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The C.R.A.P. Score

Posted

Specializes in ED, Ortho, LTC. Has 18 years experience.

A fellow nurse brought this in the ED where I work and I thought it was cute.

THe C.R.A.P. Score by D. Slow P., MD

CRAP=(OPS+AF)(SC)(EC)

OPS=Old Pain Score

AF=Adjustment Factor

SC=Story Credibility

EC=Exam Credibility

Situation: We are supposed to documents our patients' pain on a 10 point scale in order to objectify if and make sure we address it and provide timely and appropriate analgesia

Observation: There sure seems to be a lot a variability in the way people measure their pain. It's enough to make you want to throw the whole pain scale away. We all know it's true. Some people not only verbalize their pain more effectively, they also seem to experience it more effectively. These patients may come to the ER once a month with "10 out of 10 pain". They also seem to require more work notes. It seems that what was meant to be an objective scale, couldn't be more subjective.

Assessment: If the pain scale is to survive-and I'm by no means suggesting that it should-but if it is, I'm sorry to say we may have to find a way to adapt it to each individual patient. We used to think that "mild, moderate, or severe" was adequate, but now we know better, a ten point scale is quite superior. But, is it good enough? If you want to practice cutting edge medicine, get ready for yet one more complexity.

Plan: I propose that a formula be developed to enhance the functioning of the current pain scale so that each patient can be treated as an individual. The Canadian Relativity Adjusted Pain, or CRAP for short, will be calculated as noted above.

The key value here is the Adjustment Factor. For "LPT" patients (Low Pain Threshold" this will be calculated as follows: For every point over 10, which the patient reports, subtract one. If they say their pain is a "12" then subtract 2 points and start with an 8. For every visit the patient has had to your ER in the past 12 months for a painful condition that was either chronic or went undiagnosed, subtract 1 point. If you push on a non-painful or uninjured area of the patient's body, the shin for example, and they say "Ouch", subtract 1 point. For every allergy to a non-narcotic medication that could be effective for their condition, subtract 1 point. If they are wearing sunglasses, subtract 1 points. If they still have tape or EKG lead residue on their body from a prior hospital visit, subtract 2 points. For "HPT" patients (High Pain Threshold" you will be adding numbers to their pain score. If a spouse fo family member forced them to come in, add 1 point. If you check their records, and every time they've come to your ER for a painful condition something was torn, broken, ischemic, or perforated, add 2 points. If they have no allergies add 1 point. If they are tachycardic or hypertensive and 1 point.

Here is an example. A young man presents to your ER for his 7th visit this year for a migraine headache and reports his pain as "12" on a 10 point scale. He is allergic to Reglan, Imitrex, Toradol, Prednisone and Tylenol. He also has been to the ER 5 other times in the past year for back pain or abdominal pain, all times sent home with normal studies. When you enter the room he is yelling at someone on his cell phone and eathing Cheetos, but tells you, "This is a bad one doc." On exam his VS are normal and his abdomen and back are both tender. "I didn't even notice they were hurting," he says. His CRAP score sould be (10-6-2-5-5-1)(0.5)(1) which would be negative 4.5, but since his number is negative, you decide to leave out the credibility conversion for a score of negative 9. You tell him that pain medications are not indicated for his headache because his CRAP score in negative 9 and he can go home whenever he is ready.

te he he!!!!

if only......:lol2:

Ivanna_Nurse, BSN, RN

Specializes in CCU MICU Rapid Response. Has 18 years experience.

Ooooohhhh.. this is Goood!! :D

Ann RN

Specializes in ICU/CCU, CVICU, Trauma.

:rotfl: :rotfl: :roll :roll :roll

Oh, YEAH!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

chip193

Specializes in ER.

This is really, really good.

I wonder how long it will be until someone comes on here and tells us that the patient’s pain is always real, no one would ever seek drug, and that we’re just burned out. Then, as punishment for even reading this from the OP (because we should have know just by the title, don’t you know!) we should immediately turn in our nursing licenses, be prepared to be struck down by God herself – Florence Nightingale, and be forever thrust into the wilderness (like EMS!) forever.

Ready to be shot with that lightening!

Chip

Myxel67

Specializes in Diabetes ED, (CDE), CCU, Pulmonary/HIV. Has 15 years experience.

Like right now--this really is a load of crap.

Altra, BSN, RN

Specializes in Emergency & Trauma/Adult ICU.

This is really, really good.

I wonder how long it will be until someone comes on here and tells us that the patient's pain is always real, no one would ever seek drug, and that we're just burned out. Then, as punishment for even reading this from the OP (because we should have know just by the title, don't you know!) we should immediately turn in our nursing licenses, be prepared to be struck down by God herself - Florence Nightingale, and be forever thrust into the wilderness (like EMS!) forever.

Ready to be shot with that lightening!

Chip

Not quite as funny as the OP, Chip ... but good stuff nonetheless!! :smokin:

That is toooooooooo funny!!!!!!!!!

:rotfl: :bugeyes: :rotfl: :bugeyes: :rotfl:

chip193

Specializes in ER.

Not quite as funny as the OP, Chip ... but good stuff nonetheless!! :smokin:

I only wish that I were kidding...

