PAIN as the 5th vital sign ..What's it about??

Genista, BSN, RN · Dec 27, 2001

I don't know what Hillary has to do with this, but pain as the 5th vital sign has been in the works for a few years now.

http://www.nurseweek.com/features/99-7/pain.html

Traditionally, oncology nurses are great w/ pain management...but not everyone else is. There are MANY patients who are not being adequately treated for pain. Often nurses do not ask pts to rate their pain, and some nurses assume patients were not in pain because "he didn't ask for anything." We don't know any better because many of us were not taught proper pain management in school. Even docs are just catching onto it. From my experience, I know that many patients may have significant pain or discomfort, but won't admit to it unless asked (they "figured you knew," or "didn't want to be a bother" are ones I have heard). We need to make pain management important for all levels of nursing care. I know the new paperwork is a "pain" ;-) but I guess that comes with the JCAHO territory (like their restraints protocol...argh!).

Patients are being undertreated for pain, so they have finally made it part of routine assessment for us all (some of us maybe already were doing that, so it won't be a big change). But some of us do have some learning to do. I am still learning about pain management myself, and am thrilled to see it added as the 5th vital sign.

Undertreatment of pain:

http://www.postgradmed.com/issues/2001/09_01/editorial_sep.htm

~kona

LindaHP · Dec 27, 2001

I agree that patients need their pain addressed.

A terminally ill patient needs all their pain addressed. But someone who is in their 30's with chronic pain should not be given pain meds that are going to need increasing doses due to tolerance.

There is such a push to medicate people with chronic pain. Yet where are these people going to be in 30 years? This is where I get confused and am wondering what the LONG term plan is for chronc pain patients.

I write this with a certain amount of anger. My sister had fibromyalgia. I suggested she go to a pain clinic, thinking they would address her ever increasing tolerance to narcotics. No, they gave her ms contin, plus ms quick release for break through pain. She was in her 30's. She overdosed by the time she was 39. So I have a notion that there is not much out there still for a long term pain situation in a peson who is not terminally ill.

ktwlpn, LPN · Dec 29, 2001

Originally posted by kona2
I don't know what Hillary has to do with this, but pain as the 5th vital sign has been in the works for a few years now.
http://www.nurseweek.com/features/99-7/pain.html

Traditionally, oncology nurses are great w/ pain management...but not everyone else is. There are MANY patients who are not being adequately treated for pain>>>>>>>>>>>>>>This is very true-especially among the elderly and the confused...My parent's generation typically just do not complain of "pain" Also often if a pt is unable to atriculate pain many nurses will not medicate-how many of us have seen day 3 or 4 post -op fx hips with Alzhemier's going without pain meds?In l.t.c. many docs I have worked with are terribly out of date regarding pain control in the geri population-and the hospice pt in the nursing home...The JACHO regs can only benefit this population.....

Genista, BSN, RN · Dec 30, 2001

LindaHP-

I am sorry to hear of your sister's terrible experience.You have valid concerns about use of opioids in chronic pain management.Your comments do give one something to consider. However, I think anyone in pain deserves adequate relief whether they are terminally ill or not. The fact that your sister overdosed or required escalating amounts of opioids raises a red flag. I wonder what adjuvant drugs they tried? How & why did she overdose; was it b/c her pain was so severe that she overmedicated? We do have a lot to learn in this area, but we can't ignore that people are hurting & they are not being treated. At least the pain as the 5th vital sign will open up the dialog and promote assessment & intervention. My understanding is that tolerance usually develops w/ disease progression, and that many pts won't develop tolerance for a number of years, unless their disease worsens.

http://www.jr2.ox.ac.uk/bandolier/booth/painpag/wisdom/lancop.html

Anyone else w/ interest in pain management care to comment?

This is a hot topic where I work. I would love to learn more about it.

myownviews · Dec 30, 2001

Hi,

Was just cruising through and noticed this topic. Since it's one that's very important to me, I immediately registered and here I am :)

My background is critical-care nursing for almost 25 years. I hurt myself at work, and from there things have just gone downhill and I am now classified as a chronic pain patient.

It is extremely difficult as a chronic pain patient to find adequate care and relief of one's chronic pain. Most docs don't understand chronic pain management, and neither does most of the rest of the medical profession. Many patients are labeled as "drug-seekers" when they ask for more pain meds.

