The Fifth Vital Sign

[bgxyrnf]

It seems that I can rarely peruse the news in any fashion without reading about the 'epidemic' of opioid-related deaths. I know that we regularly see OD'd patients in ED.

Let's go ahead and say it: pain is *NOT* the fifth vital sign and this push to insist otherwise is a classic example of unintended consequences.

Rather than trying to confront the unfortunate truth that pain is something that we often need to learn to live with, we instead look to push the idea that every police officer should carry naloxone and a nasal atomizer. We're seeing Superbowl ads marketing medication to help treat another common narc side-effect that we see in the ED: severe constipation.

I'm sorry. Pain does suck (I speak as a chronc pain sufferer myself) and *limited* use of narcs can be helpful but let's put it in its place...

PAIN IS NOT A VITAL SIGN AND I REFUSE TO CONSIDER IT SUCH.

[Penelope_Pitstop, BSN, RN]

I have literally had patients that nobody would write transfer orders for because of the amount of IV narcotics the patient was receiving, which is a RIDICULOUS reason to keep someone in critical care. I'd try to call report when I did get transfer orders, I'd mention a dilaudid/fentanyl drip running at really high levels, and get the "Hold on, let me talk to my charge real fast, I'll call you back," and before you know it, the transfer would be cancelled.

I've done both floor and ICU.

As an ICU nurse, I would NOT allow a patient on a Dilaudid gtt to go to the floor.

That is NOT a floor patient. A low-dose PCA, yes, that is fine, but an actual Dilaudid gtt? Better be a hospice patient. Floor nurses do not have the ability to successfully monitor someone on that.

And then there would inevitably be one of those dreaded RRT calls you describe. And are Dilaudid or Fentanyl gtts allowed on your MedSurg floors? That could be part of the "problem."

[Lad345]

Where I live, I feel OK with my meds. My pts are specialized sx: Whipples, Islet auto transplants, fem-pops, flaps, liver lobectomies, some pancs/choles, stepdown level s/p CABGSs, aneurysm repairs, and wound washouts. I set up buv/epi epidurals, dilaudid PCAs, and OnQs nonstop. Initially they get high doses, but with the gradual wean off dil we start bringing things like gabapentin, robaxin, and roxi in. We do pretty good job of sending them home with just robaxin and roxi 10mg q6h.

I've noticed that when I float to GenMed floors, especially GI Med, I give an unjustifiable amount of "maintenance" narcs: morphine, oxycontin, dilaudid, roxis, and percs. Scarily enough, sometimes two of the opiods arent just present they are *scheduled* Also a side of ativan with a phenergan chaser. And don't dareb forget my nighttime xanax, 930 at night, exactly. And they have hx of multiple SBOs, but what can you do. You know they will not part with getting the meds. And, really, how do you even get them off all that stuff anymore? Especially with the huge chunk of HCAHPS devoted solely to "pain".

It can be demoralizing at times, push after push after push alllll shift long. A shift on our GenMed GI unit makes me feel like I just spent 12 hr accomplishing nothing more than getting people high

[Penelope_Pitstop, BSN, RN]

I've noticed that when I float to GenMed floors, especially GI Med, I give an unjustifiable amount of "maintenance" narcs: morphine, oxycontin, dilaudid, roxis, and percs. Scarily enough, sometimes two of the opiods arent just present they are *scheduled* Also a side of ativan with a phenergan chaser. And don't dareb forget my nighttime xanax, 930 at night, exactly. And they have hx of multiple SBOs, but what can you do. You know they will not part with getting the meds. And, really, how do you even get them off all that stuff anymore? Especially with the huge chunk of HCAHPS devoted solely to "pain".

It can be demoralizing at times, push after push after push alllll shift long. A shift on our GenMed GI unit makes me feel like I just spent 12 hr accomplishing nothing more than getting people high

When I was a new grad, almost ten years ago, I worked on an honest-to-goodness medsurg floor (fifty fifty medical and surgical patients) and had seven or eight patients every night. I felt like all I did was push Dilaudid, Benadryl, Ativan and Phenergen. I also worked in a city with a HUGE drug problem so a lot of my patients started off being quite tolerant.

