I throw out there".

Being a patient myself who has had orthopedic surgery I have a hard time eating my pain post op. I've been cut open, it hurts, it feels like someone is cutting into my foot...oh, wait a minute, someone just did...I would much rather have something easier to rate, such as mild (I can bear through it), moderate (I should probably take something be for it gets worse, but nothing too strong), and severe (should have taken something when it was moderate but didn't, now it hurts like hell and it's going to take a while to get it under control again).

I had a patient that actually said to me "It's about an 8 but I should probably say 10 so that the doctor will order something else for me"...really???

[Midazzled]

Not a Nurse, but I hate pain scales. Especially 10 point ones. Both as a patient (I race dirtbikes, which can come with predictable problems) and as a provider. I usually chart a pain number based on what I see, because my agency requires a number. I challenge anyone to make a case that this is more subjective than asking the patient. I treat any acute pain with injury that looks like it needs to be treated, based on how I would want to be treated. Show me some physical findings, and/or physiologic pain response, and I will treat it. I am very generous with acute pain control, much less so with chronic pain that should be being controlled by long term options. Bottom line? There is very little evidence supporting the use of subjective pain scales that has not been funded by sales of opioids.

[AllOfMyWat]

I hemorrhaged at work with an ectopic pregnancy. I was doing a med pass for 30 at a SNF. I had blood on my shoes, but I still was passing pills before I noticed. It was, in retrospect, 8/10 pain. The whole "must be unable to speak" to be in severe pain is a bunch of crap. Between my med pass and emergency surgery was less than 90 minutes. Listen yo your patients or risk killing them.

[HeySis, BSN, RN]

I'm lucky as far as pain and scales go, in the PACU we use a CPOT scale for unconscious patients and a FLACC scale for kids. I like those very much. Even when an adult patient is able to rate their pain I may use a CPOT to show the difference that the pain meds are making

Example: pt is moaning, grimacing, all their muscles clenched and they rate their pain a 10, then they are relaxed, no guarding or grimacing and silent (in fact sleeping) but when you wake them to ask how they are doing they state their pain is a 10.

As long as they are holding their airway and VS are good, we'll treat whatever pain they say they are having... I just like to se a difference in their comfort level based on what I've given already.

[nutella, MSN, RN]

The most common pain scales I use are the numeric pain scale, the wong-baker (faces) scale, the flacc scale, and some qualitative scale.

I find that pain scales should not be used alone to assess and determine pain. Having said that - I know that the reality of nursing is different. And the quick "what is your pain on a scale from 0-10" before and after pain medication is often only good to satisfy joint commission standards while not helping with a meaningful clinical practice.

Also, patients have caught up on the fact that unless they say 10/10 or 20/10 they will not get pain medication anytime soon or only tylenol...

There is a lot of misunderstanding how to use the numeric scale. Pain is subjective but if a patient says the pain is 10/10 and after the medication it is 8/10 or 7/10 - that is consider success. It is not so much about the actual number in many cases but more about the reduction. If the patient says 10/10 and you aim to reduce it to 1/10 with narcotics - your patient will be most likely oversedated or requireing narcan ... unless the patient is CMO - in which case we really just want max comfort.

When I do my initial nursing assessment I use a pain scale that is appropriate but I also use direct observation that is not within a validated scale. My assessment also includes the quality of pain, when the pain is worst/best, how long has the patient had pain problems? how long on a current dose/regimen, prior substance use, current acute illness/reason for admission, how the patient "feels" about the pain/coping, non medication interventions that help or have helped, prior visits to a pain clinic.

The numeric scale alone does not give me enough information.

I also want to know if the patient is satisfied with the current level of pain control and the expectation.

In dementia it can be very difficult to determine pain or no pain as even the observational scales / flacc do not always help. Example: A patient with progressed dementia fell and broke a hip, had to get surgery. Days later the patient is refusing to take any po and is not cooperative with PT/ does not want to get out of bed, is combative. The nurses gave morphine the day of surgery and after surgery a couple of times but on day 3 did not give pain medication regularly anymore or not at all because the patient did not score enough on the flacc scale. She was unable to self-report in any way and did not show any classical signs of pain.

But she had hardly been that agitated before and did not refuse to eat or drink before that much, she has been restless before and wandering - so the nurses think that it is "just her dementia". When I discussed with the primary nurse that hip surgery and PT is painful and that it is likely that this patient has pain but is unable to self report / verbalize and unable to express or understand what is going on.

We asked the MD to order roxanol in concentrated form and the patient received a dose of 5 mg sl 20 min before PT. What a difference ! The patient was working with PT as much as possible with this degree of dementia, and was able to eat and drink once sitting in the chair.

The blood pressure that was high normalized. The pain scales really did not help much - in fact they prevented the nurse from giving pain medication because "she did not score enough."