I've done extensive research into chronic pain (as I did for my other medical problems...as we ALL would) and yes, a CP patient does become dependant on the meds. Which is MUCH different than becoming addicted. The difference is WHY you take the meds. If someone is escalating their med use in order to get high and not deal with life, they are addicted. However, a CP patient takes the pain meds to HAVE a life...to be able to get out of bed and have some semblance of a normal life. Yes, they become physically dependant on the meds and will go through withdrawal if the meds are dc'd.

kona2--I'm glad to see you and others are expressing lots of interest in treating patients with pain. Heck, I graduated in 1975..and was of the school of "if they don't ask for something for pain, they must not need anything" and "geez, here comes Mrs. X again with her migraine" and we'd all roll our eyes because we were all sure she was a drug-seeker.

Nothing like having chronic pain yourself to open up the 'ol eyeballs. The question was raised about well, what about 30 years down the road?? Well, what about it? Does that mean we shouldn't have pain relief? That we should just "learn to live with it.?" I don't think so. Not ONE chronic pain patient I know WANTS to take opiates. Heck, the side effects can be tremendous. No one gets out of their bed and says "Hey, think I'll get up, take a bunch of MSContin and then I'll have to take 5 Senokot, some Miralax, and Yakima Fruit Paste so I can have a BM today." Not fun, trust me. If they came out with some non-narcotic med that WORKED for severe intractable pain, every CP patient I'm aware of would throw their meds out in a NY minute.

In this day and age, NO ONE should have to live with chronic pain.

And, in this day and age it's TOUGH to find a "real" pain management doc. Most "pain clinics" are nothing but "block shops"....ESI's and blocks to go. Pffft. I went to a pain clinic...my problem is with my leg. Well, he wanted to give me a back injection! I asked why, there's nothing wrong with my back. Well, since your gait is off, I'm sure there must be. Wrong answer.

The "drug-seeker" and "addict" labels have got to go for our CP patients. Many people classified as "drug-seekers" are just trying to get relief for their pain. It's called pseudo-addiction. We as nurses are supposed to be advocates for our patients.

LindaHP--I'm so sorry about your sister. Was it due to the pain that she OD'd? Or was it accidental? Most CP patients stay fairly stable on their pain meds once controlled...once the right dosages and meds are found. Usually only need an increase occasionally or if their disease is progressing.

Anyway, I know this is terribly long and I'm sorry about that.

If you'd like to learn more, MGH Hospitals Neurology Service, in association with Harvard, runs many neurology related forums...one of which is Chronic Pain. You can get there by going to either http://www.braintalk.org or http://neuro-mancer.mgh.harvard.edu/cgi-bin/forumdisplay.cgi?action=topics&forum=Chronic+Pain&number=20&DaysPrune=1000&LastLogin=

There's lots of our fellow nurses there who have CP, and there are many many forums. Hope some of you come on over :)

Jenny P · Dec 30, 2001

Myownviews, thank you for the information. I have been wondering about this myself because of LindaHP's post. I'm sorry, LindaHP for your loss and I can understand your anger. But there has to be something that can help those with chronic pain. Pain is something that can destroy a persons entire life if it cannot be controlled. And I do wonder where will young patients with chronic pain be in 30 years if we can't figure out some way of controlling pain better than we do now.

I do believe that the patient is the only one who knows what his pain is. We have been using the 0-10 pain scale in my hospital for maybe 5 years now, and I find it is much easier caring for patients when they can rate their pain and the medication effect rather than just telling me they hurt. I do find that there is a certain amount of our patients who are in obvious pain that tell us that their pain is a 1/10 (score of 1 out of a scale of 10); I ask them how would they rate their discomfort and they often rate discomfort as 10/10! What is the difference between pain and discomfort, I don't know, but these are often the 70+ y/o Scandihoovian males we have here in Mn! Then there are the younger patients who are laughing and talking with family who tell you that their pain is a 10/10 and if you review with them that pain of a 10/10 is worse than childbirth with the baby coming out sideways (or as a full grown adult), they will correct themselves and decide their pain is about a 3/10. Go over the pain scale with your patients and what each number or group of numbers would be and give examples of each group. I tell my patients 0= no pain or discomfort; 1-3= mild, distractable pain (such as a headache that you're aware of once your company leaves or your TV program is over);4-6= moderate pain, (such as a headache that you are aware of but you can still function and eat anyway); and 7-10= severe pain (such as you curl up into a fetal position and don't eat, nor can you function-- or pain like giving birth to an adult). Most patients can understand this.

