Rethinking Pain Assessment

beckabeckahi · Aug 21, 2004

Example if you're tired enough, you will go to sleep, and you can wake up with the same pain you went to sleep with. I was able to laugh and talk with people, and be totally ready for them to leave, but never said a word, unless they stayed beyond my ability to control my facial expressions.

I couldn't agree more, I am a person with a grin and bear it attitude and there are many times I have been in great pain and no one knows the difference. For example when I was in labor, instead of yelling and screaming like many do, I was completely quiet and the midwife asked me "Are you SURE your ok?"

No I wasn't ok, but I wanted to be 'tough" ( and yes I do know this isn't particulary good for my mental health).

My point is some people (my husband and kids) will get a paper cut and howl in pain. And others will be very ill and continue on with day to day routine. So there absolutely can be a contradiction between what a patient says and what you see.

Iamjustme · Sep 3, 2004

This issue seems as though it will never be resolved. I have had chronic pain for the last 2 years, and have dealt with nurses and Dr.s doubting my pain. In the beginning most doc's are sympathetic, but that changes in time. I do feel there is fear with the DEA regulations. I worked in LTC and had residents who had chronic pain and some res. would exp. acute pain for various reasons. As far as my addressing their pain scale I would use numeric scale or faces. Usually thier movements alone would give me the info. needed. When a resident c/o pain I give them their prn which they have been using and what has been effective for them, and reassess in 1 hour. I wish the medical community would quit being judge and jury when it comes to pain issues. I thought pain was subjective and what the pt. states his pain to be. Why is there such a problem with some staff to just give the medication? It is ordered ...so use it if needed. Chronic pain pt.s have to go through the fear of being judged whenever they see a new Dr, or a visit to the ER. Not Fair!! How do you think that makes us feel? Sometimes I feel like just giving up because it is so difficult finding a Dr. who truly believes you. Pleases nurses out there,,,think about this the next time someone wants a pain pill. They hurt...so just give them their pill! I realize there also is the issue of abuse, but does that mean everyone will be looked at as a druggie?????:uhoh21:

FutureNrse · Feb 5, 2005

Oh I love this one. I have fibromyalgia so I pretty much always have pain. I feel that I am pretty good at rating it but I dont trust that the care provider understands 1-10 the same way I do. For example: to me 1 is a mild and slightly annoying headache or pressure and 10 is full blown labor. My normal pain level is about a 3 for which I take vicuprofen on a regular basis. When it becomes a 4 I will add tylenol a 5 means I am headed for trouble and 6 is probably going to be hard to get back under control. If it is a 7 I am not very rational. I hate going to ER because I know fequent flyers are considered drug seekers and if I go in and say listen I am at a 5.5 toradol is not going to work and if I dont get demoral or dilauded pretty damn quick that isnt going to work either. They look at me like I am a bother. But ya know what I have constant pain so that is my normal state and I know where I am with it and what I need and I dont like to waste time with stuff I know wont work. Ok done with that one. Now as for my observations, I work in a facility for profound mental retarded with multiple physical disabilities most of them are not verbal. We have one guy who when in pain becomes very ornery running all over the building and pounding on things that is how we know he is in pain. Another one chants in sing song fashion. Another one moans real deep and it sounds like a cow is mooing. I have learned alot at this facility about assessing pain in the non traditional ways. Awesome thread if I think of some more is it ok if I continue adding them? Thanks Gwenith

I was told recently that the general attitude at the ED I use is "If you're that informed, you're an addict". That infuriates me. If a patient deals with pain on a daily basis, who better than them to know what will work and what won't? Something has to be done about this for chronic pain patients. I've read a post about patients carrying a card identifying then as cp patients, that contains info essential to thier treatment in the ED. What about having the doc fax a document to the ED that the patient preferrs containing all pertinent info? It would save the nurses, doc and patient much time. It could save the patient unnecessary pain. It would keep them from being labeled a drug seeker and treated poorly.

