Pain is not a "vital sign"

Love_2_Learn · Sep 19, 2009

Just as another thought, when taking care of tiny premature babies, depending on how premature they are, their vital signs changes will often be more valuable in determining their pain rather than the look on their little faces. We watch babies for their eyebrows to wiggle, tighten their eyes or show signs of crying with their mouth, but the tiniest ones can be too week muscularly to even make facial movements. Also the older preemies who have experienced pain will sometimes "give up" on crying or making facial movements signaling pain and in those cases we look at changes in their vital signs (HR, B/P, RR).

BabyLady, BSN, RN · Sep 19, 2009

There, I said it, now let the collective nursing/medical community rain fire upon me. I'm sorry, but I refuse to accept the idea that pain is a vital sign. I vital sign in a physiological response that is measurable, comparable and deviations represent a serious disruption of homeostasis. Pain is a subjective sensation felt in response to injury. The pain scale we use is useless for traditional "vital sign" purposes. I can't tell you how many times I've triaged a person with 10/10 belly pain while they sit there and eat McDonalds/doritos in front of me. I've never seen a person with a fever of 105, a HR of 180 or a RR of 40 sit there and eat McDonalds. The fact is that pain is far too subjective to be considered a "vital sign". VS are used to assess a patient's physiological condition, and are compared with normal ranges of known, universial numbers. That doesn't mean that pain is not important, because it is a useful tool. The pain scale can be used to asses the efficacy of treatment, but I don't think it's a good indication of homeostatis. For example, I once had a woman who was in a fairly minor car accident and had 4/10 side pain but she said she had a high tollerance for pain. Her spleen was ruptured. Yet our McDonalds friend is still in 10/10 pain. Without a frame of reference, the pain scale tells us little. There are a lot of other things that deserve to be a vital sign before pain does, such as pulseoximetry or blood glucose level. We care if our pt is in pain, but it should not be considered a VS... just my thoughts.

Sorry, I disagree.

Pain is not subjective...to the person that reports it...pain is a physiological response to a stimuli....just like you can have 10 people in the room that will have different heart rates, blood pressures, body temperatures, you will have people that will report varying levels of pain to the exact same stimuli.

It is measurable with proper assessement and reassessment and management.

We all don't have the same pain tolerance, pain experience, etc.

Pain can also estimated in patients that cannot speak, such as in the FLACC scale used with Neonates.

PostOpPrincess, BSN, RN · Sep 19, 2009

This post makes me think that if a nurse thinks that pain is not as important as a fifth vital sign, methinks one isn't a good nurse...I could be wrong.
I think you are misunderstanding his post. My interpretation was that the OP was not saying it isn't important, but that it does not meet the criteria to be called a vital sign. I don't think we have near enough information about him to start calling him a bad nurse, and nothing in his posts have indicated to me that he doesn't care about a patient being in pain.

From what I read in his post (OP) and having only worked ER (I believe that is what his profile states) his interaction with pain is limited to one perspective. Pain and judging pain based on what his observations from a certain population doesn't necessary mean that ALL pain is that way. A person could be sitting there just watching TV and have a high threshold and seriously have pain--without all of those visual cues/vs changes. Sometimes they just don't have that.

I have worked in the ER and remember finding an evolving MI from a diabetic lady who complained of "pinky pain." That's all she had. Nothing else. Everything was coming back normal and that was the only information we had. No EKG changes, no lab changes (yet that is.)...just pinky pain. We held her on a hunch...hours later, she had an MI.

Pain shouldn't be judged based on personal feelings alone. And if you start feeling that and distributing that assumption to non-ER populations, then you are performing a major disservice to patients in general.

A good nurse shouldn't do that; that is my two cents.

PostOpPrincess, BSN, RN · Sep 19, 2009

Sorry, I disagree.
Pain is not subjective...to the person that reports it...pain is a physiological response to a stimuli....just like you can have 10 people in the room that will have different heart rates, blood pressures, body temperatures, you will have people that will report varying levels of pain to the exact same stimuli.
It is measurable with proper assessement and reassessment and management.
We all don't have the same pain tolerance, pain experience, etc.
Pain can also estimated in patients that cannot speak, such as in the FLACC scale used with Neonates.