We had a thread a while back called "Rules for the ER" or something like that. Each of the rules was similar in nature to the OP's posting here. It lasted quite a while and then, oh my...there were threats of reporting every one to the BON, we were immoral, bad nurses, horrid humans, etc., etc.

It was rather funny to watch. What was funnier was the ER nurses kept posting new rules and the non-ER nurses who held the "moral fiber" of nursing together (and remember, fiber does make you poo), would go crazier and crazier with every post.

If it's still around, you should go read it. It sounds like you may just enjoy it!

Chip

Altra, BSN, RN

Specializes in Emergency & Trauma/Adult ICU.

I only wish that I were kidding...

We had a thread a while back called "Rules for the ER" or something like that. Each of the rules was similar in nature to the OP's posting here. It lasted quite a while and then, oh my...there were threats of reporting every one to the BON, we were immoral, bad nurses, horrid humans, etc., etc.

It was rather funny to watch. What was funnier was the ER nurses kept posting new rules and the non-ER nurses who held the "moral fiber" of nursing together (and remember, fiber does make you poo), would go crazier and crazier with every post.

If it's still around, you should go read it. It sounds like you may just enjoy it!

Chip

I participated in that thread, Chip ;)

The CRAP scoring guide will be posted in my dept.

loricatus

Specializes in ED, ICU, PACU.

:rotfl: :roll :roll Love all this CRAP...pain rating scale, of course :roll :roll :rotfl:

Tempted to use it in my charting: Pt. states 20/10 abd pain, -8 CRAP-refer to calculations on pain assmt sheet

kmblue39

Specializes in Orthopedic/General Surgery. Has 9 years experience.

Hey, isn't the pain score one of the 2007 (2006) National Patient Safety Initiatives?:)

RNtigerEMT

Specializes in Cardiac, Med-Surg, now in ED.

:rotfl: :roll :roll :chuckle :bow: :bow:

I almost snorted coffee out my nose! This is absolutely great. Wonder if we all made a big enough push if our respective hospitals would adopt the CRAP scale? Most of the doc I know would gladly accept it

CritterLover, BSN, RN

Specializes in ER, ICU, Infusion, peds, informatics. Has 22 years experience.

i saw this shortly after it was posted, earlier this week. i immediatly printed it off to share with my coworkers (but i didn't post 'cause i'm to chicken to post from work).

to me, the best part about this score is how it "upgrades" the pain of some people. we've all taken care of them -- stereotypically the macho man with the finger half gone (circular saw accident) who claims he really isn't hurting much. gives you a "3" on our favorite scale. it also comes in the form of the a/o 95 y.o. female who has been "healhty all my life. haven't seen a doctor since i gave birth last," that has the acute diverticulitis w/perforation and abscess formation. wbc 40+. she'll put her pain at about a 2/10, "a little stomach ache, nothing some mylanta won't take care of. my granson (who is 70) is just a worrywort."

we all get the pain scale concept. we do: what hurts you a bunch may not hurt me much at all. isn't that basically it?

unfortunatly, the general american public seems to think that if they don't state "10" in answer to that favorite question, their pain won't be taken seriously.

to the point that to me, as a triage nurse (when i'm the unlucky one) a pain rating of 10/10 means nothing to me anymore. you're better off telling me "my pain is a 8/10," because at least then i know you put some thought to it.

the author's point is well-taken: as a purely subjective tool, the pain scale is practically worthless. it will remain so until we put some objectivity to it.

teeituptom, BSN, RN

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

This is really, really good.

I wonder how long it will be until someone comes on here and tells us that the patient's pain is always real, no one would ever seek drug, and that we're just burned out. Then, as punishment for even reading this from the OP (because we should have know just by the title, don't you know!) we should immediately turn in our nursing licenses, be prepared to be struck down by God herself - Florence Nightingale, and be forever thrust into the wilderness (like EMS!) forever.

Ready to be shot with that lightening!

Chip

When a nurse comes on to tell you this. Then you have to wonder what drugs she is on. When her last visit to the ER was. How many shots did she recieve. How many allergies she has, but of course never to Dilaudid. Also she should be turned into the Sate Board as an impaired nurse.

Thought this was hilarious, and quite applicable, and I'm not even an ER nurse! I guess my moral fiber is softening...

Recently had a guy getting 2 mg Dilaudid q 2hours on the dot for abdominal pain (was originially bowel obstruction, but it resolved. Interestingly, the pain didn't resolve...) He was STILL getting Dilaudid q 2 hours as he was getting ready to go home. He was quite put out that we took out the PICC line, and insisted he got his last dose of Dilaudid before we pulled the PICC. 2 questions:

1. What on earth was he going to do for his "pain" when he got home?

2. Hmmm... did he have plans for that PICC line?

Oldiebutgoodie

Thought this was hilarious, and quite applicable, and I'm not even an ER nurse! I guess my moral fiber is softening...

2 questions:

1. What on earth was he going to do for his "pain" when he got home?

2. Hmmm... did he have plans for that PICC line?

Oldiebutgoodie

betcha, and if he is ever readmitted, get the PICC out before he knows he is going home, or he may bolt......

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