For as much as everyone says, pain is what the patient says it is, that does not mean that they are really treated that way. I'm sure everyone will hate to admit it, but there are vindictive docs and nurses, that will make sure that a patient is given a pain med that is not adequate for what they say the pain is. Or offer them a med that they have already clearly stated doesn't work, or makes them ill and then tell them to take it or leave it. For example, Toradol makes me vomit and itch like mad, so if it is offered to me I am not going to take it. Do they think that they are funny when they do this? Do they enjoy having so much control over another persons pain level, and abusing thier power?

UM Review RN, ASN, RN · Feb 5, 2005

For as much as everyone says, pain is what the patient says it is, that does not mean that they are really treated that way. I'm sure everyone will hate to admit it, but there are vindictive docs and nurses, that will make sure that a patient is given a pain med that is not adequate for what they say the pain is. Or offer them a med that they have already clearly stated doesn't work, or makes them ill and then tell them to take it or leave it. For example, Toradol makes me vomit and itch like mad, so if it is offered to me I am not going to take it. Do they think that they are funny when they do this? Do they enjoy having so much control over another persons pain level, and abusing thier power?

I doubt it. I think all they're trying to do is address your pain while at the same time, keeping you alive. No one likes to OD a patient, and most patients haven't got a clue about pain meds.

Obviously, you do. More power to you. Still, you seem to have a great big chip on your shoulder about this issue, since every one of your posts since joining this board are about pain management and your views on it, instead of posts about going to nursing school, as your screen name would imply.

So I have to ask: are you a nursing student? or a disaffected patient who wants to let us professionals know that you're having inadequate pain management? Because if that's the case, maybe you should be telling your doctors this, not addressing it on a nursing BB. After all, we do not have prescriptive powers, and no matter how cross-eyed the nurses look at you when you need pain meds, we basically can't do more than give you what the doc orders.

FutureNrse · Feb 5, 2005

This issue seems as though it will never be resolved. I have had chronic pain for the last 2 years, and have dealt with nurses and Dr.s doubting my pain. In the beginning most doc's are sympathetic, but that changes in time. I do feel there is fear with the DEA regulations. I worked in LTC and had residents who had chronic pain and some res. would exp. acute pain for various reasons. As far as my addressing their pain scale I would use numeric scale or faces. Usually thier movements alone would give me the info. needed. When a resident c/o pain I give them their prn which they have been using and what has been effective for them, and reassess in 1 hour. I wish the medical community would quit being judge and jury when it comes to pain issues. I thought pain was subjective and what the pt. states his pain to be. Why is there such a problem with some staff to just give the medication? It is ordered ...so use it if needed. Chronic pain pt.s have to go through the fear of being judged whenever they see a new Dr, or a visit to the ER. Not Fair!! How do you think that makes us feel? Sometimes I feel like just giving up because it is so difficult finding a Dr. who truly believes you. Pleases nurses out there,,,think about this the next time someone wants a pain pill. They hurt...so just give them their pill! I realize there also is the issue of abuse, but does that mean everyone will be looked at as a druggie?????:uhoh21:

I couldn't agree more. Maybe medical professionals should also ask themselves if it's worth the risk when they don't give pain medication. If the person really is an addict and a drug seeker, then you have merely given them one fix. In the scheme of things, is that such a big deal? Wouldn't you rather possibly make a druggie happy than make a true pain patient even more miserable? And if you can manage to give the shot/pill without the eye rolling and dirty looks, we'd really appreciate it.

FutureNrse · Feb 5, 2005

I doubt it. I think all they're trying to do is address your pain while at the same time, keeping you alive. No one likes to OD a patient, and most patients haven't got a clue about pain meds.
Obviously, you do. More power to you. Still, you seem to have a great big chip on your shoulder about this issue, since every one of your posts since joining this board are about pain management and your views on it, instead of posts about going to nursing school, as your screen name would imply.
So I have to ask: are you a nursing student? or a disaffected patient who wants to let us professionals know that you're having inadequate pain management? Because if that's the case, maybe you should be telling your doctors this, not addressing it on a nursing BB. After all, we do not have prescriptive powers, and no matter how cross-eyed the nurses look at you when you need pain meds, we basically can't do more than give you what the doc orders.

