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.

[FurBabyMom, MSN, RN]

After my father had surgery, one of the anesthesiologists I work with got upset with me for explaining that I felt my father was exaggerating his claims of pain (I was telling a story about part of my father's post op course). I tried very hard to explain that when you know someone really well you CAN tell when maybe they're not being 100% truthful. You learn their tells, and how they handle things in general... I explained that if I were indeed the NURSE in that situation, I would treat it and take it as true. As the DAUGHTER, I can be skeptical at least a little. I did not suggest my father not be medicated, but I expressed skepticism at the severity of it all. (I would never do this if I were the assigned nurse and not a close family member)

When I was in the ED for appendicitis - they tried to WAY over medicated me. To be honest, the first dose of IV morphine was enough to make the pain tolerable. They kept offering more IV narcotics...like a lot. The zofran only helped some, my biggest complaint waiting in the ED and OR Holding was my nausea (made me feel like I needed to vomit, which would cause me to feel like I might need to move causing my pain to bother me as my pain was well controlled unless I was moving). I did ask for phenergan - because I got minimal relief from the first dose of zofran, and then a second dose of zofran before it was my turn for surgery.

I *will* say this. I do think it is easy to assume we know it all based on the 5 minutes we interact with someone that hour. It was a struggle not to do it when I worked the floor.

[Double Dunker]

People don't set their cell phone alarms for their next Zofran pushes!

Actually, they do. Especially if they can have it along with IV bendadryl and dilaudid.

[twozer0, NP]

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.

Nowhere did i mention that you cannot have pain. I expressed that the pain should be considered adequetly treated if the patient is asleep. C fiber pain is unmyelenated and yes opiates help. If you want more on this ill be happy to provide more with several references.

[MunoRN, RN]

Nowhere did i mention that you cannot have pain. I expressed that the pain should be considered adequetly treated if the patient is asleep. C fiber pain is unmyelenated and yes opiates help. If you want more on this ill be happy to provide more with several references.

Pain should not be assumed to be adequately controlled if the patient is able to sleep, again, it's well established that sleep is possible even with severe pain. The perpetuation of that myth leads to poor control and unnecessarily excessive opiate administration. Pain makes it harder to sleep, but at some point most patients will sleep regardless of pain severity.

Please do provide references that support the claim: sleep always equals adequately treated pain.

[twozer0, NP]

Pain should not be assumed to be adequately controlled if the patient is able to sleep, again, it's well established that sleep is possible even with severe pain. The perpetuation of that myth leads to poor control and unnecessarily excessive opiate administration. Pain makes it harder to sleep, but at some point most patients will sleep regardless of pain severity.

Please do provide references that support the claim: sleep always equals adequately treated pain.

When i get time tomorrow ill break it down for you. Hard to type all of this on my phone.

[Pat_Pat RN]

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.

A vital sign can be objectively quantified. Pain can not be, therefore should not be considered "the 5th vital sign."

[Been there,done that, ASN, RN]

"we instead look to push the idea that every police officer should carry naloxone and a nasal atomizer. "

You may not want to realize pain as a fifth vital sign.. but you are not realizing the truth behind the opioid epidemic.

[staceemichelle]

The biggest problem is "drug seekers". We, as nurses, have lost all control over a real assessment of pain due to government mandates. I would love to give a massage or provide patients with alternative pain control measures, however, since according to JCHAO "pain is what the patient says it is" I must treat the pain with medication prescribed, when anyone off the street can tell that a pt complaining of a headache with all the lights on, the tv blaring, and talking in the phone is NOT a 10/10 pain. My biggest frustration in nursing is wasted time giving narcotics to a patient that "likes" the feeling that IV pain medication gives them. For crying out loud let me take care of the patients that need care, not mandating that I give a person a "fix"

[ClaraRedheart, BSN, RN]

I once pushed 2 mg of dilaudid to a sickle cell patient who was listening to this: https://www.youtube.com/watch?v=ySRGTtcAzgI I never felt like such a drug pusher. Luckily, I don't see opioid addicted patient's often. It can burn you out.

[RNdynamic]

I agree that pain is not a vital sign. Vital signs are objective, not subjective, and they are values that indicate how well or poorly someone's body is functioning.

I agree pain needs to be given special consideration, but calling it a vital sign is just daft.

[RNdynamic]

IMH (umble)O, we need to solve these two problems before starting to teach people to suck it up and live with it. As right now, everything a proverbial Joe the Plumber who pulled his back three months ago while cleaning the toilet in your house can get for his now officially chronic low back pain of 6-7/10 is that Vicodin script from your ER.

Unfortunately the USA is a culture of pain. The amount of narcotic scripts per capita is the highest in the world, scores higher than any other first world country. Legions of Americans have an expectation that their life must be completely pain free and that any sort of discomfort or pain is a problem that must be medicated immediately, or else they cannot function. This is as true for the pregnant mom who wants narcotics for "back pain" throughout pregnancy, to the occasional headache, to getting a C-Sec because they're afraid natural childbirth will be too unpleasant.

[heron, ASN, RN]

I once pushed 2 mg of dilaudid to a sickle cell patient who was listening to this: https://www.youtube.com/watch?v=ySRGTtcAzgI I never felt like such a drug pusher. Luckily, I don't see opioid addicted patient's often. It can burn you out.

Don't get me started on sickle cell patients - try having a total body infarct r/t a lifelong and life-limiting illness sometime, then come and tell me allll about drug-seeking. I agree that it can burn you out - but I think that we need to be careful to not set up a vicious cycle of behavior>assumptions>rejection>behavior>power struggle.

The combined dynamics of chronic severe pain and the development of an addiction/pseudo addiction - which is not the same as tolerance - are complex and very difficult to sort out in the setting of an acute exacerbation. I hate seeing that over-simplified. It's bad for the patient and bad for us (none of us wants to be ineffective, angry or hostile!).