The neonate population suffer needlessly because those visual cues are subtle and difficult to detect. That's why it is very important, like you say, to constantly assess, manage and reassess. I totally agree.

BabyLady, BSN, RN · Sep 19, 2009

The neonate population suffer needlessly because those visual cues are subtle and difficult to detect. That's why it is very important, like you say, to constantly assess, manage and reassess. I totally agree.

An infant that has not had surgery or other invasive procedures and a soft belly, should not be in pain.

We assess pain hourly if a little tyke has had a procedure.

~Mi Vida Loca~RN, ASN, RN · Sep 19, 2009

Yes, pain is not a vital sign. I agree. I see patients, eating macdonalds with pain 10/10 nearly evey day because after Mcdonalds they want percocet for decert. There is an agenda to make as more drug addicts in our hospitals as possible. Hospitals are stealing bussiness from dope dealers. Yes, Cancer patients needs strong painkillers but I do not think so about surgery. I myself had surgery, according to docs, with very painfull recovery. After wakening up, I have not taken any painkiller and still alife.

Being in pain has nothing to do with being alive. If you have pain it doesn't mean you will die. Have you ever experienced pain that in that moment you wish you were dead??? I have! Of course I didn't really want to die but when you are in severe pain you aren't exactly thinking rationally. Because you did fine without pain killers or lived should not take away from others.

I am sure you can have your leg amputated surgically without pain medication and live. Doesn't mean you should have to experience it that way. Dope dealers seem to do just fine even with the big bad nasty hospitals in order.

sissiesmama, ASN, RN · Sep 19, 2009

I think some posters hit the nail on the head when they said "fifth vital sign" just means that it is that important and needs to be assessed for at least as often as "the other" vital signs. Pain level, in my opinion, is not a vital sign, but by calling it a vital sign it is given the attention and frequency of assessment it needs to have. Furthermore, if you have a patient with elevated vital signs (the traditional four), wouldn't it be nice to know if that patient is in pain. I do want to thank the OP for this thread, because it covers an important and ever changing area of nursing. And to those who see this as a pointless discussion - you are free to refrain from contributing.

That is how our facility takes pain as the 5th vs also. I have worked on various units from ER, Oncology, post op, ect. I understand that some staff do not feel that pain is indeed a "vs", but at our facility you are required to ask about this 5th vs on rounds when you get the other 4. We have had staff written up over this, because it is hospital policy.

When I am a patient, and I do have a recent cardiac hx and had to have surgery, the staff did ask me about this one also, and it did make me feel better in my care. I do understand drug seekers may come in and say they are at a level of 10/10 just to get their Dilaudid or whatever, but we still are required to check that 5th vs and document as per policy. Like you stated, pain level (to me, at least) is an important tool in myevaluation of my patients, and I would like to be able to tell the doc that 5th vs when he/she asked instead of having to say, "... UUMM, well, let me go check..."

I know some religions/cultures have different ways of conveying their pain status, and I would like to be able to get that information when I am getting other vs, hoping they will be comfortable telling me their level then as another vs.

Thanks OP for this thread. It is definetly a good one, with varied opinions.

Anne, RNC

JomoNurse · Sep 19, 2009

Pain is NOT a vital sign people. Let's use our noodle on this! The OP hit it right on the head. It's not objectively measurable. The ONLY reason it was taught to us recently in NS as a vital sign is because a few nursing scholars got bored and decided to recognize it as one. It's just part of our assessment as nurses. Ask an educated doctor if pain is a vital sign and he or she will sit there and laugh at you.

Nurses will argue that grass is orange if you let them, so I think it's pointless to debate this topic with eachother. We only see and believe what we want to believe :0 )

But the fact of the matter is, pain is not objectively measurable. We were all taught that pain is subjective. I find that nurses with a higher level of education (a nurse practitioner, for example) tend to agree that pain is not a vital sign. Lower educated nurses (associate's, bachelor's, for example) tend to regurgitate this brainwashed "pain is a vital sign" garbage.

