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.

[Horseshoe, BSN, RN]

NSAIDS act in a completely different way and there is a big chasm between the two types of receptors on which they act, plus they carry their won set of long term complication like heart disease.

I work in an endo facility, and I wish I had a dollar for every time I heard a doc tell a patient with a bleeding ulcer to get off all NSAIDS.

What the heck are these people supposed to do? Many of them have tried everything-including the holistic measures like acupuncture, meditation, other "distraction" techniques, etc. And still have life altering, attitude-killing, chronic pain. I really feel for them.

I don't know how these people cope. The few times I've been on a vicodin regimen, it SOOO screwed up my digestion. It seems like people on long term narcs would by necessity become obsessed with how to score their next normal bowel movement, forget scoring their next narc. Really, that stuff does a number on me. No way would I be able to do it long term.

[twozer0, NP]

I work in an endo facility, and I wish I had a dollar for every time I heard a doc tell a patient with a bleeding ulcer to get off all NSAIDS.

What the heck are these people supposed to do? Many of them have tried everything-including the holistic measures like acupuncture, meditation, other "distraction" techniques, etc. And still have life altering, attitude-killing, chronic pain. I really feel for them.

I don't know how these people cope. The few times I've been on a vicodin regimen, it SOOO screwed up my digestion. It seems like people on long term narcs would by necessity become obsessed with how to score their next normal bowel movement, forget scoring their next narc. Really, that stuff does a number on me. No way would I be able to do it long term.

COX 2's homie!

[MunoRN, RN]

Maybe you just didn't read my write-up. Pain is not objective, its subjective. You cannot express pain if you are asleep (you're unconscious). Since pain is a perception and how we treat pain is based on how a patient is expressing discomfort, how do you suggest they have a 10/10 pain if they are sleeping (its impossible). The second article was to show that people having pain do not experience sleep, it does not mention pharmacological intervention, it was used to help provide framework. Put it this way.. if you give opiates (or even multi modal approach) to a patient and they fall asleep, do you keep pushing narcotics on them? I dont because perceived pain is controlled and we risk running into airway issues. I can understand if this is a hard concept to grasp. You keep pulling at straws here.

Central modulation of pain

neurosurgical and medical management of pain by brisman

I did read your write-up and I get the gist of your hypothesis, but using your hypothesis as the reference to support your hypothesis is scientific quackery. While the source in your previous link does reference the relationship between sleep and pain, specifically that reduced sleep quantity and quality modulates the pain experience, it makes absolutely no claim that pain completely blocks the ability to sleep, particularly the broad definition of sleep that would be included a nurse's observation of a patient "sleeping".

If you are really intent on disproving the currently accepted knowledge of pain and sleep such as this from the American Society of Pain Management Nurses;

Remember that sleep and sedation do not equate with the absence of pain or with pain relief.

Or the conclusion of the Agency for Health Care Policy and Research

the sedated or sleeping patient can still be in pain

then you really need to support your claim, otherwise you're doing a great disservice to pain management education.

How the knowledge that while pain can make sleep less likely it does not completely block the ability to sleep is applied to a patient varies based on a number of variables, just as all pain management does. First you must consider the mechanism of the pain the patient is experiencing. Pain that is likely to be persistent, therefore requiring basal intervention, should not be discontinued at night just because a patient is able to sleep. This should involve some sort of discussion prior to sleep to establish a plan with the patient. If you're providing basal pain coverage with something that you know is effective for about 4 hours for the patient, and that if a subsequent dose isn't given until 6 hours after the previous that the patient's pain will become significantly uncontrolled, and require the basal dose plus multiple 'catch-up' doses to get back to baseline, then it would be appropriate to discuss continuing the daytime regiment with the patient and medicating at 4 hours (to replace the previous dose that is now wearing off). To assume that because they are sleeping at 4 hours means that the pain medication/pain level correlation that was occurring during waking hours has somehow now resolved is pretty absurd.

[stiffneck84]

From the provider side, sloppy execution of the pain as the 5th VS concept, along with laziness and cost cutting are amongst the reasons for the problems we're seeing. From the patient side, lack of interest in understanding what the provider is asking, and lack of interest in being forthright when asked for a pain rating are also to blame.