If you've read all of my posts then you know that I have said very plainly that I am not a nurse or a student. I am a social worker. Because of what I've learned here and at a couple other sites, and because of my own experience with chronic pain, I have decided to go into patient advocacy. Yes, I do know quite a lot now because I've had no choice but to learn, and yes I can be quite rabid about this subject because of my own experiences and because the social worker in me just can't stand to see suffering. I am not disaffected, I assure you, and I do have adequate pain management now, it is my past experiences that are a problem, and obviously a problem for many others here as well.

UM Review RN, ASN, RN · Feb 5, 2005

You seem to be taking this very personally, is that because you have been guilty of mismanaging pain yourself? Or maybe you've just had a bad day. My statements weren't directed at you so I'm unclear on why you've taken such exception to them.

I'm a professional. Managing pain is one aspect of my job, and I'm very good at what I do. I come on this board to learn new techniques, schmooze, hear new ideas, and in general, broaden my base of knowledge as a nurse.

On the other hand, you're making assumptions about healthcare professionals that are insulting and make me question why you say you want to be a nurse. Comments like these:

I'm sure everyone will hate to admit it, but there are vindictive docs and nurses, that will make sure that a patient is given a pain med that is not adequate for what they say the pain is. Or offer them a med that they have already clearly stated doesn't work, or makes them ill and then tell them to take it or leave it. For example, Toradol makes me vomit and itch like mad, so if it is offered to me I am not going to take it. Do they think that they are funny when they do this? Do they enjoy having so much control over another persons pain level, and abusing thier power?

Since you have now clarified your goal as "being a patient advocate," instead of being a "Future Nurse," I have gained an understanding of what kind of information you seek from this BB and I can respond accordingly. Had you said you were a nurse or a nursing student, my response at this point would be very different. Thank you.

mwbeah · Feb 7, 2005

RECOGNIZING THE DRUG SEEKER

Drug seekers often give away their intent, and most are poor actors whose scripts read much the same. An index of suspicion is the best starting point. If something in the patient's history or physical examination does not "feel" right, it probably isn't. The clinician must be attentive to objective findings in the examination that do not match the subjective history.

Emphasis on a specific medication is a potential red flag: The patient may request it by name before the examination, describe it as the only effective treatment (going so far as to argue pathology with the provider), or claim that it is the only choice to which the patient is not allergic. The drug seeker may claim to have developed a tolerance to the medication and to need increased dosing. He or she may intentionally mispronounce the medication's name to appear innocent.

The drug-seeking patient may bring along a friend to validate the history and confirm the patient's distress. Even an infant or a grandparent may be used to make the story more believable.

Attempts to "dupe" can manifest as scams, sympathy seeking, aggression, or outright stealing. Scamming may take the form of a "doctor shopper"--a patient who sees multiple practitioners to obtain adequate supplies of a controlled medication. Doctor shoppers often present to the ED or urgent care clinic after hours with a fictitious scenario, such as rotted teeth, old war wounds, or lower back pain; being from out of town or recently moved to the area; lost, stolen, of ruined prescriptions; or complex insurance problems. (4,6,9,16)

Sympathy is a ploy often used by patients with a history of a significant medical condition who have developed an addiction to their medication. In theatrical fashion, they give a current history fraught with social and subjective terms rather then objective medical facts. One might complain, "I ran out of my pain medication early because my grandmother has cancer and I gave her some," and another might claim, "I have such terrible back pain that I cannot take care of my children."

Some drug seekers are overly friendly, striving to win over the prescriber. Others may become noisy, aggressive, or disruptive, hoping the practitioner will do "whatever it takes to get them out." Those who are refused may curse and slander the office and staff in a last-ditch effort to wear down the provider.

