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.

[Hollybobs]

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.

They are using the pain scale to says "it hurts a lot".

The pain scale is only part of any assessment of pain and good starting point. You could pretty much always make something hurt more/differently. Hypothetically, if someone had been tortured for 5 days then you tortured them for 5 more days and set their foot on fire- would the first five days not qualify as a 10/10 level of pain? No-one, by the above logic could, in normal circumstances ever reach 10/10 pain.

[nutella, MSN, RN]

Part of the dilemma is that patients now also know that if they feel that their pain is severe but they give it a 5/10 instead of let's say 9/10 because their worst imaginable pain is the pain from h*** nurses will take longer to get their pain meds. By the time they arrive the 5/10 is probably a 7/10 and much harder to control.

Nurses are very busy and it is not uncommon for a patient in severe or moderate pain to wait half an hour or longer until the nurse comes with the medication after they state that they need prn.

[twozer0, NP]

If I could only break out my pain lecture... Physiologically it is impossible to sleep through C fiber pain since part of its pain pathways end in the reticular complex (pons/medula) area of the brain (this is chronic, deep rooted, chemically mediated pain). This area is responsible for sleep/wake and as a result, if your patient is sleeping it can be concluded that adequate pain management has been acheived. A delta fiber pain can be slept through albeit lightly but if your patient is snoring there is no way physiologically they can be having that much pain. At this point they are just trying to feel high.

We could get into this in more detail but this is the basics.

[anh06005, MSN, APRN, NP]

They are using the pain scale to says "it hurts a lot".

The pain scale is only part of any assessment of pain and good starting point. You could pretty much always make something hurt more/differently. Hypothetically, if someone had been tortured for 5 days then you tortured them for 5 more days and set their foot on fire- would the first five days not qualify as a 10/10 level of pain? No-one, by the above logic could, in normal circumstances ever reach 10/10 pain.

I would accept any traumatic event or acute situation as 10/10 pain. I guess I should have clarified: when people want me to give them more pain meds for 12/10 pain for chronic knee issues when they are already obviously groggy and hypotensive (had a similar patient recently/fresh on my mind).

I didn't mean to paint everybody with a broad brush and I'm always happy to refer to pain mgmt for chronic pain for them to do the job right with (hopefully) a combination of pharm and non pharm therapy.

I know none of us will all agree on the topic of pain buuuut it's hard to believe some of these people. Like the ones whose hands/wrists hurt too bad to even WRITE yet digs through a bag and uses a smart phone to text/play games with ease. PART of a pain assessment can be objective.

[Lad345]

Something I've also noticed is inadequate maintenance. Get more things involved earlier. Take advantage of synergists and adjuvants in the realm of pain; we've got more options than just opioids. Yeah, dilaudid will relieve them but I've had pts scared to sleep BC of their short-acting wearing off and waking up backtracked with their pain. Most physicians are good about coverage, but every now and then I get a doc adamant about yanking them clear off q2 dilaudids and going straight to q4-6 oxys. I just don't feel that's appropriate for pts that have documented pain.

We use bridge therapy with heparin/coumadin. I think its worth adapating the model for pain management.

[Hollybobs]

I would accept any traumatic event or acute situation as 10/10 pain. I guess I should have clarified: when people want me to give them more pain meds for 12/10 pain for chronic knee issues when they are already obviously groggy and hypotensive (had a similar patient recently/fresh on my mind).

I was responding to the bit about the hammer.

I agree with the pharm & non-pharm therapy management, a holistic management of pain and a good use of the range of analgesia, not just narcs. If a patient is routinely receiving intravenous narcs on a general unit then their pain and/or expectations are being poorly managed. (I don't mean a post-op self-controlled drip or palliative cancer pain syringe driver).

I would find it hard to objectively assess another human's pain, I wouldn't know how to do that for my my assessment.

[NurseGirl525, ASN, RN]

Oh yay, another discussion on pain, where other people want to sit there and judge somebody else's pain because they all know the patient's body better than the patient.

My my question to the OP is, do your supervisor's know you are refusing to recognize pain as the fifth vital sign? Being anonymous on the Internet and putting it all in caps is one thing, but when you make a statement like that, make sure your employer knows so they can know how to appropriately deal with it. They need to know in case you chalk somebody's pain up to being what you deem a seeker, refuse to accurately chart, and something gets missed, and a patient dies.

Everybody reacts to pain differently. Their demeanor will be different. It all depends on the pain they regularly deal with on a daily basis. I'm so saddened by the comments on here.

[MunoRN, 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!

That's not really how opiates work. While it's true that the euphoric/impairing effects relative to the analgesic effects are strongest in someone who is opiate naive, the decrease is relatively small and certainly doesn't go away completely.

Finding an opiate that will only act on mu pain receptors is the holy grail of pain meds, and is basically what tramadol does. Although what we've found is that the euphoric effects play a major role in how someone perceives their pain, and without it they aren't considered as effective.

If the opiate is able to affect pain then by definition of how it works it is also providing some degree of impairing effects. There's no evidence that at even properly prescribed doses opiates have no impairing effects, but there is quite a bit of evidence that those taking opiates as prescribed are at much higher risks for accidents and injuries. We also know that people who are impaired are not good judges of their own impairment, which seems pretty obvious if they are impaired. It's similar to saying someone who's drunk is a reliable judge of whether or not they are impaired.

[kakamegamama]

If I could only break out my pain lecture... Physiologically it is impossible to sleep through C fiber pain since part of its pain pathways end in the reticular complex (pons/medula) area of the brain (this is chronic, deep rooted, chemically mediated pain). This area is responsible for sleep/wake and as a result, if your patient is sleeping it can be concluded that adequate pain management has been acheived. A delta fiber pain can be slept through albeit lightly but if your patient is snoring there is no way physiologically they can be having that much pain. At this point they are just trying to feel high.

We could get into this in more detail but this is the basics.

More, please! This was a great refresher on pain--thanks!

[bgxyrnf, MSN, RN]

Please do not misunderstand: I am all in favor of assessing pain and treating it as appropriately.

I found Muno's post very informative.

I think this was mostly a rant provoked by another stint in the ED where nearly everybody labels their pain as a 9 or a 10... I get so tired of it and its meaninglessness.

I suffered a severe and gruesome orthopedic injury and can say that I empathize with pain. I will also agree that I see undertreated pain, particularly from our bone docs. But to consider pain as being "what the patient says it is" is counterproductive, at least if we're going to feel compelled to treat it based on "what the patient says it is."

[MunoRN, RN]

If I could only break out my pain lecture... Physiologically it is impossible to sleep through C fiber pain since part of its pain pathways end in the reticular complex (pons/medula) area of the brain (this is chronic, deep rooted, chemically mediated pain). This area is responsible for sleep/wake and as a result, if your patient is sleeping it can be concluded that adequate pain management has been acheived. A delta fiber pain can be slept through albeit lightly but if your patient is snoring there is no way physiologically they can be having that much pain. At this point they are just trying to feel high.

We could get into this in more detail but this is the basics.

C fiber pain typically refers to nueropathic pain, pain that responds well to opiates is not C fiber pain. One of the most damaging myths that interferes with appropriate pain management is that someone can't be in pain and yet sleep. You absolutely can be in pain, even in severe pain, and still sleep. It tends to be a different quality of sleep, and certainly reduced quantity of sleep, but please don't feed the myth that someone who can sleep shouldn't be medicated for pain.

[smartassmommy]

Could a solution to this be a standard of practice requiring a referral to pain management after a set number of narcotic scripts are written?