Opioid analgesics are fast acting, effective, and cheap. From the provider side, it is far less of a drain on resources to just write a script, or give a pill, than it is to undertake a series of trial and error non-pharmacological pain interventions. From the patient side, its faster and more effective short term pain relief to just say "...my pain is a 10..." (regardless of how it actually feels) get your percocet or vicodin and slip into a pain free stupor. I've never seen any patient who says anything along the lines of "my pain is a 10, I'd like to try repositioning myself, then some alternating hot and cold compresses, and then follow that up with some physical therapy tomorrow, and perhaps some accupuncture. While we're at it, have a CNA sit here and engage me in conversation to try and distract me from my pain" People want the pill, and they want to feel better shortly (and I dont necessarily blame them)

I found works for me, is to make a more detailed explanation of what a zero feels like and what 10 is *supposed* to be, a debilitating pain that prevents the patient from performing any activity. Often times that gives the patient a moment to think and reconsider how they actually feel.

[twozer0, NP]

I did read your write-up and I get the gist of your hypothesis, but using your hypothesis as the reference to support your hypothesis is scientific quackery. While the source in your previous link does reference the relationship between sleep and pain, specifically that reduced sleep quantity and quality modulates the pain experience, it makes absolutely no claim that pain completely blocks the ability to sleep, particularly the broad definition of sleep that would be included a nurse's observation of a patient "sleeping".

If you are really intent on disproving the currently accepted knowledge of pain and sleep such as this from the American Society of Pain Management Nurses; Or the conclusion of the Agency for Health Care Policy and Research then you really need to support your claim, otherwise you're doing a great disservice to pain management education.

How the knowledge that while pain can make sleep less likely it does not completely block the ability to sleep is applied to a patient varies based on a number of variables, just as all pain management does. First you must consider the mechanism of the pain the patient is experiencing. Pain that is likely to be persistent, therefore requiring basal intervention, should not be discontinued at night just because a patient is able to sleep. This should involve some sort of discussion prior to sleep to establish a plan with the patient. If you're providing basal pain coverage with something that you know is effective for about 4 hours for the patient, and that if a subsequent dose isn't given until 6 hours after the previous that the patient's pain will become significantly uncontrolled, and require the basal dose plus multiple 'catch-up' doses to get back to baseline, then it would be appropriate to discuss continuing the daytime regiment with the patient and medicating at 4 hours (to replace the previous dose that is now wearing off). To assume that because they are sleeping at 4 hours means that the pain medication/pain level correlation that was occurring during waking hours has somehow now resolved is pretty absurd.

Agreed, the sleeping patient can still have pain (never once have I refuted this). The whole point of my writeup was to prove that a sleeping patient has CONTROLLED pain and is able to sleep, which by sleeping perceived pain is absent. I see this all the time in the OR with anesthesia treating pain of patients who are sedated with increases in heart rates after banging on a knee, yes your body responds to pain while asleep. But the whole purpose of pain is to be able to perceive it and if a person is unable to perceive it, even if they are sending pain signals, we dont treat it outside of anesthesia. Even under anesthesia treating pain isnt a requirement, it just makes my job in the recovery setting easier as well as its nice for the patient. If we have a sedated or sleeping patient (out of surgery), why would I contribute to their sleepiness and their sedation by providing them with more medications that do just that? This puts the patient at risk for loss of airway or hypercapnia. Its not quackery, its called using judgement based on solid physiologic explainations. You can refute your reasons and keep stating what you want about people having pain while they sleep.