The drug-seeking patient may resort to theft. Clinicians should carefully guard prescription pads, name stamps, and DEA numbers--all highly prized items for the patient who is willing to bypass the system altogether. Drug seekers will use the phone and masquerade as pharmacists, insurance agents, or health claims adjusters to obtain a prescriber's DEA number--or a prescription. (9,16)

The drug seeker's relationship with the medication is clearly much more important than that with the provider. (9) Thus, even when the patient steals, providers must remember not to take drug-seeking behaviors personally.

THE CONFRONTATION

Once the drug seeker has been identified, the greatest obstacle for the clinician is to confront him or her. It must be made clear that no means no. (9) The clinician who gives in to pressure once can count on reliving the scene many times.

At the outset, the patient has all the information, and the provider has little. To regain the advantage, the practitioner must obtain information that either verifies or nullifies the patient's history. Interactions can then be based on facts. Of the many ways to get this information, all take some legwork, but the clinician's decreased anxiety and the potential benefit to the patient are worth it.

(hope this article helps)

Mike

mwbeah · Feb 7, 2005

What to Ask the Patient

Three questions asked during the history and physical examination can be useful in determining the legitimacy of a patient's complaint:

* When was the last time you were seen for this condition?

* When was the last time you were seen by any health care provider (including EDs, minor emergency centers, clinics)?

* What was the last medication, including narcotic prescriptions, that you had filled? Where? When?

FutureNrse · Feb 8, 2005

The drug-seeking patient may resort to theft. Clinicians should carefully guard prescription pads, name stamps, and DEA numbers--all highly prized items for the patient who is willing to bypass the system altogether. Drug seekers will use the phone and masquerade as pharmacists, insurance agents, or health claims adjusters to obtain a prescriber's DEA number--or a prescription. (9,16)

I've received prescriptions with the DEA number printed on them. Is this unusual?

PA-C in Texas · Feb 20, 2005

Well this is damned if you do, damned if you don't; as I've said before. They may sue you for not adequately treating pain, and they may sue you for contributing to their addiction. So let's just ignore the legal aspects for a moment and concentrate of providing the best medical treatment.

The logical extension of the argument presented here is that you should continue giving a patient opiods until you max them out. If they say they have pain, you should treat it until it goes away. WRONG. "Pain is what the patient says it is." That's nothing more than a regurgitation of a simplistic cop-out.

I get to use my judgment to determine what a patient's pain level really is and to decide on the best course of treatment. When a patient is complaining of 10/10 pain, and they are laughing and eating a Snickers (except when you are in the room), it is very appropriate to ask the tough questions. "Why does it seem like you are feeling much better when I pass by your room, but you seem a lot worse when I come in?"

It is also appropriate to assess the physiological signs that accompany pain when making a decision. If someone is stating 10/10, but their general affect does not suggest distress, their pulse is 72 and their BP is 118/64, something it needs further investigation. If their symptoms seem out of proportion to their diagnosis, they might need more pain medication, but they need a more detailed workup also. I tend to err on the side of treating the pain. In fact, I developed the reputation of being very liberal with regards to narcotics. But my good will and concern is not infinite, and a stupid saying like "pain is what the patient says it is" is not a substitute for good medical judgment.

So- "Who are you to judge a person's pain?" I'M THE ONE WITH THE DEA NUMBER!

---------

"Sedation does not equal analgesia". That's another little gem, and it never fails that someone spouts that off when giving phenergan with a narcotic is mentioned. But statements like that discourage critical thinking about the topic. It's a tool for the weak minded. I agree that the best evidence today suggests that pain relief is not enhanced by the addition of a sedative. However, I am not fully convinced on the subject. Why? Because pain is incredibly difficult to study. It is difficult to quantify, and we can't even seem to account for it in a qualitative sense. Someone else made the comment that being asleep does not equate to pain relief. That may be, but I am not convinced of it either. Anesthetics and amnestics do have a role in managing pain, or else we wouldn't be giving midazolam for minor oral surgeries and we would be cutting people open while they were awake. If someone is able to sleep well, then that is effectively the same as administering an amnestic- THEY DON'T REMEMBER. Yes, they may wake up in pain. But I woke up in pain after I had my wisdom teeth removed.

