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.

[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.

https://allnurses.com/general-nursing-discussion/understanding-pain-pathways-1036856.html#post8906596

Here you go. Inside this lengthy writeup I discuss the physiology of pain and how sleep does mean the patient is not perceiving pain.

Some other things to note. I teach lectures on this stuff to my colleagues including understanding pharmacological interventions. I work directly beside Anesthesia daily, of which I have gone over things like this with them numerous times. The article I linked I typed up here at work with limited resources but I'll think you'll understand. I dont understand how perpetuation of a myth that you made up of a patient sleeping and pain equates into more opiate use? Enjoy!

[LTC_LPN2]

Tell that to the survey folks who question the Residents they interview regarding pain location, Level of pain, Nurse intervention? Effectiveness? And then have one tell them you don't give it because "you think" living with pain is doable and becomes justifiable because the risk of opioid induced constipation is far greater and because your opinion is golden...won't go to well and not how it works. Give the folks their prn pain meds for Christ sake; Tylenol, monitor, then assess for effectiveness; then go to the heavier more potent prns if pain isn't relieved, no order, get one!...I be damned If I allow a resident with cancer metastasis to suffer because of my opinion on the subject. They will get his prns as needed and pain patch q 3 days until hospice takes over...I'm not in service to me I'm in service of others! pain is a vital sign that must be charted on the Mar, pain flow sheets, and charted in their record with end result; effective or not?...repetitive entries? Even..I'm a little opinionated on that one. Sounds as if you have seekers that worry the crap out of you being at the cart every 4 or 6 hours on the dot while laughing through a voiced level 8 rating of pain....narcotic seeking is considered a behavior...notify dr, document it and follow up with POC...

[nutella, MSN, 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.

Sickle cell is a terrible illness and can be very disabling, result in severe pain, and death for some.

Unfortunately, some of those patient get labeled as "drug seekers" when in fact they fall under the category of "pseudo addiction" - where a pat has severe pain but the signs,symptoms, and request for pain relief are misinterpreted as drug addiction behavior. I also feel that there is a lot of hidden racism and stereotyping because "white" people are typically not among the ones who get sickle cell.

[CathySweeney]

In reading the many comments about pain management and chronic pain all I see is the use of narcotics. Good pain management is not about narcotics only. The use of other types of meds in conjunction with narcotics is crucial to pain management. Anti-seizure medications such as Gabapentin for nerve pain, anti-inflammatory meds such as ibuprofen for bone pain can make a huge difference. I have seen people whose narcotics were just not working get relief from adding one of these meds. I have chronic pain and have managed my nerve pain for years with the use of Gabapentin or Lyrica (rotated) and Cymbalta (anti-depression meds work for nerve pain) with a back-up of Vicodin to be used when necessary. When hospitalized I am very concerned that someone will change my pain meds and will not allow that to happen. I have been seeing a "pain" doctor for years and we work together to manage my pain with minimal use of narcotics. It can be done by seeing the right doctor.

[Ellie G]

Of course there is pain and pain. But let me tell you that as a palliative and hospice nurse I see under treated pain all the time! Pain management is often not done well.

Of course pain is not a VS like BP - I think it is more of a metaphorical idea to illustrate the important of pain assessment.

What I do notice is that pain is addressed often too late and once out of control or severe hard to catch up on. Or insufficient amounts (in the community as well as the hospital).

as a hospice nurse, pain is something you work to relieve regardless of any fears of addiction or dependence and that is appropriate. I think the OP was considering the people who come in, state their pain is a 10/10, are allergic to everything but dilaudid and are eating from a bucket of KFC and going out for a smoke. Is it right for us to feed these people's addiction?

[1sttime]

I can tell you as someone who was both practitioner and patient under this brilliant idea that I will never again fall for some administrative push to change nursing practice.

1) There are so many outside interests that want to change practice to make money- when nursing care is really about the basics.

2) I became addicted to opiates as a direct result of an MD who bought into the hype.

These unilateral policies, and the resulting swings the other way (Opiates for everyone! now Opiates for none!) are harmful to people, patients and practitioners alike. See also beta-blockers for all in evidence based practice- talk about mortality

[CathySweeney]

I have read what was written. I was taught in hospice, in my ELNEC training and in maany classes taken that a person may be sleeping and still have pain. The quality of the pain may not be good but sleep may be present anyway. I can tell you that when I am having a bad pain day sleep helps me get through. Yes I am on meds to control my pain and also have hydrocodone and apap for break through pain but like to avoid the use of the opioid. When pain is bad I will take the opioid about every 5 hours with no more then 4 a day. Sleeping when I can sometimes because I have found a position to decrease the pain but movement will bring the pain up to 8-10. I move very little when I sleep unless things are really bad and then I toss and turn.

We need to find a way to assess if a person is abusing opioids or in real need of them so we can believe our patients. Until that day I will believe my patients and discuss any doubts with the team (doctors, nurses, social workers and pastoral care) to form a plan to make any changes. Using opioids as a first line pain medication is not the best way to go unless the person is dying. We had an axiom in hospice "start low and go slow" to provide pain management for most patients.

