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This site is for student nurses or nurses starting out. Letters to a Young Nurse are blog posts written like letters to help you find your way and make your journey as a nurse less difficult. 

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PAIN!

Updated: Aug 6, 2023



One of the most difficult tasks for a nurse to grasp and get good at is assessing pain. So, let's do a little experiment. Take a rubber band and choose a finger, any finger will do. Wrap the rubber band at the first joint line like the picture above. Go around as many times as you can until it is VERY tight. As soon as it is tight start a stopwatch or timer on your phone or clock. Now continue reading this letter. DO not take the rubber band off until it hurts so much that you cannot concentrate and then wait a few more seconds.


I am quite certain that every nurse who was listening in nursing school or at clinicals knows pain is the 5th vital sign. It is AS important to ask about and recognize as any of the other vital signs. Ignoring pain or not assessing it properly can have devastating consequences. According to research (Christ, 2020) pain is one of the most common conditions affecting over 70% of ER patients. Pain management is affected by our background, cultures and beliefs. An important part of pain management is the realization that pain is not just a sensory experience. It is felt in the sensory receptors and nerves in the finger (for this experiment), but it also affects the brain and the heart and the soul. It can be caused by more than a physical issue.


How is your finger feeling? Is it changing color? Does it hurt less if you do not move it? Is it taking over your ability to read? Take note of what is happening in your body.


In a national survey of Swiss ERs, it was found that a validated pain scale was used in only 14%, an analgesia protocol in <5%, and 1.1% had a nurse-initiated pain protocol (Christ, 2020). Since we (nurses) have more time with the patients' nurses should have the highest percentage. But sometimes we get busy with the technical tasks and forget to assess the patient holistically. Or maybe you do not know how to perform an effective pain assessment.


A pain assessment can be done quickly if you know the appropriate questions to ask. I love the acronym PQRST.

  1. P = Provokes, what makes the pain better, what makes it worse? In some instances, you have to probe further. Most patients think only pain medication will make the pain better. But there are other nonpharmacological interventions like heat, ice, rest, etc.

  2. Q = Quality Is the pain dull, sharp, sore, aching? Ask the patient to describe the pain in their own words.

  3. R = Radiates I always ask the patient to point to the pain and then ask if it radiates up, down, left right and how far?

  4. S = Severity This involves asking the patient to choose a number from Zero to Ten with zero being absolutely no pain and ten is having a tooth pulled without Novocain.

  5. T = Time Is the pain worse at a particular time of day? Is the pain worse after a particular activity? Is the pain worse when waking up or is the pain worse when the patient puts their feet on the floor?

And I add a question about the cause of the pain. I work in a jail and often my patients have chest pain after a court date or have back pain when being transported out of jail to prison. Takotsubo cardiomyopathy, or broken heart syndrome, is a condition often triggered by physical or emotional stress. It can mimic a myocardial infarction and has long lasting effects on the heart (New Zealand Heart Foundation, n.d.). We need to be sensitive and mindful of the patient's words and mannerisms, too. If the patient looks down while talking or looks away from you it might have a deep-seated cause like sexual abuse or trauma. Pay attention and listen with your ears and your heart.




How is your finger feeling? Is it changing color? Does it hurt less if you do not move it? Is it taking over your ability to read? Is it getting colder? Take note of what is happening in your body.


While you continue with the experiment let me tell you a personal story. When I started nursing, we did not have "lift teams" or Hoyer lifts or any of the other fancy equipment used now to move patients. My first and second job involved helping patients move in and out of bed several times during the day to go to therapy or to the bathroom, etc. If you could not find another nurse who was free to help you move the patient, you did it yourself. I vividly remember a patient who was a tetraplegic (she could only move one arm) and she weighed over 300 pounds. I often moved her by myself. To this day I can pick up almost anybody from a sitting or lying position by myself including patients who have had strokes and are unable to help move. Because of that history my lower back used to leave me unable to get out of bed several times a year. It was the most excruciating pain and left me bedbound for days at a time. Until I figured out the true cause of the pain.


