Pain Management in the Hospital

Hello my Zebras and Spoonies! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I want to talk about the way that pain is managed (or not) while those with chronic illness are in the hospital.

The first reality that must be mentioned is that there is a significant inequity when it comes to pain management in our current health care system. Women are less likely to get medicated for their pain then men and they are less likely to get adequate pain control. This is equally true if you are a person of color. And if you are a woman of color you will face even more hurdles. There is also the reality that if you have a history of substance abuse you will like not be given any pain management at all. I find all of this this completely disgusting as a nurse and completely infuriating as a patient. I’ve experienced this on both sides. I’ve seen patients that were not being well medicated and I couldn’t account for it beyond their gender or their history of substance abuse. And I have been the patient in pain that has not been taken seriously.

In general, I feel that there is a standard of disbelief and suspicion around a person having pain that is a provider’s baseline and it becomes the patient’s responsibility to prove that they are in pain. I hate this culture and I feel that it needs to change. There are many assumptions about how a person will present when they are in pain that are simply untrue. I have heard providers say things about pain presentation that I know are not true because they do not line up with my personal experience with pain. And the challenge is that when you are in the hospital, you bring all of your medical problems with you, not just the one that needs hospitalization. That means that your chronic pain is going with you and will need to be managed while you are in the hospital.

The first thing to know is that you have the right to adequate pain control. If the provider is not managing your pain, they must be able to adequately justify the reason for it. And there are times that it is dangerous to give people pain medication, but that is not usually what is going on when a doctor declines to write orders for pain control. If you are not getting pain control, request to speak with your doctor about this directly rather then having the nurse act as a go between. Have a family member or friend present when the doctor sees you. If possible, have that person be a male. As much as I don’t like it, the reality is that them being a male will make it more likely that you will get what you need. Also, this is a time to consider recording your encounter with your provider. But be sure you know the recording laws in your state. I have a post about that here: Recording Doctor Appointments.

The nursing standard of practice indicates that the pain is what ever the patient says it is. That means when a nurse is assessing a patient’s pain, they are not supposed to use anything other then an accepted pain scale. The one used most often is the numeric scale that is a simple scale of 1-10 with 10 being the worst. The next most common is the faces scale which is also a 1-10 numeric scale but it includes the images of faces to help clarify how bad that number would be. There are non verbal pain scales that can be used. And they are worth being familiar with as they will educate you on what it is that health care providers are looking for as signs of having pain. The FLACC is the most commonly used non verbal scale.

I personally hate the FLACC because it paints the picture that a patient pretty much has to be hysterical in order to be having a 10 on the pain scale. And the truth is that this is how many providers see pain. I know that you can be in severe pain and not be hysterical and that you don’t have to present the way that this scale suggests. Granted, this scale was meant to be used to assess children, but it is often used to assess adults as well. And that kinda makes my head hurt.

The last commonly used pain scale is the Pain Assessment IN Advanced Dementia (PAINAD). It is usually only used for those who have cognitive impairments. But I feel it is a better non verbal pain scale than the FLACC, honestly even for most children. However, I still can think of plenty of times that I was in severe pain and was not presenting in the way that this scale suggests that a scale 10 would present.

The next thing to know is that you do not have to ask for PRN medications. Not even PRN pain medications. I have no idea where this weird idea comes from, but there is no rule that indicates that a patient must request a PRN medication in order to get it. That makes no sense and goes against things that we commonly do in practice. We usually have a bowel regime in place for patients so they are offered bowel medications if they haven’t had a bowel movement in three or more days. We don’t wait for the patient to ask for these medications, we offer them once the criteria is met. We often have people with order for PRN hydralazine to get if the BP gets above a certain number. We don’t wait for the patient to ask for that.

How do PRN medications really work? There are 3 things that must happen in order for a patient to be given a PRN medication:

  1. They must meet the criteria set in the order.
    1. Every PRN medication will have a reason to give that medication included as part of the order. In order to get the medication, the patient must meet that criteria as written in the order.
  2. Enough time must have passed since the last dose.
    1. Every PRN medication will have a frequency as part of the order. Within the order it will state how often a medication can be given such as every 2 hours or every 4 hours or daily etc. In order to get the PRN medication, the right amount of time must have passed since the last dose.
  3. The patient cannot be presenting with any adverse effects from the medication.
    1. Part of the nurse’s job is to monitor their patient’s for adverse effects from the medications that we are giving. If a patient begins to have an adverse effect from a medication that we have given (scheduled or PRN), the standard is to not give that medication and to contact the doctor for an assessment. In order for a nurse to not give a PRN medication due to the concern regarding an adverse effect from a medication, that nurse must communicate with the doctor and have those adverse effects addressed. Holding (not giving) the medication is not enough.

So, what does this mean in practice? First, it means that if a nurse ever tells you that you need to ask for your pain medication because it is a PRN medication, they are wrong. It also means that if you ask to be woken up for pain medication this can, in fact, be done and is done with scheduled medications all the time. If a nurse refuses to wake you for pain medication, you should ask them to instead wake you for a pain assessment. Make it clear that you want to nurse to come into you room and wake you up at set intervals to assess you for your pain. Having regular pain assessments is a standard of practice and they will have a difficult time justifying in their charting not providing you with regular assessments. In the end, if a nurse sticks to their guns and refuses to come in for regular assessments you will be left to ringing for that pain medication. There is no reason you cannot set an alarm to let you know when that pain medication is due again and ring for it.

When we are in pain, it can be easy to lash out at those around us. But I promise you that you will get more from the nursing staff if you remain respectful and polite to them at all times. Nurses will be more likely to go out of their way to help you if they see that you are treating them as a person and that you are being respectful. And you want your nurse to be your ally. They are the ones that are going to be calling the doctor and they are the ones that are going to be bringing in your medications. Having a nurse there to advocate for you is something truly powerful so don’t make them your enemy. Granted, a good nurse will do these things for you regardless of how you treat them. But remember that we are people too and we are often working in really crappy and stressful conditions. This means that we are less likely to go that extra mile simply because we are going to be running on a chronic spoon shortage.

In the end, there is no magical way to make sure that you are going to be getting the pain control that you need. But things that can help is being sure that you are speaking up for yourself. Don’t be afraid to make a formal complaint if your pain isn’t managed. Remember that there are patient advocates that can sometimes help you. And the last thing is to be sure that you are keeping an open line of communication with your doctor and nurses. Because there are going to be times that your pain isn’t managed well because it is too soon for the next dose or it’s not safe to give you more medication. These times suck, but they do happen.

Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!

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