Three or Under

As a nurse, assessing for pain is part of the job. Falling behind temperature, heart rate, respiratory rate, and blood pressure, pain is “The Fifth Vital Sign.” It seems simple, but learning to assess pain is the first step in providing adequate pain management.  


In the hospital, we want you to quantify your pain. Give us a number. We use the 0-10 Numeric Pain Rating scale and tell you if zero is no pain and ten is the worst pain you’ve ever had,  we want to know what you’d rate your pain.


I’ve had patients post surgery say, “Zero.”




Yeah. Zero.”


I’ve had a patient with no diagnosable injuries, just sore after a car accident, or those who just woke up from (what seemed to me) a deep sleep and report “Ten.”






Okay. Ten.


Pain is subjective.


But the results of pain are objective.


Inadequate pain control affects the healing process of an injury or wound, has systemic effects, and can decrease a patient’s mobility (which sets them up for complications from immobility secondary to lack of pain control rather than the actual injury or diagnosis). And this is saying nothing of the far reaching, wide and divisive arms of pain’s psychological affects. 


But. We don’t just want to know you’re in pain. We want to know details. You’ll need to identify and qualify it for us. Where is it? How often do you have it? What causes it? What exacerbates it? Is it intermittent or constant? Tell me what it feels like. We use words like burn, throb, pulse, stab, dull, sharp, ache, tingle, cramp, radiate, hot, and pound as prompts and explanations.


In the intensive care unit, it’s just as common (if not more so) to have a patient unable to speak, or interact in any way, to express if (let alone how) they are in pain.


If a person can’t speak (if they have a breathing tube, for instance) and/or are too sedated to lift zero to ten fingers, we use non-verbal assessment tools.


The Wong-Baker FACES pain rating scale is designed to be used for anyone over three years old. “Tell me which face matches the pain you’re feeling.”



And there are others, like the ones to assess a patient’s face, activity, body movements, if they are crying, or consolable. We look at agitation levels. We watch vital and clinical signs: pupil dilation, sweating, increased heart rate, blood pressure, and breathing rates.


Pain is one of the most complex aspects to a person’s recovery.




Impossibly, at this time of year, my mom died twenty years ago. 


How could that much time have passed? How have I lived without her for this long?


I was trying to figure out how to explain, or understand for myself, what this feels like—To move so far into a life of my own that my time without her only grows and (is it fair to say?) starts to outweigh my time with her.


Could I use pain scales to explain it? To share what it’s like? Qualify it. Give it a number. 


Acute pain typically lasts under six months. Pain resolves as the area heals.


The first two years after her death, my pain level was between a 6 and a 10. Sharp, jabbing, stabbing, aching, crushing, throbbing, constant. It made me physically sick. Sleep was a reprieve.


Distracting injuries distract a person’s ability to adequately report pain in certain areas.


They weren’t injuries, but in the next two to six years, I got married, moved out and away, started at a new university, and began my first real (and very intense) job. My pain was a 2 to 4. A dull ache bilaterally in my shoulders. At least that’s what I would have told you.


Exacerbated pain is a worsening or increase in the severity, which can stem  from multiple causes.


Chris had his brain surgery, a time when we thought his life may end or at least our lives could be severely and forever altered, seven years after my mom died. Recovery was hard. My pain was a 6-8 initially. Pins and needles in my hands and feet. It lessened to a cramp in my gut, a 3-6, depending on how much movement we made, after that first tenuous year. It often spiked high as we struggled to adjust.


Some people “are never pain free, but their pain types and pain severity can vary from one moment to the next. This is called variable pain. For these people, the increases can be severe, so that they feel they have moments of very intense pain (“breakthrough” pain), but at other times they can feel lower levels of pain (“background” pain). Still, they are never pain free. Other people have pain that really does not change that much from one moment to another. This is called stable pain.” 1


We started having kids and the last ten years have been a mix of feeling like my wounds have healed (No, really, Zero. I’m pain free!), having acute flare ups (Is it possible to hurt this much after this long? Like after giving birth to my first child, or explaining to a four year old that Mommy’s Mom is in Heaven, or the year, my Half-and-Half, when I realized I’d lived as long without her as I had with her, and sobbed myself to sleep in bed next to my husband), and being busy and adjusted and simply used to it enough, the pain is simply there. A 2 or a 3 in the background; a dull rub, posterior to my heart, almost back against my spine, with which I’ve learned to live.




As nurses, one of the questions we ask in the ICU is, “What is your desired level of pain control?” Most people say Zero.


But there are those, with chronic symptoms or who understand the complex nature of their injuries enough, who know they may never be completely pain free.


Many of them say, “Three. Three or under.”



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Three or Under




Sonya Spillmann


  1. Wow. This must be one of my favorite posts from you yet. You masterfully wove your clinical expertise into the many facets and stages of your own grief and loss (pain), and the power of it hits me in my gut. Beautifully written, friend, and I’ll be re-reading this one for sure. Xoxo

  2. So true, my friend. My Mom has been gone 10 years and it’s down to a 2 or lower…..partly because she was so ill (cancer) and it was such a relief to see her freed from life that was no longer life. But Dad….almost 4 years, and approaching the anniversary. This was a much harder loss for me and it stabs up badly at this point, periodically…..the knife in the gut still twists. Even though I know, pragmatically, that he is in heaven just like Mom and also free from pain.

    And though I am old enough to be a grandmother, part of me is still the little girl who lost her Daddy.

    Beautifully put, Sonia. No one who hasn’t experienced pain could have said this so well.

  3. Thanks for sharing your heart’s feelings Sonya! I recently attended a funeral service and this poem was inside the memorial card….Grief never ends….but it changes. It’s a passage….Not a place to stay. Grief is not a sign of weakness….Not a lack of faith. It is the price of love…..Scott Kelli Continue to love those who are with you now as you did your mother!

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