My other comment on this is that any institution that can add "26 stinkin questions" concerning pain to it's assessment flowsheet has gone overboard on trying to document pain, meds, effects, and who knows what else. I think our flowsheet has no more than 10 assessments re: pain and that seems to be plenty.

Sleepyeyes · Dec 30, 2001

We were taught in nursing school (about a year ago) that pain is:

"Whatever the patient says it is." It must be addressed in that

fashion. We use a scale of 1 (the least) to 10 (the worst) to

measure the Pt.'s perception of their pain, or

assessment findings for confused folks such as: restlessness,

moaning, grimacing, or crying out to justify giving pain meds.

People with chronic pain will have no rise in vs, will be able to

carry on without "looking like" they are in pain, even sleep though

still in pain, and need to have meds on a regular schedule.

(I've had elders who refused to say the word "pain;" they were given

meds based on their "discomfort" because "they couldn't sleep at night

from the discomfort." They were moaning and grimacing though.)

I justify not giving a scheduled med based on respirations and LOC.

Just touching on some points here; hope it helps. As with KTWLPN,

I work LTC and agree that the elderly have real pain issues, but

I must say, here in FL we have the best Hospice in the US, so

we have learned a lot about pain management and the patients

(and their families) really benefit since we have less elderly

"suffering" and the poor families (and staff) forced to stand by

helplessly.

LindaHP · Dec 30, 2001

Hi all, still a very good topic. Yes, my sister was labeled as a "drug seeker". She was taking the pain meds as instructed to my knowledge. There were other factors with her, but the main thing is that she would be needing pain med for the rest of her life, since no one seems to get better from fibromyalgia.

My main concern and what I still dont understand is do long term pain patients have to continually increase their doses of, for example, oxycontin? And if so, where does that leave them in 10 years?

I agree that pain management is very important. I have had my share of back injuries and even though I thankfully get better, those weeks of pain are horrible. It effects every aspect of my life if I am hurting.

P_RN, ADN, RN · Dec 31, 2001

Very interesting and well controlled discussion all of you .

I have been "attending" mgh neurology forums for several years now. I advocate them highly for ANYone who wants to see exactly what pain can do to a person. My username there is the same as here.

As a CP person myself I have a different take on this than most. I urge you all to re-think any hesitancy you may have in relearning how to deal with the 5th vital sign. It's not at all about paperwork.

P

dtweed · Dec 31, 2001

Some of us in LTC are working on pain as a fifth vital sign also. We just implementated a pain management policy in the facility I work in. We have a long way to go, but it is very necessary. When we cognitive impaired individuals we need to learn torecongize pain and treat it. We also need to treat pain in the dying. My mother-in- law died in March of 1999 and her pain in LTC was treated very well with duragesic patch and then IM morphine. My mother passed away in February 2000 and her pain was not. They died in different facilities and with different doctors. Pain mangement is something tha is close to my heart becausse of it. The staff where my mother was afraid morpine would surpress her respirations. She hadn't eaten in three days by then, surpressing respers was the least of there worries. She had made the decision not continue to live housebound on home oxygen any longer. When people make those decisions we need to support them and help them be as comfortable as possible. I know I have alot to learn yet but I want to make a difference.

VAC · Jan 1, 2002

Hi,

I saw this topic and wanted to ask if anyone else shared my pet peeve about the 26 question pain assessment, and all the emphasis on us nurses assessing every imaginable detail of the patient's pain. I have yet to see a change in the doctor's approach to pain management. Anyone else out there deailing with doc's reluctant to prescribe pain meds, or stuck in their rut of prescribing the same doseage and meds for everyone??. I was under the impression that the joint commision had more to do with the 'pain the 5th vital sign' campaign than Hillary.

Yes, nurses's should be aware of and assess patient's pain, but, like many issues in nursing, I think more should be expected of the physicians who have the power to prescribe pain meds; instead of 'killing trees' while we assess and chart the patient's pain to death.

I'm sorry to hear of other's not being treated for chronic pain, if anything, the patient should have all options, be informed, and be able to make the choice of long term opiod use.