Nursing Voices

Thursday, January 18, 2007


I'm thinking of changing the way in which I describe the pain scale to patients before asking them to rate their pain.

As a small part of the volumes of charting we are required to do for every patient, we must enter a digit into the computer, detailing where on the pain scale the patient is rating their pain. Then, we're able to reassess the pain at various intervals, and determine whether or not interventions used to ease the pain have been effective. Great, in theory.

This is how I usually phrase the question: "So tell me, how would you rate the pain, on a scale from zero to 10, zero being no pain, 10 being the worst pain you can imagine?"

Key word, imagine.

Apparently some of my patients suffer from a grave lack of imagination.

Imagining that "worst pain" seems to be a difficult concept to grasp, despite my assurance that this is not about whether you have experienced severe pain in your lifetime and how your current pain feels in comparison. I understand that if you've never been in labor, never had a serious injury, never had major surgery, it can be hard to imagine that kind of intense pain. But seriously, TRY.

Do patients think that I find it amusing that they rate their pain "11" out of 10, when they're conversing with their friends and answering their cell phone, whilst the poor woman across the hall can barely utter "7-8" out of 10 while she sweats and groans and writhes on the bed? And I'm not talking about some ultra-stoic multip. Often, it's the first-timers who like to think that early labor must be as bad as it can possibly get. As I said, key work, imagine. Otherwise, it just defeats the purpose.

The thing is, I really don't intend to judge others on their perception of pain. I frequently elaborate on the fact that we all experience pain differently, and that the pain scale is intended to help us monitor "where we go from here." But it is useful to have a somwhat accurate picture of the current pain level and perceived intensity of pain for each individual patient. Chances are, if you can chat and laugh through a contraction... it's not that bad. Some patients will even go so far as to keep one eye on the monitor so that they will know when they are contracting and can be sure to act accordingly. Believe me, if you're really in labor, you don't need the monitor to tell you when the pain comes!

Apparently, I need to rethink my assessment technique on this one.

How would this work? "So tell me, how would you rate your pain on a scale from zero to 10, zero being no pain, 10 being the pain you would experience while being run over by a steam roller?"

I wonder what kind of a response that will evoke. Probably wouldn't be making too many friends.

Another tactic...

The New-and-Improved Labor Pain Scale:

1. "I think someone just pricked me with a pin, but I can't remember exactly where because I can't feel it anymore."

2. A twinge of pain that's definitely there, but quickly forgotten.

3. Headache pain that is distracting enough, but treatable with a little ibuprofen and a cup of coffee.

4. "Whew, that pain was pretty bad, and made me stop in my tracks and breathe for a minute."

5. Now, c'mon girls... I know not everyone experiences period cramps, but who has never had really bad diarrhea, when you think the cramps are promptly going to expel most of your bowels, along with their contents?

6. When you stub your toe so hard, you're fairly certain it's broken, and probably won't be able to walk on it for a day or so.

7. I have dislocated my shoulder, so I speak from experience when I say that this worth at least a "7" on the scale... that feeling of almost having torn one of your limbs from your body.

8. I've heard really bad back labor described as, "It feels like the baby is trying to come out through my tailbone, like my body is ripping itself in two!"

9. Being dipped in boiling oil... not sure, but this seems like it would be unbelievably painful.

10. Last but not least, the aforementioned steam roller/crushing experience.

Now, some of these are open to interpretation and finesse, but I think perhaps I'd get a more accurate assessment of the patient's pain if she were obligated to take this scale into consideration. Anyone else have fun ideas or suggestions to work into the scale?

***I know... seriously tongue-in-cheek. C'mon, tell me you've never rolled your eyes when your patient rates their pain an "8" out of 10, only to turn around and ask for a sandwich and "How long is this going to take?"


Sean said...

LOL!!!!! I get a LOT of people who will calmly (after some greate deal of quiet thought) tell me 10/10. I don't hesitate to clarify. "Really, right at this moment you're experiencing the greatest pain you could ever possibly imagine?"

Sometimes I even tell them what I would imagine as being the worst pain, such as, "being slowly dipped in a vat of boiling oil, feet first while somebody pulled my nails off one by one."

Sometimes they say, "ok...maybe an 8 then," but often they cling to that 10/10. I figure if you're talking, breathing, walking, eating're a 5/10 at MOST.

