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

[prn nurse]

I must have had a depressed cognitive 2001...I heard some talk about pain as the 5 th vital sign, and,, several folks commented " it's all Hillary's fault, " but I didn't pay much attention or attend any inservices, seminars, etc on it. Now, we have new flowsheets with 26 stinkin questions to be asked/observed/answered ! all regarding pain...evaluation, interventions, outcomes. One of my coworkers said, JCAH has made it mandatory, so we got to do it. Will someone tell me what is going on? How did this sneak up on me? Is it really a federal law? What, if anything, did Hillary have to do with it? I work oncology, and have always been heavy with the pain meds, so why is pain such a big issue NOW?

[NurseDennie, BSN, RN]

I agree that chronic pain is a major problem in any number of ways. There are some pain clinics here that advise that if you have something that causes chronic pain, then your focus should be on coming to terms with the pain, as opposed to having it relieved. I can't imagine the frustration and depression that would set in if you were sent to one of THOSE clinics in chronic pain. It's a sin.

I have to say that pain control in general is probably MUCH better no than it was 15-20 years ago. I had a doctor tell me then that elderly patients don't feel paiin the way younger adults do, and that pain control isn't much of an issue to her (regarding total hip replacement surgery on an octogenarian female).

On the other hand, I went to a pain control conference in 2000, and the nursing part of it was centered on "pain is what the patient says it is" and the Ortho-docs all were centered on "people with chronic pain or back pain are drug seekers and realize secondary gains related to being in chronic pain." So there still is a lot of room for improvement!!

I always thought that I'd never be the type of nurse that "pressed" pain meds on my patients. But when you have a post-op who is grimacing, has that anxious look and yet denies pain, I generally have a heart-to-heart and explain that you don't have to, and probably shouldn't suffer just because you've had surgery. I can't guarantee complete comfort, BUT if you're in too much pain to relax your muscles, your blood supply to the site is going to be compromised and healing will take longer, you'll be less likely to do your deep-breathing, and we'll have the pleasure of your company longer as you recuperate from pneumonia, etc. I HAVE to get you out of bed, let's do the pain meds first, okay?

So there you have it.

Love

Dennie

[Jenny P]

I'd like to clarify that I have never withheld pain meds even when a pt. rates his pain different than what his body language says. I just like the pt. and myself to be using the same language when I medicate and document meds and effects, and I make sure that I document how the patient refers to his pain.

The nurses were quite unhappy with pain management in the past and it was nursing that researched and devised our pain management program, and we worked with pharmacy to development and then took it to the medical director who took it to the medical staff for approval. For our post-op CABG pts., we give MSO4 4mg (IV) Q4H (scheduled) and can supplement with up to 6mg MSO4 (IV) between scheduled doses. With this pain management program, our patients are able to move easier and their length of stay is shortened, AND the patients are much more comfortable and they use much less pain meds than before we implemented this protocal.

[NRSKarenRN, BSN, RN]

Heartly agree with myownview, P RN and Jenny P's advice. Have attended many pain inservices over the years, especially when in Hospice. Anyone get a chance to take the Pain mgmt/Hospice inservices offered by Fox Chase Cancer Center, Phila go for it! Your eyes will be opened. As another nurse in chronic pain, I can certainly empathize with the patients I worked with and learned from over the years.

This is a subject close to my heart due to own discomfort, my patients/clients pain management issues and relatives experiences.

Here are some resources to check out.

Two "Pain Bibles":

Book:

Pasero C, Paice JA, McCaffery M. Basic mechanisms underlying the causes and effects of pain. In: McCaffery M, Pasero C, eds. Pain Clinical Manual. 2nd ed. St. Louis, MO: Mosby Year Book; 1999:15-34.

Pamphlet:

Agency for Health Care Policy and Research. Management of Cancer Pain. Clinical Practice Guideline 9. Publication 94-0592. Washington, DC: US Department of Health and Human Services, Public Health Services; 1994.

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JCAHO Doesnt Have Time for the Pain

Anne Llewellyn, RN.C, BPSHA, CCM, CRRN, CEAC

http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=728

.....The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced in August 1999 that it would require hospitals, home care agencies, nursing homes, behavioral health facilities, outpatient clinics, and health plans to implement ways to assess and manage pain.

The new pain standards, which are being included in 2000-2001 JCAHO standards manuals, require providers of healthcare services to

*recognize the rights of patients to appropriate assessment and management of pain,

*assess the existence and if positive, the intensity of pain in all patients, record the results of the assessment in a way that facilitates reassessment and follow-up,

*determine and ensure staff competency in pain assessment and management, and address pain assessment that supports the appropriate prescription or ordering of effective pain medications,

*educate patients and their families about effective pain management, and

address patient needs for symptom management in the discharge process.

The standards will first be scored for compliance in 2001......

The WHYs of Pain Mismanagement: Is Your Bias Showing?

Lorraine Steefel, RN, MSN

Nursing Spectrum July 30, 2001

http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=4591

CE Article

What's New in Pain Management

Home Healthcare Nurse

November/December 2000

Volume 18, Number 10

http://www.nursingcenter.com/ce/test/article.cfm?id=4853DDAF-AA15-11D4-83E0-00508B605149

Pain Management for Nurses

http://www.nursing.about.com/cs/painmanagement/

"Pain" is now the fifth vital sign. Use these links to discover the latest trends in the assessment and treatment of chronic and acute cancer, postoperative, back and other types of pain. Included is information on pain pharmacology and alternative therapies.

BROWNson's nursing notes - Pain Management

Excellent list of pain links.

http://members.tripod.com/~DianneBrownson/pain.html

P.S. Check out Dianne Brownson's other links.......great site, I periodically browse here.