I came across a wonderful book by Carolyn Myss Called Sacred Contracts. Carolyn Myss is a Medical Intuit which means she can "read" people's energy and their chakras and can determine where energy is being lost and what the person is suffering from. She works with a physician named Dr. Norm Shealy. I know what you are thinking, "energy" and "chakras" all sounds like New Age mumbo jumbo. But it worked for me. Listen with an open mind. Carolyn says your spine is your support. It holds up the skeleton and supports our body. So if you look at it from a symbolic or metaphysical viewpoint, if you are not feeling supported somewhere in your life and you do not pay attention to it then it will manifest as back pain. So I started paying attention to the timing of my back pain. Every time I didn't feel supported at work, or supported at home, or financially, or emotionally supported I would develop excruciating back pain. But when the twinges in my back started, instead of ignoring it, I would pay attention and see where I could change the experience. Sometimes it meant leaving a job that was toxic. Sometimes it meant leaving a partner who was no longer supportive or invested in the relationship. Sometimes it happened when my family was emotionally distant and cruel. And sometimes it happened because I was out of alignment with my values and beliefs. As soon as I paid attention, the pain would go away and the excruciating pain in my back that would put me in bed for days never returned. I firmly believe that pain can be a warning sign to something that you are not paying attention to. And if you don't pay attention the first time, it returns harder until you are flat on your back. I always compare it to being alerted with a feather across the face the first time, a 2x2 across the head the 2nd time and a 4x4 across the head the third time. But if we are disconnected from our feelings and disconnected from the signals our bodies are sending out then the body will find a way to get our attention.

Myss, C. (1996). Anatomy of the spirit. New York: Harmony/Rodale.


How is your finger feeling now? Did you take the rubber band off yet? Is it getting harder to concentrate? Take note of what is happening in your body.



If you watched the entire video then the rubber band has been on about 12 minutes. The first time I tried this I could only keep the band on for about 10 minutes. This time I kept it on for 16 minutes. Maybe I am less sensitive to pain or something else was going on that allowed me to keep it on longer this time. And that is a key point about pain. The experience of pain can change.


What did you learn from this little experiment? Hopefully you were able to see that the longer the painful stimulus lasted the harder it was to concentrate and to stop thinking about the pain. The physiological events happening in your finger were impacting your attention, your concentration, your ability to distract yourself. What kind of voices were your hearing in your brain? Did the pain finally get so intense that you had to remove the rubber band? And then what happened? Ironically a return to comfort took a substantially less time than it took for the most intense pain that made you remove the band. It was less than 3 minutes for the color to return, the skin to go back to normal and the pain to be gone completely. This little experiment is a little taste of what intense pain is like for patients. And that is why you have to believe what the patient says about their pain.


I do want to add that sometimes what the patient thinks is pain may not be pain, or rather what they think is causing the pain may not be the cause. For example, during clinicals the nursing student did her pain assessment but came and got me because the patient wanted pain medicines but the nurse was on break (out of the building). I took the nurse with me and went to the patient's room. The patient had a stroke and was paralyzed on her right side. She kept repeating over and over that she was in agony and she needed pain medicine. Something made me ask her about her last bowel movement. It was four days ago. So rather than giving her another pill to constipate her I suggested that we get her on the commode. The second I got her on the commode she exploded with gas and bowel and was immediately out of pain. The look of relief on her face was priceless. It is important that we do a thorough pain assessment but the cause is not always what the patient thinks it is if we ask a few more questions.




Myss, C. (1996). Anatomy of the spirit. New York: Harmony/Rodale.


University of Florida Emergency Medicine Research. “Pain Neuroscience Education 101.” Www.youtube.com, 23 June 2023, www.youtube.com/watch?v=c8fqMIwquRI. Accessed 7 Aug. 2023.

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