Quote from SuzieF
Oops, I agree, it would be the "6th Vital Sign" now that I think of it. I guess I am showing my age, because way back when the "pain campaign" started, sats were not done routinely.
Thank you for setting me straight.
I have to agree with hiddencatRN that "pain level" is part of an assessment. Pediatric patients probably are grossly under medicated and well as the dying and elderly. This is where an astute nurse is worth his or her weight in gold. Assessment and observation are key in pain management/intervention for patients.
My concern is when we are focusing solely on a patients subjective report of pain and chasing that with (narcotic) medication. When patients report pain levels of 9-10 while eating and talking on the phone, we have to wonder if self-reporting has been watered down.
Accidental overdoses happen this way. I know personally of more than one.
I suppose I don't see the difference between calling pain a "vital sign" and referring to it as part of an assessment. Vital signs are part of assessment as well. With any abnormal vital sign, I will evaluate it along with the patient's diagnosis, clinical status and other symptoms to determine if interventions are needed and how effective they are.
One of the biggest reason that awareness around pain management has increased is because of Press-Ganey and HCAPS scores. Patients are now asked if their pain was assessed and how well they feel their pain has been managed and hospitals can be dinged if their scores in this area are poor.
Pain is, and always has been subjective. I've seen laboring mothers who can talk and laugh between pushes during a medication free birth. I've seen teenagers/adults moaning in pain while reporting a pain level of 5. I've seen the same population reporting pain of 8-10 while outwardly appearing comfortable. Everyone manifests pain differently. It's not an assessment for the nurse to say, "This patient is not in pain because they are talking on the phone." That's a judgement. Patients with pain, especially chronic pain, become very good at using distraction and detachment to manage their pain, but in no way does that mean they aren't experiencing pain.
I do agree that pain in often under treated in the young pediatric, disabled and elderly patients. They cannot self report and cannot let us know if their pain is controlled. However, I'm not sure that equates to pain being over-treated in the adult population, simply because they can self report. I believe that, in most cases, patients are honest about their pain. They do not want to be in pain and with proper education, they will understand that the goal is to manage, not eliminate, their pain.
"Accidental overdoses" should not happen in the hospital. A patient who is alert, talking, with stable HR, BP and respirations complaining of pain is not going to overdose because they are given another dose of medication. Their clinical condition- level of consciousness, respiratory rate, etc. will change before they experience adverse reactions from pain medication administration. Now if a patient who is barely arousable, with a RR of 8 is given additional narcotics, I can see your point. But it would definitely be a medical oversight to medicate such a patient without proper monitoring of their response/adverse effects.
I believe that there is still a pretty prevalent lack of education and understanding regarding pain management in the medical staff. I think that often emergency medical staff may be too worried about adverse reactions to properly treat pain. Here's a couple of examples:
1. Our ER sees a pretty large sickle cell population. Patients in sickle cell crises experience immense pain, and they are not narcotic naive. Many of these patients take narcotics for pain management at home on a regular basis. If a patient reports to the ER with sickle cell crises pain and they take 60mg of morphine sulfate for pain at home, but are medicated with 10mg of morphine IV, that may seem like a big dose. However, 60mg of po morphine is equivalent to 20mg of IV morphine. So that 10mg IV dose is only half of what the patient routinely takes for pain at home. Of course, the morphine does very little for the pain the patient is having, even though the same dose would knock out someone who is narcotic naive. So the patient is labeled as "drug seeking."
2. My husband was recently hospitalized for gallstones. In the midst of an acute gallbladder attack, his pain was very high (as in he was yelling and crying at home before we got to the ER). He knew that the only way he could prevent it from getting out of control was to remain calm and try to distract himself with TV, his phone, conversation, etc. By no means did that mean that he wasn't experiencing pain. The first pain management ordered by the ER was 1mg of IV dilaudid every 6 hours. After the first dose, his pain was back after about 20 minutes. The nurse told him that (and I quote), he "can't have any more pain medication right now because the kind of medication be got can cause you to become addicted to it and if you get too much it can make you stop breathing." Now I don't know about you, but if I wasn't medically educated, that statement sure would prevent me from requesting more pain medication. Thank God he had a nurse with him who could point out that, sorry, 1mg of IV dilaudid for my 180lb, perviously healthy, alert husband is not going to cause him to stop breathing without warning and taking this medication over a short period of time is not going to get him addicted to it.
Just two examples of how pain in the adult population continues to be mismanaged despite the ability to self-report.