April 29, 2013 at 9:55 PM #6663
Jason Hautala RNMember
The zero to ten pain scale used in most hospitals is a worthless tool that provides no value. Even if you want to believe that pain is subjective, although having worked in the ER for so long, I don’t even believe that any longer, the scale does not provide any meaningful data. The purpose of the pain scale is to take a subjective symptom and objectify it with a number that can be collected as if it were real data and statistics and other analysis can be performed on it. Unfortunately, people in suits have decided that the raw data is significant, and policies can be made based on this number, such as “Nobody can be discharged from the ER if their pain level is still five or more on the scale.”
First of all, pain is a multifaceted condition based on severity, quality, quantity, duration, coping skills, expectations, etc. and all of these cannot be summed up with a single number. Secondly, people will say whatever they think will get them the quickest care with the ‘best’ drugs. Thirdly, an honest to God pain of 10/10 for one person may not require narcotics at all, but just an ice pack, a darkened room, and a kind word, while someone with a pain of 6/10 may benefit drastically with the use of a stronger pain medicine. The number they give us is worthless when it comes to how we are going to treat their pain. How they are coping with their stated pain level is more important than the actual number.
The ONLY useful thing about a numeric pain scale is the fact that you can trend their pain level with it, but never be fooled into believing that any of the absolute numbers they give mean anything in isolation. You can tell a patient to remember their pain when they first walked into the door, and give that pain a 5 on a zero to 10 pain scale, and then ask them were their pain is in relationship to that. I have found letting the patient use their own words is more useful than trying to get them to pick a number out of a hat. When asked how they are doing, record what they say, “better, a lot better, worse, no change, etc.” These words, while not making the statisticians and administrators happy are actually far more useful than “4/10.”
I can’t even guess how many times a patient has given me a number greater than 10 when asked how bad they hurt on a zero to ten scale. When reminded the scale only goes up to 10, they still stick with their “25 out of 10,” which just goes to show that five fourths of all ER patients do not understand fractions. Had one patient whose pain went from 25 out of 10 down to 10 out of 10 after some Dilaudid, and he was unhappy that he was being discharged home while still having 10 out of 10 pain. I told him we more than reduced his pain by more than half and to have a nice day. Maybe we could have given him more pain medicine, but since I had to wake him up for him to tell me he was still having 10 out of 10 pain, we didn’t think he really needed anything else besides his scripts and a taxi voucher.
In addition to being worthless in general, it is totally inappropriate for chronic pain. Chronic pain has so many other aspects that must be addressed, and not just the quantity of the pain at that particular point in time. Sometimes it can just become too much for your coping skills to handle and you just can’t take it anymore. The pain isn’t necessarily worse than it was the day before, but because of life stresses, you just can’t cope with it as well today as you did yesterday. Maybe you don’t need any additional pain medication at all, but some Ativan? The point being, the number provided by the patient is worthless data and we shouldn’t even be collected it. We should actually EVALUATE their pain and their reation to the pain and proceed from there.May 3, 2013 at 10:45 AM #6743
I agree a patients words are a better indicator than numbers on the pain scale. I also look for physical indicators like curling up on their sides or holding onto the part that hurts when they think no one is watching. I look for breathing changes and sweating or clamminess as well. If there is true pain no matter who the person is there will be over signs as well. I can’t dispense meds yet, but I can report what I observe to the ER nurses and DRs I work with. I know pain is relative and sometimes all they really need is someone to listen to them.May 6, 2013 at 2:25 AM #6767
Joshua Felts RNMember
Alright Sarge, my rebuttle.
Firstly, the zero to ten scale is a means to and end, not an end in and of itself.
As you know, Bentham argued the people pursue pleasure and avoid pain. Well, unless you’re a masochist, but I digress. And, of course, Bentham discusses utility, which is, essentially, a means of measuring pleasure and pain.
Albeit, the modern zero to ten scale wasn’t created by the genius of Bentham, it nevertheless seems to solve the same fundamental problem: a means of measuring pain.
Now, regardless of how you view the scale, it’s goal is to gauge a patient’s pain. It is, simply, the only tool we have in which to measure it. Yes, it’s true that pain is subjective, as we all have different tolerances, but it solves a fundamental problem: the pain, regardless of what it actually is in relative terms to us, is relative to them. In other words, we have an idea inside their mind’s eye as to the pain in which they’re suffering at the very moment we ask them.
Now, you argue, or at least infer, that patient’s lie. Well, yes they do. And, just like everyone else, patients have the right to be stupid. If they, with their inability to reason, want to nullify the scale with idiocy, this is their choice, and their choice alone.
I rest my case. I’m sure you will rebuttle my rebuttle.May 6, 2013 at 8:28 AM #6770
I used to think the pain scale was subjective and useless *until I found a tool* that explained what each number meant and used it in my daily practice. When I pull it out, I make sure to explain to my patients that “I’m in no way trying to minimize your pain, I’m just trying to make sure when you say your pain is an 8 (6,4,etc), we’re all on the same page what your pain level describes your pain to be” I then read off from the following chart I keep in my smartphone:
# Symptoms Medications
1 Very minor annoyance. Occasional minor twinges.
No medications needed
2 Minor annoyance. Occasional minor twinges. No medications needed.
3 Annoying enough to be distracting.
No medications needed.
4 Can be ignored if busy, but is still distracting.
Mild painkillers are effective (Motrin/Tylenol)
5 Can’t be ignored for more than 30 minutes.
Mild painkillers relieve pain for 3-4 hours. (Motrin/Tylenol)
6 Can’t be ignored for any length of time, but you can still work/do social activities. Stronger painkillers reduce pain for 3-4 hours. (Vicodin/Codeine)
7 Makes it difficult to concentrate. Interferes with sleep. You can function with effort. Stronger painkillers are only partially effective. (Vicodin/Codeine)
8 Physical activity is severely limited. You can read and converse with effort. Nausea and dizziness.
Stronger painkillers only minimally effective (Vicodin/Codeine)
9 Unable to speak. Crying out or moaning uncontrollably.
Strongest painkillers are only partially effective (Oxycontin / Morphine)
10 Either you are unconscious or it makes you want to pass out.
Strongest painkillers are only partially effective. (Oxycontin / Morphine)
When I read the description and the medication listing for the number the patient gives me and the medication description required to alleviate that pain, I then say “Does this sound like this is the number that best describes your pain?” I’d say 70% of the time the patient says “Of, I guess my pain is a lower number than that…” I read the two numbers below and *let them decide* what number best describes their pain, and I keep going until I reach a number that they say is appropriate for them.
I tell them -again- that we’re not trying to minimize their pain level, but since one person’s #8 and another person’s #8 may be completely different, in this manner we all know what a #8 on the pain scale means and we can treat everyone appropriately. They seem to really appreciate this and understand that I’m trying to understand exactly *what level of pain relief they need*.
I hope this helps you. Of course… you’ll still have someone who refuses to listen or states their pain is an 11 or 25. Those can’t be helped or won’t listen. But those others can be EDUCATED about the pain scale and I feel at least I’ve done the next nurse a great service – even if that next nurse is me 🙂
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