What was my point? Oh yeah...that healthcare system has ix-nayed with the IVP Phenergen. That helped...somewhat. People don't set their cell phone alarms for their next Zofran pushes!

[Penelope_Pitstop, BSN, RN]

It's been my experience that a lot of people really don't understand the pain scale.

Amen!

When I've been a patient, I can't even begin to fathom what my pain is on a scale of 0-10. I despised asking the question! It was nice when I worked in ICU and could go based on MY assessment and the vital signs.

[heron, ASN, RN]

Pain management and addiction are certainly related issues, especially if one considers addiction as a particularly dysfunctional way of managing pain. Both are very complex, poorly understood and too often conflated.

The picture is further complicated by the unspoken assumption that pain tolerance and addiction are indications of character and moral goodness, rather than biochemistry and conditioned behaviors.

As Muno pointed out, early and consistent pain relief, including scheduled med dosing for prolonged pain, is far more effective in preventing over-use of opioids than a scattershot approach that forces us to play catch-up all the time. Pro-active works better than re-active.

How that plays into the whole issue of addiction and pseudo addiction is a whole other thread.

[iluvivt, BSN, RN]

When you have chronic pain and are being treated with narcotics you do become dependent on the medication and that is very different than being addicted.If you are using your medication as prescribed you do not get a high feeling nor do you feel impaired. You can actually function and focus better because your mind is off the pain and your level of stress is much lower as you are not searching for a way to get some relief!

[dinah77, ADN]

I disagree that pain is totally subjective. When someone claims they're in 10/10 pain while calmly texting and VS are WDL, I think it's pretty evident they're not

[Rexie]

I disagree that pain is totally subjective. When someone claims they're in 10/10 pain while calmly texting and VS are WDL, I think it's pretty evident they're not

I think at times it's pretty evident they're lying, or perhaps they really don't understand what 10/10 means.

[heron, ASN, RN]

I disagree that pain is totally subjective. When someone claims they're in 10/10 pain while calmly texting and VS are WDL, I think it's pretty evident they're not

No, actually, it's not evident at all. If the only factors you consider when assessing pain are demeanor and vital signs, then you aren't assessing anything but your own preconceptions.

[kbrn2002, ADN, RN]

I work in LTC and over the past six months our primary provider started decreasing and in many cases discontinuing long term narcotics. Not a single resident had an adverse effect from the reductions. No increased pain subjectively stated or objectively observed. No increase or changes in anxiety levels for residents that had those meds decreased or changed to non-narcotic options. PRN use of meds for breakthrough pain has not increased and in fact has decreased. So from personal observation I would have to agree that over prescription of these meds is not necessarily a good way to manage pain.

[anh06005, MSN, APRN, NP]

When someone say their pain is 12/10 (like they do) and they are sitting calmly it's tough to believe them. I understand chronic pain patients do learn to live with their pain but I always want to ask if I took a hammer to their foot what would their pain be then? Comparable to where their pain sits day in and day out or worse? If it's worse when I take a hammer to their foot (hypothetically) then they are NOT maxed out on the pain scale.

[Here.I.Stand, BSN, RN]

When someone say their pain is 12/10 (like they do) and they are sitting calmly it's tough to believe them. I understand chronic pain patients do learn to live with their pain but I always want to ask if I took a hammer to their foot what would their pain be then? Comparable to where their pain sits day in and day out or worse? If it's worse when I take a hammer to their foot (hypothetically) then they are NOT maxed out on the pain scale.

A hammer to the foot is also an example of very acute pain...which nobody would have developed coping skills for.

I am not a chronic pain sufferer, but have friends and family members who live in pain every day, every waking moment. And no, they don't act like someone just took a hammer to their foot.

I actually find hyperbolic illustrations of "10/10" annoying. On one occasion I rated (acute) pain 10. It was a post-traumatic spontaneous corneal erosion. Yup, a sore eye. Again just my opinion and experience as a pt, but I would have been pretty upset if a nurse had said "Well a 10 is the worst pain you can imagine, like if someone cut your legs off and set you on fire." No, I just said it was a 10 beecause I am in agony and that scale is one way I had to convey that.