Anyway....I guess we need to maintain that (everybody now) "pain is what the patient says it is."


P.S. I have a headach now...I would rate it 2/10.

Laura said...

i remember when i broke my arm a few years ago, the nurse asked me to rate the pain. i looked at him and explained that i had given birth to 4 children and would do all 4 right at that moment rather than deal with the pain of my hand hanging at a right angle from my horribly twisted, crooked wrist. he was quite generous with the morphine.
after recent;y arguing, yes arguing with a pediatric dentist working on my 10 y/o who was in obvious pain that yes, it might be "all in her head" but if she was perceiving pain then it was real pain.
i guess when it comes to pain, i am working from the arear where my patients can't tell me with words so i focus on the other things going on.
i would also add that my labors, except that one back labor were very easy so i imagine i would be that "bad" nurse nerw moms complainabout who tell them to suck it up and just breathe through it.

Anonymous said...

I always do my pain scale by saying "with 10 being the worst pain you have ever felt". So if in thier lives they haven't felt much pain and they say 8 or even 10 then I know this is very serious pain for them. Fine. We'll deal with this pain being the worst they have ever had. For alot of people labour pains are the most serious pain. The pain scale is so subjective.

Labor Nurse said...

I wish that there was a better way at this. I am totally with you on the whole "It's a 10!" while they are able to talk on the cell phone, ask when they can eat, and still smile. I want to say, "Oh, yeah, you think this is a ten??Hmmm??? Just you wait!" But I can't. Although if the patient is answering 10 in this scenerio, it's a great warning sign to me that this person has NO coping skills and I will be dealing with a writhing, crying, sobbing, mess when active labor kicks in.

My best friend is a surgical nurse and asks patients, "So, on a scale of 0-10, 0 being no pain, and 10 being childbirth without drugs, what is your pain?" She says she almost never gets a "10" when worded this way.

However, that technique wouldn't work for labor nurses.

frectis said...

I like the steamroller reference personally. LOL. At home births when they ask for an epidural, I expect the baby shortly. Epidural at home = steamroller ;)

apgaRN said...

Sean, I can't believe you actually use the boiling oil reference with patients... that's too funny. Of course, "pain is what the patient says." It's all relative. Fortunately, on labor & delivery, I can come back to them later, as their labor progresses, and they must admit that they need to revise their own pain scale, due to the fact that NOW they're having real pain!

Laura, I broke my arm like that, too (the whole hanging at a right angle and everything!). Granted, I was only 16 at the time and it was my first traumatic injury, so I was pretty distraught. While my labors were relatively smooth and "easy" and I've blocked out much of the pain I felt, I can still remember the whole-body-gripping pain... wanting either to die or be done. Oh my.

labor nurse, Yes, I can usually tell which patients will have difficulty dealing with active labor, as they are completely incapable of coping with the latent phase. Strangely, I enjoy caring for patients who really want my help with different strategies for laboring naturally... it's the ones who whine and cry for pain meds and "an epidural yesterday" that kind of drive me crazy.

frectis, That's pretty funny, too. With my second child, I told my husband to remind me that if and when I started asking for something for pain, he was to remind me that I must be almost done. For some reason, transition really didn't hit me that hard, and I never asked. But I hear you on the steamroller thing!


Midwife with a Knife said...

What I get totally frustrated with are the people with the "normal discomforts of pregnancy" who state that "Nobody can possibly expect me to feel like this for another 4-5 weeks, can they? This hurts!"

Oh, yes we can.

Anonymous said...

I always tell people that the pain of the two homebirths I had, was NOTHING compared to the "you aren't supposed to be in pain anymore" *read we won't give you any Tylenol even after you've wandered down to the station with your baby five hours post surgery* cesarean for my first child.
Pain sucks. But at least it didn't last like the post surgical time I dealt with! I looked taken aback when the surgeon walked in two days later and wondered why I looked so sick. I told her that I was informed that I didn't need pain meds as she wrote me a script for Tylenol 3's. I also heard her freaking on the women at the station down the hall mere moments later.
Don't think she ever continued her "long weekend vacation time" with a post surgical patient without first double checking the meds instructions again! I hope.
And this is why I never stepped foot in a hospital again. Regulated/funded amazingly well trained Canadian midwives for me! Forever
Have to admit I love your ideas. As a doula... I love the nurses who obviously have the steamroller quip brimming at the tip of their tongues... But then again, that is what I'm there for, help with the pain guage. I use broccoli. Mom says broccoli. I KNOW she has had enough. No more shower, ball, walking, counter pressure... GET THE WOMAN SOME DRUGS!!! She is a raving lunatic to use the word broccoli in the middle of a contraction. ;-)

Kim said...