What I would like to see is some polysomnographic data on people who are given sedatives as an adjunct for pain control. We know that the sedatives will effect sleep architecture. Does a painful condition similarly effect it? That is something I would like to find out.

leslie :-D · Feb 20, 2005

Well this is damned if you do, damned if you don't; as I've said before. They may sue you for not adequately treating pain, and they may sue you for contributing to their addiction. So let's just ignore the legal aspects for a moment and concentrate of providing the best medical treatment.
The logical extension of the argument presented here is that you should continue giving a patient opiods until you max them out. If they say they have pain, you should treat it until it goes away. WRONG. "Pain is what the patient says it is." That's nothing more than a regurgitation of a simplistic cop-out.
I get to use my judgment to determine what a patient's pain level really is and to decide on the best course of treatment. When a patient is complaining of 10/10 pain, and they are laughing and eating a Snickers (except when you are in the room), it is very appropriate to ask the tough questions. "Why does it seem like you are feeling much better when I pass by your room, but you seem a lot worse when I come in?"
It is also appropriate to assess the physiological signs that accompany pain when making a decision. If someone is stating 10/10, but their general affect does not suggest distress, their pulse is 72 and their BP is 118/64, something it needs further investigation. If their symptoms seem out of proportion to their diagnosis, they might need more pain medication, but they need a more detailed workup also. I tend to err on the side of treating the pain. In fact, I developed the reputation of being very liberal with regards to narcotics. But my good will and concern is not infinite, and a stupid saying like "pain is what the patient says it is" is not a substitute for good medical judgment.
So- "Who are you to judge a person's pain?" I'M THE ONE WITH THE DEA NUMBER!
---------
"Sedation does not equal analgesia". That's another little gem, and it never fails that someone spouts that off when giving phenergan with a narcotic is mentioned. But statements like that discourage critical thinking about the topic. It's a tool for the weak minded. I agree that the best evidence today suggests that pain relief is not enhanced by the addition of a sedative. However, I am not fully convinced on the subject. Why? Because pain is incredibly difficult to study. It is difficult to quantify, and we can't even seem to account for it in a qualitative sense. Someone else made the comment that being asleep does not equate to pain relief. That may be, but I am not convinced of it either. Anesthetics and amnestics do have a role in managing pain, or else we wouldn't be giving midazolam for minor oral surgeries and we would be cutting people open while they were awake. If someone is able to sleep well, then that is effectively the same as administering an amnestic- THEY DON'T REMEMBER. Yes, they may wake up in pain. But I woke up in pain after I had my wisdom teeth removed.
What I would like to see is some polysomnographic data on people who are given sedatives as an adjunct for pain control. We know that the sedatives will effect sleep architecture. Does a painful condition similarly effect it? That is something I would like to find out.

first i'd like to point out that vs are not always a viable indicator of a pt's pain status. acute pain will increasse the vitals; chronic pain will not.

i'm not sure exactly what you're asking in your last paragraph. but what i will tell you is as a hospice nurse, i have seen many patients sleep and be in pain. their faces are not relaxed, brows knitted together, and this is on ativan, xanax or valium. but for effective analgesia to be attained, (i'm talking about my end stage ca pts), you need a narcotic such as morphine, oxycodone, fentanyl, dilaudid which will travel to the appropriate opioid receptors and do what they need to do. and i frequently have a talk with the doctors that prescribe mso4 2 mg. for bone ca.....and i do tell them that i intend to document the poor effect in my nsg notes and how the md did not want to prescribe anything more....that's when they ask what i want for them.

but back to the original point, yes yes yes, pts can sleep and be in pain. it is not a restful sleep at all.

leslie