[Susie2310]

Agreed, the sleeping patient can still have pain (never once have I refuted this). The whole point of my writeup was to prove that a sleeping patient has CONTROLLED pain and is able to sleep, which by sleeping perceived pain is absent. I see this all the time in the OR with anesthesia treating pain of patients who are sedated with increases in heart rates after banging on a knee, yes your body responds to pain while asleep. But the whole purpose of pain is to be able to perceive it and if a person is unable to perceive it, even if they are sending pain signals, we dont treat it outside of anesthesia. Even under anesthesia treating pain isnt a requirement, it just makes my job in the recovery setting easier as well as its nice for the patient. If we have a sedated or sleeping patient (out of surgery), why would I contribute to their sleepiness and their sedation by providing them with more medications that do just that? This puts the patient at risk for loss of airway or hypercapnia. Its not quackery, its called using judgement based on solid physiologic explainations. You can refute your reasons and keep stating what you want about people having pain while they sleep.

It sounds as though your knowledge of pain management is not sufficient. Patients can still feel pain when they are sedated, asleep, or paralyzed. How do you know the patient is unable to perceive pain just because they are unable to communicate/are not communicating their pain in a way that you are able to observe/register? It is humane and ethical to treat pain, and round the clock dosing is necessary for some patients, even if the patient is unable to report or otherwise express their pain.

I recommend Medscape's article "Pain Assessment In The Patient Unable To Self-Report." I also recommend reading about palliative care and pain management.

[twozer0, NP]

It sounds as though your knowledge of pain management is not sufficient. Patients can still feel pain when they are sedated, asleep, or paralyzed. How do you know the patient is unable to perceive pain just because they are unable to communicate/are not communicating their pain in a way that you are able to observe/register? It is humane and ethical to treat pain, and round the clock dosing is necessary for some patients, even if the patient is unable to report or otherwise express their pain.

I recommend Medscape's article "Pain Assessment In The Patient Unable To Self-Report." I also recommend reading about palliative care and pain management.

How do I know the patient is unable to perceive pain? I'm confused as to what you are suggesting here. They are unable to perceive pain due to being sedated, asleep, or paralyzed? Did you even read the quotes that you quoted me on? I think this is going way over a lot of peoples heads.

1. You have a patient we give them a narcotic for pain, patient rates pain 10/10.

2. After 2mg dilaudid patient rates pain 6/10, respirations are 12

3. After 3mg dilaudid the patient is now asleep, no pain assessment is needed at this time, respirations are 10. So you're suggestion by your logic that this patient is still having soo much pain that its inhumane. So you're saying I should give them more narcotics even if they wake up and give me a 6/10 pain score? Yes I probably need more education on pain management... give me a break. You know why we call narcotics a CNS depressant right? We are depressing the pain from the top down, this is why your patient falls asleep. Please read my big writeup if you need A and C fiber pain modulation.

Yes I'm well aware that the signals of pain are present, the patients perception of them has been depressed to the level of sleep. This patient is now unconscious and unable to perceive pain. Should we WAKE the patient and ask them, we could get a pain level but while asleep, pain is not perceived. You need to be conscious to perceive pain signals (you know, tell someone you are in pain). Oh and I'm well aware of the non verbal ques of pain (I work in the PACU, you know where we get everyone in pain). So before you start on that, when a person is cutting logs from IV narcs (c fiber modulation) maybe you can be the one to tell them that we arent controlling their pain adequately.

[Monday1]

Amen!!!

[heron, ASN, RN]

How do I know the patient is unable to perceive pain? I'm confused as to what you are suggesting here. They are unable to perceive pain due to being sedated, asleep, or paralyzed? Did you even read the quotes that you quoted me on? I think this is going way over a lot of peoples heads.

1. You have a patient we give them a narcotic for pain, patient rates pain 10/10.

2. After 2mg dilaudid patient rates pain 6/10, respirations are 12

3. After 3mg dilaudid the patient is now asleep, no pain assessment is needed at this time, respirations are 10. So you're suggestion by your logic that this patient is still having soo much pain that its inhumane. So you're saying I should give them more narcotics even if they wake up and give me a 6/10 pain score? Yes I probably need more education on pain management... give me a break. You know why we call narcotics a CNS depressant right? We are depressing the pain from the top down, this is why your patient falls asleep. Please read my big writeup if you need A and C fiber pain modulation.