[enc123]

I couldn't agree with you more. Pain is more often than not under treated and stigmatized and people are stereotyped. I am a nurse who started off as a molecular biologist now moving into the NP realm and guess what my specialty will be? Pain managment. Yes I know there will be the drug seekers but as someone who suffers chronic pain and severe acute pain as I have Sickle Cell Anemia one of the most misunderstood pain diseases out there you can bet that I will do my research and make sure I care for my patients to the best of my ability. Post like this really upset me because if the assessment was performed thoroughly and correctly doling out narcotics to a patient in pain wouldn't be that taboo. I can't tell you how many times when I myself have been in the hospital in an extreme amount of pain and my physician has ordered for me to have a large IV push of Dilaudid the pushback that was recieved but after I received the dose and nurses took time out to really look at me they recognized there was no faking here. I have been given 16mg Iv push of dilaudid at once and I remember I myself giving that same IV push to a palliative patient and still watching her cry out in pain until her body gave out and she died later that day. I recieve treatment from the same group of nurses and doctors so it's not an issue now so I dread the day I have to move to a new city and come across the doctors and nurses who don't understand and don't care to understand and let my pulse jump back to 170 and watch me sweat profusuely and writhe in pain crying hysterically as pain pulses threw my body because they think I am that sickle cell patient who just want narcs.

[enc123]

Yes exactly!!! I take 200 mg morphine ER BID and I do not get high. Yes it is an extended relief providers not in palliative do not understand that. the moment I show my medication to a new provider I get "OMG you take this much how do you stay awake!?" Well first of all it's MS contin ER so no there isn't a high that goes along with it you can function. I am wide awake not impaired and this is why my doctor started me on it so that I could function in my science role then as I moved into the RN role my manager and I contacted the board to make sure this was okay and they stated I would be more impaired if I had to work in pain. What all healtcare providers need to learn is that MS contin ER is not the same as IR and when you take this daily your tolerance builds up and tolerance is not synonymous with addiction.

[enc123]

I have read what was written.

We need to find a way to assess if a person is abusing opioids or in real need of them so we can believe our patients. Until that day I will believe my patients and discuss any doubts with the team (doctors, nurses, social workers and pastoral care) to form a plan to make any changes. .

But we do have some ways to determine this. We can take a look at vitals. More often than not when a person is abusing the narcotics pulse rate is going to drop bp is going to drop and you see the classic falling asleep mid sentence. I am not saying you can not sleep while being in pain. I have sickle cell of all things and when I am in the throws of a crisis that is a "10", believe me there is no sleeping I am moving back and forth and crying with tears streaming down my face, my bp is elevated my pulse is usually 165+ and I sweat profusely because the pain is so bad. Picture a women in labor in the final stages where contractions are coming often and she's sweating and trying to breath threw that pain. That is my 10. I understand the pain scale so when I am in a bad crisis that make me go to the hospital its usually an 8-10. symptoms like these are indicators. Once my crisis has made its way down to a 5 if you give me that 16 mg iv push dilaudid my bp is going to drop my pulse will drop etc. This is when dosages can now be adjusted. My pain management doctor always said if you are in true severe pain you won't OD because the pain receptors will be there to take up the medication. Once you fall asleep then you won't push that PCA button in your sleep and this is why we tell family members not to so all of the assessment techniques are there we just need to utilize them in healthcare and we arent. We are just seeing everyone the same and saying well this is a high dose it would stop my breathing and we are failing to see that some people may have developed a tolerance and someone elses pain may be more.

[heron, ASN, RN]

There is widespread ignorance in our profession around opioids that makes nurses terrified of the numbers - but I think that's another thread.

What really concerns me is the polarization - the black and white thinking I see in all of these threads. One side insists that pain is real and presents in complex and highly variable ways. The other side insists that addiction and its associated behaviors exist and are worsened - enabled, if you will - by the ignorant or uncritical use of opioids/benzos or whatever.

Well, please pardon the yelling but, BOTH ARE TRUE AND OFTEN EXIST IN THE SAME PATIENT AT THE SAME TIME.

Pain is a fundamental survival tool, built into every living organism more complex than an amoeba. It is our built-in early warning that badness is happening. Ignore it at your peril. Yes, it IS the 5th vital sign.

At the same time, unrelieved pain carries it's own adverse effects, including depression severe enough to lead to suicide. This, along with simple compassion, mandates that pain be effectively relieved as much as possible.

None of that changes the fact that many of the chemicals that relieve pain also alter mood and can result in a whole host of dysfunctional behaviors aimed solely at repeating or perpetuating the fun. AKA addiction. Nurses bear the brunt of those behaviors because we have the drugs. It wastes our time and wears us out.

Focussing exclusively on dysfunctional addictive behaviors or trying to address pain with a single chemical tool are both ignorant over-simplifications. Not to mention damaging - possibly abusive - to the person actually experiencing the pain.

It's time we started really doing the critical thinking we all like to brag about.

[Ellie G]

Those same symptoms of sweating, high pulse, resp and BP can also be symptoms of withdrawal. It is extremely important that an accurate determination can be made. Nurses are often afraid to give the high doses of pain medicines. With a PCA there is less likelihood of overdose and now with capnography monitoring less likelihood of oversedation. Anyone with chronic severe pain should have a pain management consult. My own 84 year old mother suffered chronic pain for sometime and had been taking Vicodin as prescribed. When she had her total knee done her pain was severe and unrelieved because they were convinced this little 5 foot tall 80+ woman should not need ATC Percocet or morphine for her post-op pain. She was under medicated and in a great deal of pain until they referred her to a pain management specialist. Eventually after getting home she had to wean off the Vicodin because she had become physically dependent to some degree. That dependence did not negate the fact that she should not have had to be in agony before being medicated whilst in the hospital.