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.

[MunoRN, RN]

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.

Here's is what you said:

...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.

You've been provided with evidence that your claim contradicts the established knowledge of whether or not a sleep can be equated with adequate pain control and still have not provided any evidence to support your claim. While the mechanisms you're referring to certainly do exist, you're attributing effects that we know don't exist; that any pain beyond mild pain makes sleep not possible. You're essentially arguing the world is flat and using the fact that it looks flat when you look at the horizon, and completely ignoring the available evidence regarding the topic.

Respiratory rate and ability to sleep are not the same variable when assessing response to opiates. You wouldn't continue to medicate with opiates in the event of excessive respiratory depression regardless of whether or not the patient is able to sleep.

As an example, you've got a patient with a persistent source of pain. You already know that the patient's pain medication keeps their pain tolerably controlled for about 4 hours, and that after about 5 hours it's moderate and at 6 hours it's severe, pain crisis sort of pain. If they wake up at 6 hours from the last time they were medicated in severe pain, according to your theory they only began experiencing more than mild pain at the moment they woke up, which contradicts what we know about pain progression as pain meds wear off.

[heron, ASN, RN]

Totally agree with twozer0 and 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. 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. What are some non-verbals that may indicate pain in a sleeping patient? What are some contributors? 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 in many ways.

No, the same logic does not apply because pain =/= sleep. It all depends on the individual clinical situation. Withholding pain medication d/t sleep can allows the level of medication drop too low to block the pain effectively.

This is a problem for those who need constant control of chronic pain (sickle-cell patients, for instance) because they then have to play catch-up to damp it down again. As we've seen, this often exposes them to assumptions of drug-seeking and the development of pseudo-addiction behaviors.

You just can't make this kind of blanket rule that sleep (or the appearance of sleep) contraindicates the administration of pain meds in all situations. This widespread inability to deal effectively and rationally with chronic severe pain control is a major, but not the only, factor in iatrogenic opioid addiction, in my opinion.

[nurseactivist]

When I was younger I had horrible migraine headaches and I had multiple hospitalizations for them. I can relate to the sickle cell patient that was treated as drug seeking. Finally, neurology figured out that I was having rebound headaches from narcotics and even tylenol resulted in pain that was even worse than the original headache.

I have had chronic pain for years. Now I have RA/poly arthritis. I have also had numerous kidney stones. Of all the pain, intractable migraine is by far the worst!

Luckily, I rarely get migraine headaches now. Just for purposes of understanding the sleep issue, I will say normally I rarely remember a dream unless it is a nightmare. Now when I finally fall asleep with a rare migraine, it is not uncommon for me to wake up with my heart pounding due to dreaming that someone was bashing me in the head or that I was in a car accident and smashed my head. So, I do believe that you can have pain while sleeping. The only time I have that type of dream is when I have horrible migraine.

After years of chronic pain and the backlash from family and friends, eventually it becomes easier to try to hide your pain or deny my pain. I share this on an anonymous website, but most colleagues and even family and friends have no idea that I am having pain. The only exception is if I have severe migraine, the pallor, nausea/vomiting may give me away.

[RN7916]

Just in response to your comment about finding out of pain affects sleep (and hope I am showing what post I replied to, I'm new to posting here, but a long time stalker ). There is a ton of research on this. My husbands doctor has actually published regarding this. It's all quite complicated and fascinating. There is also a correlation with increased pain when a patient is unable to enter normal sleep cycles. If you have made buddies with a doc and are really that interested, most hospitals give docs free access to most research publication sites that us nurses don't get. You can read lots of great stuff!

[Horseshoe, BSN, RN]

A lot of the arguments being made about pain and sleep are strawmen.

Here is what is usually going as to patients in pain sleeping:

"My patient is a drug seeker, plain and simple. She claims to be in terrible pain, and has insisted I call the doc to get her narc dosage increased. I'm waiting for him to return my page and I walk by her room, and what do I see? She's SLEEPING!!!! No way this lady could sleep if she's really in 10/10 pain!"

Most of the time this is the claim that is being made, and it's completely, patently false. Same with the whole "but her heart rate and blood pressure were fine. She's lying." The fact that people in chronic pain should not be assessed with the criteria appropriate to someone in acute pain is apparently completely lost on many nurses, who should know better. Either they aren't being taught this in nursing school, or they have allowed their personal biases to cloud their judgment. Either way, it's a disservice to the patient.

[Horseshoe, BSN, RN]

Just in response to your comment about finding out of pain affects sleep (and hope I am showing what post I replied to, I'm new to posting here, but a long time stalker ). There is a ton of research on this. My husbands doctor has actually published regarding this. It's all quite complicated and fascinating. There is also a correlation with increased pain when a patient is unable to enter normal sleep cycles. If you have made buddies with a doc and are really that interested, most hospitals give docs free access to most research publication sites that us nurses don't get. You can read lots of great stuff!

You need to push the "quote" button at the bottom right corner of the particular post you want to respond to if you want us to know to which post you are responding.

[twozer0, NP]

Here's is what you said:

You've been provided with evidence that your claim contradicts the established knowledge of whether or not a sleep can be equated with adequate pain control and still have not provided any evidence to support your claim. While the mechanisms you're referring to certainly do exist, you're attributing effects that we know don't exist; that any pain beyond mild pain makes sleep not possible. You're essentially arguing the world is flat and using the fact that it looks flat when you look at the horizon, and completely ignoring the available evidence regarding the topic.

Respiratory rate and ability to sleep are not the same variable when assessing response to opiates. You wouldn't continue to medicate with opiates in the event of excessive respiratory depression regardless of whether or not the patient is able to sleep.

