Is pain still the "5th Vital Sign"?

Meriwhen, ASN, BSN, MSN, RN · Dec 7, 2012

I still consider it the fifth vital sign, because you'd be surprised how many people WON'T volunteer that they're in pain...often because they don't want to seem like a bother, they don't want to be labelled a drug-seeker, or are trying to "tough it out." I feel that asking about their pain gives them an opportunity for them to tell me about it without feeling like they're imposing on me. I think it also reassures them that they don't have to try to be heroes and suffer in silence.

Even on the days in outpatient, it's become my habit to ask about pain as I put the cuff on their arm.

hiddencatRN, BSN, RN · Dec 8, 2012

BP, HR, RR, SpO2, Temp. I count 5 there. I don't think of pain as a vital sign. It's an assessment. An important one, but an assessment rather than a sign. As far as encouraging drug abuse, all the current research I've seen on pain management suggests that other factors are in play when it comes to addiction and that we are often still under-treating pain (particularly in peds).

I'm still surprised how many patients won't mention anything about pain or discomfort until asked directly if they have any.

Sun0408, ASN, RN · Dec 8, 2012

I thought pain was the "6th vital sign" but either way, I do ask.

SuzieF · Dec 8, 2012

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.

ThePrincessBride, MSN, RN, NP · Dec 9, 2012

Yeah, I was just about to say it is still taught as the sixth vital sign with respirations, 02 sat, temperature, blood pressure, and pulse rate being the other signs. And yeah, a nurse should always as if the patient is in pain and to rate it. As a PCA/SNA, I ask if they are in any pain and to rate it so that I may inform the patient's nurse promptly.

Penelope_Pitstop, BSN, RN · Dec 9, 2012

When I was a new grad, we didn't use Sp02 as a routine vital sign, so pain *was* the fifth vital sign. We checked Sp02 per our judgement.

turnforthenurse, MSN, NP · Dec 9, 2012

I'm still surprised how many patients won't mention anything about pain or discomfort until asked directly if they have any.

I've noticed this too. I had a patient go into non-sustained v tach, so I went to check. The patient was awake but sleepy. They said they are okay, but as soon as I asked if they are experiencing chest pain, they say to me, "now that you mention it, I am having chest pain!" :facepalm:

Regardless, a nurse should always assess a patient for pain. I was taught it was the 6th vital sign in nursing school, but I consider it more of an assessment rather than part of the vital signs.

Altra, BSN, RN · Dec 10, 2012

I am sure that the original “pain campaign” probably originated with evidence-based research. It would be interesting to now see the data of how prescription drug dependency has changed in the last decade after the “pain campaign.” I was a newer nurse when it all started, but I don’t remember seeing as many medication dependent patients before then.
I am just wondering what you guys and gals think?

I agree that medical culture has changed. It is now the goal, and the expectation, for patients to be pain-free. This is a very different concept than that of pain control.

Outpatient prescribing for self-limited conditions/injuries is out of control, as is acute care administration of IV narcotics.

Aurora77 · Dec 10, 2012

I agree that medical culture has changed. It is now the goal, and the expectation, for patients to be pain-free. This is a very different concept than that of pain control.
Outpatient prescribing for self-limited conditions/injuries is out of control, as is acute care administration of IV narcotics.

As a post op nurse, I find this incredibly frustrating. Most people understand that it's impossible to be entirely pain free after having major surgery but some people just don't get it. I send a lot of time doing patient teaching on pain management, stressing the fact that it is management not elimination. On the other hand, I also stress the importance of evaluating treatment and if the pain control regimen we're using isn't working, I'm happy to call the doc.

SuzieF · Mar 1, 2013

As a post op nurse, I find this incredibly frustrating. Most people understand that it's impossible to be entirely pain free after having major surgery but some people just don't get it. I send a lot of time doing patient teaching on pain management, stressing the fact that it is management not elimination. On the other hand, I also stress the importance of evaluating treatment and if the pain control regimen we're using isn't working, I'm happy to call the doc.

Aurora77,

I agree, it is all about pain management, not elimination. I also do not hesitate to call the doctor if the pain management regiment is not effective. I often suggest the use of Toradol. I have very often seen it work when the big gun narcotics are not cutting it. It is a wonderful adjunctive, or even primary pain medication.

Suzie

Double-Helix, BSN, RN · Mar 1, 2013

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.