Another example is the pain assessment with deaf adults, I have written about it before at some point. The first language for deaf people is american sign language. A lot of terms or scales do not make sense for a person who is deaf. The right scale to use is the wong-baker scale. It is also difficult to correlate the quality of the pain. A deaf patient with an epidural abscess, which is very painful, was in despair because the nurses felt that the patient was "drug seeking" and not in pain based on the fact that he was very expressive (gestures, facial expression) when asked about his pain but did not moan that much. They thought that he was "dramatic" and therefor drug seeking. He had chronic pain before the infection in his spine but was not on much pain medication before. He was also perceived as "difficult" and "angry". He had a significant abscess that was pressing on the nerve roots in his back - that usually leads to terrible severe pain. The nurses were surprised that small amounts of oxycodone "did not do anything".

After a pain assessment with the wong baker scale, an "interview" about the pain with an ASL and CDI the patient was started by the MD on appropriate medication and later switched to a fentanyl patch. He was able to get out of bed with the right pain medication, was not sedated and felt better. I handed the patient the faces pain scale to keep at the bedside for better communication and copied the scale for the nurses and did education on pain and communication for deaf patients.

Yes, I use pain scales but not in isolation as it does not provide enough information.

[Beaue]

A few months back when I had a bladder infection, It was definitely an eight on the pain scale. After having to sit in the doctor office bent over in pain, I stopped drinking soda drinks or any kind of drinks with carbonated water. Occasionally, when I am sick, I drink a sprite. Waiting to see a doctor takes forever, which always seems like an eternity when one is in any kind of pain. My mother said I cried day and night when I was a baby. I had a rotten tooth. At age 15, I had an abscess front tooth that dentist fixed by doing a tooth canal. We never knew what made the tooth abscessed. Believe tooth aches and ear aches are the worst pain ever. even now, I have bad luck with my teeth. perhaps, I shouldn't eat so much chocolate. One last thing, Did you know chocolate makes your clothes shrink?

[HeySis, BSN, RN]

WKShadowRN said:

A pacu nurse documented my lack of body language after a hysterectomy after she roused me and asked for my number. I told her 7. Having an organ removed is not a piece of cake. Being 114# (at the time) and a reported low tolerance for anesthesia (PONV) I was still groggy despite pain . And, for the record, I hate dilaudid.

If my post op patient told me they were a 7, I would treat the pain, even if they were groggy... as long as they can hold their airway and not tank their vitals. Sometimes when a patient is very still, I can see them trying to hold on against the pain... everyone is different.

There is definitely a difference between someone "holding still" and someone you have to rouse (I don't consider speaking to someone and having them answer as having to rouse them, I'm thinking more like patting the shoulder firmly, sternal rub or nailbed pressure) in order to get a response or falling back to sleep and becoming apneic. There are times we have to decide between pain control or keeping them alive. We always choose to keep you alive. I wish it was easier, but most pain meds given in PACU have those potential side effects.

Our surgical patients also need education that their pain will not be a zero and have a realistic goal, although that too is subjective. I've had patients tell me that they want some interventions with anything greater then a 3/10 and some that say they don't want anything until they hit 8/10.

And there are occasions that the pain they had before surgery was so great that the pain after surgery is a relief, like a nasty appendix coming out. For me, my hysterectomy was a relief, once the N & V stopped.

[Harveyslake]

Yes, the 10/10 pain scale is meaningless. I was in the ER as a patient once with abdominal pain. I was asked the standard questions about pain. I honestly stated it was a 10/10 because it was the worst pain I've ever had,....but, I followed with it was annoying pain but tolerable. 10/10 pain is not always debilitating, excruciating pain. Stupid, subjective pain scale. Completely meaningless. Next!

[djh123]

I love the 'I look like #3 but feel like #5'. Many of us have had 'those' patients who always want a strong pain med when they're not showing many or any signs of pain.

[HeySis, BSN, RN]

Harveyslake said:

Yes, the 10/10 pain scale is meaningless. I was in the ER as a patient once with abdominal pain. I was asked the standard questions about pain. I honestly stated it was a 10/10 because it was the worst pain I've ever had,....but, I followed with it was annoying pain but tolerable. 10/10 pain is not always debilitating, excruciating pain. Stupid, subjective pain scale. Completely meaningless. Next!

I explain the scale as rate on a scale of 0 to 10, 0 being no pain and 10 being the most excruciating pain from being burned up you can imagine (cause most people have had at least one burn and understand the pain that goes with it). That way they are not rating based on their exact experience with pain in the past (the worst pain they've ever had) but the worst pain they can imagine. I think it puts it into perspective for some, and I have had patients that are hurting so much they continue to rate it a 10/10. And that's fine.

Worst is trying to get a pain scale out of a patient when just waking up from anesthesia and they rate it a 7/10, you give meds and then 5/10 mins later they are more awake and state it's gotten better but now rate it a 8/10.

And I hate zofran for post-op nausea, it may work prophylacticly, but once they have that feeling.... phenergan all the way.

And I love when people let their anesthesiologist know that they've had post-op N/V before hand. Our anesthesiologist will give dexamethasone, reglan, zofran and sometimes even a beta blocker (if their heart and BP can handle it) while still in surgery and do a little propofol slurry there at the end.

Because lets face it opioids make N/V worse so who wants to choose between hurting and throwing up?