My back hurts from laughing so hard...I'd say a 5/10! : D

PushMama said...

Darn, I've always thought 10 was a sharp stick in the eye. Now I know it is a steamroller. Good to know! :)

Judy said...

Sometimes you just have to take the patient's word for their pain level, even when they're chatting with the relative who brought them in.

My middle son experiences pain differently than most people. He never complained when teething - or when his eardrums were badly infected and near rupturing. He continued to play soccer for over 30 minutes after poking a stick in his eye, only coming in when the blurred vision interfered with his playing. He ruptured his ACL and didn't appear to be in enough pain for the ER doc to offer him so much as a Tylenol (he's still angry about that). He simply does not respond to pain as most of us expect. When he says he is in pain, I believe him -- and I expect any nurse or physician who cares for him to take his '8 out of 10' at face value, because he's had enough injuries not to have to imagine your steamroller.

I know that many of your patients are reacting to fear of pain more than they are to actual pain, but you need to find a way to address that fear instead of rolling your eyes and making fun of them.

Airway Control said...

i like your new and improved pain scale a lot.

those 10/10 patients who just lay there, talking to their friends, yeah, they kill me. i want to ask them, "how bad is your pain on a scale of 0-10, 0 being no pain, 10 being the pain you would feel if i jumped up and down on your head and crushed your airway?

seriously, sometime i invert the relationship by asking:

how bad is your pain 0-10, 10 being no pain and 0 being the most pain you can imagine?

i usually get a more accurate/truthful answer because it goes against the whole psychology of relationships that they've been trained to recognize so easily that they often respond inaccurately. because they must actually "stop and think," the response is often more "thoughtful." and even if they still want to say 0 (in order to get the nurse "jumping," the elasped time renders that response almost comical, AND THEY KNOW IT.

Anonymous said...

Love your scale :)
My favorites are when the patients rate the pain higher than a 10/10 because they have a different pain tolerance than most people. "What most people call a 10, for me is a 20 because of my pain tolerance level." For which I promptly re-educate them on the pain scale.

I will have to use the 10/10= steam roller

mitchsmom said...

Love it!

drytears said...

As a patient I'm never sure how to answer the pain scale because I want my pain to be taken sersiously but when I was in the hospital, and was still suffering from my headaches I knew that I would only get tylenol from them and that wouldn't work but my pain at the higest would be a 7, and I would manage w/o pain meds, while another lady would complain of a headache what was a 10/10 and be up and walking around and fine, and it just blew my mind that she thought that was 10/10

Sure everyone has different pain tolerance levels but if your feeling a 10/10 I don't see how you can be moving around and doing stuff!

dr B said...

I usually ask for a rating of 0-10 where 10 is "suicidal with pain." If the patient says 10 too blithely and I am feeling ornery then I say, "so if you had a loaded gun with you right now you'd be tempted to shoot yourself?" Really. Often (not always!) the patient backpedals to "9."

TDub said...

I love it when the patient looks up from her hand of cards and says, "Oh, I'd say it's about an 8. GIN!" and slams down her cards.

I had what I thought was a gallbladder attack. I waited at home til 6am rolling on the bed in agony because I didn't want to wake up the doc. Then when we got to the ER, they asked "On a scale..." I groaned "I had two children without anesthesia and one of them was NINE AND A HALF POUNDS and THIS is WORSE!" all screaming indicated.

They saw me right away.

Anonymous said...

As a patient, I imagine 10 being that scene in Mercy where Kathy Bates uses a sledgehammer to break both of her patient's ankles. That blinding, immobilizing, I'd-be-better-off-dead-no-morphine-will-do pain.
I fell badly and did something horrid to my back, and I rated it a 5. And then the doc wouldn't give me pain meds.
It makes me bitter that the docs learn to round down from the stupid drama folks. OW, DAMMIT.
Anyway, highly entertained!

Titus said...

Here, I do not really suppose this will have effect.
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