I'm not trying to in anyway downplay the importance of assessing a patient's pain level, i'm just saying that it's not considered a vital sign.

Woodenpug, BSN · Sep 19, 2009

Yeah. We can reach a fair compromise by calling pain a Vital Symptom.

"Fifth sign

The phrase "fifth vital sign" usually refers to pain, as perceived by the patient on a Pain scale of 0–10.[1] For example, the Veterans Administration made this their policy in 1999. However, some doctors have noted that pain is actually a subjective symptom, not an objective sign, and therefore object to this classification."

From http://en.wikipedia.org/wiki/Vital_sign#Fifth_sign

PostOpPrincess, BSN, RN · Sep 19, 2009

An infant that has not had surgery or other invasive procedures and a soft belly, should not be in pain.
We assess pain hourly if a little tyke has had a procedure.

I was referring to surgical neonates, intubated micros and bigger, as well as those who've had procedures from IV sticks to UVAs/UVs, PICCs placed, pylorotomies, PDA fixed, etc.,

When I worked the NICU, there were many nurses who were afraid to medicate CPAP newborns out of fear and not really knowing the FLACC scale--or rather interpreting it well. Or generally just afraid of giving fentanyl or morphine to babies.

PostOpPrincess, BSN, RN · Sep 19, 2009

Pain is NOT a vital sign people. Let's use our noodle on this! The OP hit it right on the head. It's not objectively measurable. The ONLY reason it was taught to us recently in NS as a vital sign is because a few nursing scholars got bored and decided to recognize it as one. It's just part of our assessment as nurses. Ask an educated doctor if pain is a vital sign and he or she will sit there and laugh at you.
Nurses will argue that grass is orange if you let them, so I think it's pointless to debate this topic with eachother. We only see and believe what we want to believe :0 )
But the fact of the matter is, pain is not objectively measurable. We were all taught that pain is subjective. I find that nurses with a higher level of education (a nurse practitioner, for example) tend to agree that pain is not a vital sign. Lower educated nurses (associate's, bachelor's, for example) tend to regurgitate this brainwashed "pain is a vital sign" garbage.
I'm not trying to in anyway downplay the importance of assessing a patient's pain level, i'm just saying that it's not considered a vital sign.

If that's the case, there are many assessments that can include the "measurable" cues. Yes, pain is subjective, but CAN--not always--be objective as well...i.e. facial grimacing, increased muscular tension, higher heart rate, etc.,

Dismissing it altogether is also a mistake.

Pain CAN BE both objective and subjective.

Pain can be JUST subjective.

Pain can be JUST objective (note: patients intubated, paralyzed for neuro/ARDS, high frequency vents, etc.,)

Pain is the 5th vital sign.

I highly recommend that those who do not believe that it is a 5th vital sign peruse or participate in a unit that relies completely on objective signals. (ICU, CVICU, NICU, OR--anesthesia providers base their pain management on "bucking" of the vent, increase in VS alone etc.,) to a unit that relies heavily on subjective details (PACU, chronic pain management, rehab etc.,).

It is a good way to learn that one's perspective is NOT the only way.

PostOpPrincess, BSN, RN · Sep 19, 2009

I also find that this is the reason (not believing it as an imperative) that a LOT of patients end up in such unnecessary pain, or rather "continued" pain. I have often found that when I super-dose a patient (say...patient gets 4-10 mgs of Dilauded before he leaves surgery even after a simple procedure like a choleycystectomy) nurses on the other units FREAK out and never medicate the patient again; they never take into consideration that the person smokes pot, or drinks frequently and had a higher threshold to overcome.

When I do post-op rounds, I have found patients crying, in pain all night, and all the negative post-op implications of uncontrolled discomfort. It's sad.

When I see that people "brush off" pain on pre-judgments, it's a slippery slope. I truly believe it is better to err on the side of believing the patient rather than not--even if the patient has an IQ of a banana.