Nursing CEUs for Pain Management

Thirty one CEU articles available here.

http://www.nurseceu.com/pain.htm

I found this site while doing a search; no experince re this company/site.

Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline.

Panel Co-chairs: Daniel B. Carr, M.D., Massachusetts General Hospital's Division of Pain Management, and Ada Jacox, Ph.D., R.N., Johns Hopkins University School of Nursing.

Guideline Release Date: March 5, 1992.

http://www.ahcpr.gov/clinic/medtep/acute.htm

2000 Oncology Nursing Today Outline

Pain Management for the Oncology Nurse

http://www.stratosinstitute.com/ONToday/ONT0001out.htm

Easing the Pain of Sickle Cell Anemia

Nursing Spectrum Magazine Articles

Lorraine Steefel, RN, MA

http://community.nursingspectrum.com/ MagazineArticles/article.cfm?AID=664

[sajaha]

It is sooooo sad that ANYBODY in this day and age have to suffer with pain. It should be criminal NOT to treat a person with chronic pain. Unless you have had to deal with it, it would be hard to understand I suppose. I come from mostly critical care background. I learned there very quickly that if you have a patient who suddenly becomes restless and/or anxious, and his vital signs change, he quite possibly could be in pain. Treat the pain, you'll have your patient back under control.

As for people with chronic pain from disease or injury, their pain needs to be addressed just as any other patient's pain would. People who have chronic pain have a poor quality of life. Treat the pain, you'll have a much more productive human being. One that could possibly work again, be a spouse, or a mother. There is absolutely no reason for a patient's pain to be ignored by any member of the health care team.

[deespoohbear]

I have tons of trouble with docs and PA's about ordering adequate pain meds. I just had a round with a PA about a pt. This patient had some nasty ulcers on her legs. I mean the kind with gangrene and necrotic tissue and muscle and tendon showing!! This pt had 25mg of Demerol IV ordered Q 4 hours! It would only hold her for about 2 hours. I tried to tell the PA that this pt's pain was not being controlled by the Demerol. He went in and talked to her and came back out and told me that she didn't have any pain. Well, I told him it might be because that I just gave her Demerol 20 mins ago! I called him 2 1/2 hours later when the pt's pain was becoming worse, and he still refused to order more meds! I wanted to pull his hair out!! I wonder what JCAHO will do in a case like that? I told my manager, but she just kind of shook her head. This little old lady was hurting. What are we suppose to do in a case like this? Our DON has no backbone and pretty much lets the docs and PA's do as they see fit. Makes it really hard to comply with JCAHO mandates when the docs and PA's refuse to comply!!

I personally believe we don't give enough pain meds. I will not hesitate to give pain meds unless there is some valid reason such as a head injury or trying to figure out why a pt is having pain. My favorite is when you have some person dying of terminal CA who is obviously in pain. And the doc or nurse won't order or give the MS because it may depress their resps! And the down side of this is? I don't believe in euthanasia, but I do believe in letting people have adequate pain relief!!

You know what will happen in a couple of years? JCAHO will probably come through and say we are overmedicating the elderly with pain meds, and everyone else under 65 is a drug seeker! LOL!!

[mustangsheba]

Pain management is one of my soap boxes. When I was in school almost 20 years ago, the criteria was the same as described here: Pain is what your patient says it is. I treat pain aggressively. In 20 years, I have had to give Narcan only twice, and those times were because the patient was intolerant of the particular medication. All the facilities in which I work have pain as the 5th VS. We don't have the 26 questions. All we have to do is prove that we've addressed and managed pain. Still, I frequently follow nurses who have not taught patients how to report pain and why it's important that it be adequately treated. Not moving, not coughing, deep breathing, or using your IS is not the way to manage pain. I have a close friend who has suffered CP for many years. Before finding someone who would treat her chronic pain, she woke up in tears, crawled to the bathroom on her hands and knees every morning because she couldn't stand, was unable to find any joy in life, and attempted suicide several times. She now takes MS Contin daily and was able to enjoy Christmas with her family for the first time in many years. Is she addicted? Is a diabetic addicted to insulin? Who cares as long as

there is quality of life. I strongly agree with several other posters that in this day and age, there is no reason for anyone to suffer debilitating pain. I saw an interesting special on some kind of sea snail whose sting paralyzes it's victims; survivors report that they experience no pain when stung. They are researching the use of this venom for treatment of pain - without the paralyzing part, of course. Has anyone else heard anything about this research?

[LindaHP]

The sea snail venom is a good idea.

My view is that in this day and age there should be some better drugs out there that are non narcotic.

This is not a black and white issue, there are lots of gray areas. I cant make a blanket statement like ALL people should have their pain down to a 1 or 2 because that might be impossible for some. It is important to put our personal feelings aside about pain control issues and look at the patient at hand. Just as I cant look at my patients and think, "oh he's going to od someday like my sister, lets not get him any pain med." Other nurses need to put their own chronic pain aside and look at the patient that is before them. Their pain might not be able to be totally controlled. Or they MIGHT be an addict. In which case they are going to have a lot of other problems besides pain.

I, as a nurse, can only go through the options that are available at this time for this patient. If I see signs of addiction, (not tolerance, but addiction) then I can address that at the time.

I cant go out there as a nurse and insist that each and every person with pain have it completely eliminated.

I do home health and I see a lot of chronic pain patients. My experience is that some need some changes in the type of pain medicine they are using.

Some get good results with things like tegretol, for example. Some get no results with demerol and good results with vicodin.

There needs to be better non narcotic drugs out there. And maybe that is coming since there is more of a market for it now. Hmmmmm....where can I buy stock in Sea Snails : )