When I was in nursing school, we talked a lot about pain. Let me summarize 2 years worth of pain knowledge for you in a couple sentences.
1. Pain is whatever the patient says it is.
2. The most widely used way to judge pain is on a scale of 0-10 with 10 being the worst pain you've ever experienced.3. One of the hardest parts of nursing is figuring out legit pain that needs better management and people who's pain in primarily made up in their head (or drug seekers, or addicts, or people who want to get high for a while, or any combination of the above.)
Note what I just did there? I saved you all thousands of dollars and painful hours of lecture. You’re welcome.
Anyway, I recently had a patient who needed some pain scale education, apparently.
After I got report where I heard that this patient was constantly demanding IV pain medication (the beez-neez of meds...gets you nice and high real quick), and the doctors had determined their condition required a different form of pain management because of a couple of underlying disease processes. I read through the most recent doctor’s note, where it is also noted that the patient is not to receive any further IV pain medicine, but to use several other pain pills to manage the pain.
Armed with this information, I roll into the patient's room for my assessment. Sure enough, the first thing the patient tells me is that he/she's pain is "10 out of 10 and the doctors told me that I was going to get my IV pain medicine this morning, but they never ordered it, so can you go call them and get it for me. Even a one time dose."
Actually, this wasn't the first thing the patient did. The first thing they did was have me talk to their mother because their pain was too "severe." The mother is appropriately freaking out on the phone so it took a minute to calm down both the patient and the mother, who was a hot mess herself.
I explain to the patient that the disease process they have is better managed with various pain pills and per the doctor's note, and that's what they told the patient that morning. The patient then says, "But that's not what they said. They said I could have my IV pain medicine." I say, "So you're telling me that not only is the note wrong, but every doctor your nurse talked to all day was also wrong?" The patient says, "Yes." Then I said "OK. Let me call the on-call doctor and ask about it."
I think the patient thinks he/she is so brilliant for pointing all of this out to me and will get what he/she wants. HA HA HA.
A while later the patient's pain meds are due, and the patient is resting in bed with their eyes closed, looks quite relaxed, and is chatting on the phone. (I mention this because when one is in some sort of pain closer to the top of the pain scale, they are rarely relaxing in bed, chatting with friends on the phone.) I bring them in and ask "what number would you give your pain right now?"
The patient says "10."
I reply "You're telling me right now, in this moment, the pain you are experiencing is the most excruciating pain you've ever felt?"
The patient says, "Yes."
I say "Ok."
A while later I go back in and check on the patient. I ask what their pain is now, after the medication. The patient wakes up enough to say, "10, and when am I getting my IV pain medication?"
My clinical note then said something along the lines of: "Patient states pain is 10 out of 10. Patient is resting in bed with eyes closed. There is no guarding, grimacing, or diaphoresis (sweating). Patient vital signs stable." I chart all of this because those things are physical indications of pain and we use those indications just as much as what the patient says in some situations.
This situation pretty much repeated itself for the rest of the night. Every 30-45 minutes the patient would call out asking for IV pain medication and every time I would explain that they wouldn't get any. I offered heating packs, ice packs, warm showers, snacks (of which the patient ate abundance), various positioning techniques, and several other things. All of which the patient refused because "nothing works except my IV pain medicine." To which I reply, "Have you ever tried these things?" To which the patient replies, "No." To which I reply, "Then how do you know they don't work?" Because at this point I am just enjoying myself because the patient is being ridiculous. The patient says "I just know it won't work."
At one point the patient told me they were "constipated." I asked if they had had a bowel movement that day. The patient said, "Yes." I said, "Well, I'm happy to give you a laxative, but if you are already pooping, it could give you explosive diarrhea. Do you want explosive diarrhea?" Much to my surprise the patient said "no." I replied, "Well, I guess you won't be getting a laxative then."
*Disclaimer: taking a laxative will not necessarily give you explosive diarrhea, but there is a remote possibility that it could. I "might" have been "embellishing" for the patient.
So, by the end of the night, I was having a great time dueling it out with this patient in a battle of "who will win the IV pain medication war." I'm pleased to say the patient received all of their non-IV pain medication, including every PRN medication I could give in a vain attempt to bring the pain down from a “10 out of 10,” the vital signs remained stable for the entire shift, they slept for several hours (in spite of what they told the doctor in the morning about how they couldn't sleep because of the "pain"), and there were no other clinical indications of pain.
That’s what I call winning.