As an example, you've got a patient with a persistent source of pain. You already know that the patient's pain medication keeps their pain tolerably controlled for about 4 hours, and that after about 5 hours it's moderate and at 6 hours it's severe, pain crisis sort of pain. If they wake up at 6 hours from the last time they were medicated in severe pain, according to your theory they only began experiencing more than mild pain at the moment they woke up, which contradicts what we know about pain progression as pain meds wear off.

I still think you are missing the connection here. The only reference you gave me was from the nurse pain association of which what you quoted was just the authors opinion, there is no citation there. Patients can still have "pain" when sleeping. We are not stopping the pain signals from firing (like how lidocaine works with sodium channels), we are just suppressing them on how the person perceives pain (top down, decending pathways).

Please read about the reticular activating system

Once you know what it is "Moruzzi and Magoun found that by stimulating the reticular formation, they could awaken animals from normal sleep". which formed the basis of understanding the RAS THE BRAIN FROM TOP TO BOTTOM

So now after reading this you know that reticular formation will cause wakefulness when stimulated of which stimulation can occur with c fibers that terminate in this area

Please read - https://www.ucl.ac.uk/anaesthesia/StudentsandTrainees/PainPathwaysIntroduction

make note of dorsal horn and its location into the proximity of the reticular formation. Understand that opiods down to the dorsal horn (transmission, decending pathway).

Next read - The Mechanism for Opioid Analgesics in the Treatment of Pain

Now all of the puzzle peices can be put together. We know that reticular formation stimulation leads to wakefulness, we know that C fibers terminate from the dorsal horn all the way up to higher brain structures. Since we now know sleep is an active process, any painful stimuli able to reach the reticular formation will cause the patient to wake and thus perceive pain. The graph in the second link has a good example of the decending pain pathway. So yes you cannot sleep if pain signals stimulate your reticular formation. I've provided you with a myriad of evidence both now and prior to this posting. I'm not sure what else I can do.

I do not disagree with you about routine medication administration, we did not discuss half lives or duration of effect for pain medication (to be honest i figured this was a given). Yes even if the patient is sleeping we can wake them to give them more pain medication to thwart off the impending increase in pain.

So I will await your inevitable response that sleeping patients can have pain (which we already know the signals still fire) and how I see the world or how twisted this knowledge is (when its pretty clear). I still havent received a credible source of information that you have provided to say that this is impossible.

[heron, ASN, RN]

That has got to be the longest non sequitur I've ever read.

[Guest219794]

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!!!

Well, if it's ordered and you would like it, I'll get it.

The respect and compassion you demand- sure, why not?

But, 10/10 would mean there is no room for any more. And, I really think that if somebody was to smash your texting hand with a hammer, you would feel more pain. Which, de facto, means that when you said 10/10, you were exaggerating.

It's a math thing.

[Hollybobs]

Well, if it's ordered and you would like it, I'll get it.

The respect and compassion you demand- sure, why not?

But, 10/10 would mean there is no room for any more. And, I really think that if somebody was to smash your texting hand with a hammer, you would feel more pain. Which, de facto, means that when you said 10/10, you were exaggerating.

It's a math thing.

Is that the case? By that math you could never say you had 10/10 pain and the scale would either end at 9/10 and/or become meaningless. If 10/10 was the original pain plus the hammer smashing the testing hand, the original pain would be 9/10. If you then smashed all the hands and the feet plus set the patient on fire and informed them of a traumatic emotional event there would be a new 10/10, the original pain plus the hammer blow would shuffle down to 9/10 (maybe lower) and the original pain would be 8/10. If you keep going along those lines then it becomes meaningless.

There is an argument for using "none, mild, moderate or severe?" as an alternative to the 1-10 scale.

Also, you can experience severe pain in your sleep as you can dream you are on fire for a while and then wake up in severe pain. Reasons why a patient might remain in severe pain but not wake include exhaustion and remains of anaesthetic agents in the patient's system post-op. If the patient has taken a sleeping pill or another medication which has a sedating effect they can be in pain but too sedated to wake up and explain to the nurse that they are in severe pain (in whatever tone and manner that individual nurse would deem correctly demonstrates the patient is indeed in severe pain).

[Kooky Korky, BSN, RN]

It's not all the time, but at least 3-4 times a week, and it's at least half of rapid response calls. Especially if the patient is having a COPD exacerbation and is already having trouble getting rid of CO2 when somebody slams in an opiate and drops his/her respiratory rate.

I don't know why people don't advocate for some Toradol or something when somebody teetering on the edge of buying himself a tube because of high CO2 complains of pain.

Do they still give Toradol after C Section? That is what my wife received many years ago. I thought they were giving Demerol in too small doses. 3rd post op day, switched to po narcotic, informed surgeon that the pills worked a lot better than Toradol. I will never forget his look of confusion when informed of pill working better than Toradol.

Expecting someone who has been laboring and sliced open to have sufficient relief with an NSAID, even IV, and expecting her to pick up the rooming-in newborn and do all of his care before fully recovering from the spinal anesthetic and with an IV still in to rehydrate her (loss of a litle CSF with spinal) - cruel and stupid. May everyone who inflicts this kind of "care" on others experience it themselves. No one would help her to the toilet her first time up, she was dizzy - called for assistance , told that her nurse was at lunch. Yes, I know all the staffing and workload issues. But it is infuriating and outrageous. We've likely all been there. I told her she should have called the Nursing Supervisor and her doctor. Well, it's a long time past and it still is horrible to think about.

And of course, not everyone can take Toradol.

[MiniNurseintraining]

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.

Thank you for pointing that out. -A nonsickle cell human, but very observant.