Yes I'm well aware that the signals of pain are present, the patients perception of them has been depressed to the level of sleep. This patient is now unconscious and unable to perceive pain. Should we WAKE the patient and ask them, we could get a pain level but while asleep, pain is not perceived. You need to be conscious to perceive pain signals (you know, tell someone you are in pain). Oh and I'm well aware of the non verbal ques of pain (I work in the PACU, you know where we get everyone in pain). So before you start on that, when a person is cutting logs from IV narcs (c fiber modulation) maybe you can be the one to tell them that we arent controlling their pain adequately.

I think you guys are talking about two different things. You are referring to the conscious experience of pain while unconscious, either in sleep, under sedation or due to pathological obliteration of higher brain function. You are correct, strictly speaking, since one cannot be conscious and unconscious at the same time.

Personally, I think it would be fascinating to investigate whether people with severe pain are actually in a normal sleep state or something else. But that's another topic entirely.

When most people point out that people can be asleep and still be in pain, we are usually addressing the assumption that people who can sleep must be lying about their pain when they are awake. It's a kind of imprecise shorthand, if you will, for the fact that unrelieved pain does not block a retreat into unconsciousness either through sleep (due to exhaustion, perhaps?) or a self-induced trance-like state.

As a specialist, you are skilled in one very narrow aspect of pain control: acute post-operative pain in the immediate post-anesthesia setting. I woulndn't expect you to have a grip on the wider picture.

You are correct about the technical imprecision of asserting that a sleeping patient can still be in pain, but I would urge you to let go of some of your contempt and the unnecessary snark. You clearly don't know what you don't know.

[Thunderwolf, MSN, RN]

Totally agree with twozer0 on most of his rationale. To put it in even more simpler terms, would you wake up a patient to give him/her a sleeping pill? No. The same logic applies here with pain medication. Wakefulness and pain are both conscious experiences, for the most part. If unconscious/asleep, what are you truly medicating? Now in saying that, does that mean pain is not present? It depends. We all experience some discomfort when we sleep to one degree or another. One example of this is when we change positions off and on during our time of sleep. Lying too long in one position often becomes uncomfortable, so we turn and reposition ourselves while sleeping. We tend to do this unconsciously. Does that mean we need to medicate it? No. Does that mean pain will not wake us up? No. If a level of threshold discomfort is achieved due to injury/surgery/disease, we may awaken and then may/will become conscious to our level of comfort/discomfort. At that time, yes, it may become appropriate to medicate for pain then. Will I automatically wake up a patient to medicate them with a prn pain medication if he/she earlier requests that I do? No, 99% of the time. I will medicate for pain only if the patient awakens on his/her own and then becomes aware of pain and requests it. So, what may contribute to discomfort while one sleeps other than injury/surgery/disease? What are some non-verbals that may indicate discomfort/pain in a sleeping patient? How about a full bladder? And...do you medicate that? No. You toilet. Is the room too cold or too hot? Do you medicate that? No. You adjust the room temperature. There are many things that can contribute to unrestful sleep. That is where sleep hygiene comes into play. Good job, twozer0, in your explanations on this thread. You are most correct regarding a patient who is unconsciously sedated. It does, however, become a tad different with a patient who sleeps that is non-sedated chemically. This is where nursing becomes more an art mixed with science than vice versa.

[Monday1]

I've been a nurse for many, many years and find it disheartening that my fellow co-workers feel they have the right or ability to say when a person is in pain or not. I for one have a high pain tolerance and can function and text just fine in pain but if I ask for a pain pill or tell you my pain is 10 out of 10 then you best show me some respect and compassion and if you can't, I hear McDonald's is hiring!!! Furthermore you get paid pretty damn well to "push,push,push" all night so DEAL!!!

[Nurse Leigh]

Totally agree with twozer0 and his rationale. To put it in even more simpler terms, would you wake up a patient to give him/her a sleeping pill? No. The same logic applies here with pain medication. Wakefulness and pain are both conscious experiences. If unconscious, what are you truly medicating? Good job, twozer0, in your explanations on this thread. You are most correct.

Except that I *would* wake SOME patients to take pain medication so that their pain does not get out of hand and we're basically back to square one as far as properly controlling pain.