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.

[nurseswholovenursing]

I worked as an Oncology nurse for over 15 years. We did get overflow of med/surge patients if we had beds, and i remember patients "frequent fliers" who no floor wanted because we all "knew" their clocks were set for their next dose of whatever pain med was ordered, bed assignments would try to take turns for which floors they would try and admit them to, because no one wanted them on their units.

Yes, there are drug seekers in hospitals. But my job is to assess, try non-pharm interventions, if ineffective, administer meds and do a follow up assessment. Do I believe someone who is laughing, talking on the phone, rolling around joyfully....not my call, and sleep is NEVER an indication of pain relief. I do the best assessment I can, try alternate interventions first, and then give the ordered pain medication, and make sure I have documented the facts. It is what they tell us it is, regardless of our own "opinion". If a patient tells you that they are having chest pain, but their vitals are good, color good, doesn't appear to look like anything is wrong, do you decide, based on your super powers to know your patient better than they know themselves, to do nothing, because you know better, of course not. Pain is what the patient says it is. I make sure that I have explained the pain scale to the best of my ability, I will ask for a referral for psych, social work, discuss it with their Dr., tell him/her your concerns, if I think they may have issues with pain meds (non-cancer pain that is) and i will continue to do all that because I believe pain is always subjective. Judgement of patients complaints is not good practice. How do you know if they are in pain. Because they tell you they are.

[Tenebrae, BSN, 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.

I've had patients who have been sleeping and as a result the nurse before me may have skipped giving them regular pain relief.

Usually what happens is that the patient wakes up 30 minutes into my shift in screaming agony I then spend most of my shift trying to play catch up and get their pain under control

[Tenebrae, BSN, 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)....

I disagree. Sure, a person can not verbalise "I have 10/10 pain".

However thats when paying attention to the non verbal indicators of pain play a role.

Look at how the person is sleeping Are they still? Or are they tossing and turning?

Is their breathing equal and slow or is it shallow and rapid?

Do they look peaceful or or are they frowning/grimacing?

Example in point, Mr C (name and identifying details changed to protect privacy) was in end stage cancer with bony mets. Mr C was spending 98% of the day sleeping. At the start of my shift Mr C was sleeping however appeared very unsettled, and had a solid grimace on their face. Gave some PRN meds S/c and sure enough within a very short space of time Mr C was sleeping much more settled and the grimace had disappeared from his face.

[Horseshoe, BSN, RN]

I've had patients who have been sleeping and as a result the nurse before me may have skipped giving them regular pain relief.

Usually what happens is that the patient wakes up 30 minutes into my shift in screaming agony I then spend most of my shift trying to play catch up and get their pain under control

After my first C-section, I was on a PCA pump. I would fall asleep, only to wake up in agony. I wouldn't be able to catch up, and never had good pain control. That's why I preferred po pain meds. They would last longer.

After the second C-section, they left my epidural in. That was a huge improvement in pain control.

[banterings]

As to pain and sleep; Has anyone not ever been so tired that they can sleep through anything? After dealing with pain keeping one awake for 3 days straight, they can sleep through anything.

As to addiction; Perhaps the addiction in some is being free of the pain, being normal. Is that so bad?

We will never know exactly how another perceives the world. Many will never know what it is like to live with pain. It is far better to act in a truly compassionate manner lest God deems that we walk a mile in their shoes...

[Here.I.Stand, BSN, RN]

As to pain and sleep; Has anyone not ever been so tired that they can sleep through anything? After dealing with pain keeping one awake for 3 days straight, they can sleep through anything.

Unrelated, but years ago we had a primary sourcebook as required reading for a WWI history class. Some of the journal entries described soldiers falling asleep standing up while on night duty (in a trench and with frostbitten feet). So yeah, I would think it's possible for someone in pain to fall asleep in a warm dry bed.

As for the nurse who thinks it's her duty to try nonpharm interventions first.... while hospitalized after my 5 births or in tge ED after one of my corneal erosions... I'm not even sure what to say to that. To say nothing of sickle cell pts, or trauma pts with fractures and/or degloving injuries. Yeah.. let's try some guided imagery and an ice pack first and if that doesn't work, THEN I'll allow you access to the prescriptions your provider has ordered? I'm sorry, that makes me mad.

[Thunderwolf, MSN, RN]

After reading many posts on this thread, this seems relevant to the discussion.

Medical goal of eliminating pain can lead to over-prescribing pills, accidental dependence | The Columbus Dispatch

"Americans have been told that we can and should be pain-free," said Constance Scharff, director of addiction research at the Cliffside Malibu Treatment Center in Los Angeles. "And doctors have been told that there are medications that will make that happen. That's the root of the whole drug epidemic."

And in part with this, if we have ongoing chronic pain issues ourselves as nurses, does this lend ourselves as nurses to medicate/overmedicate a patient more often because we refer back to what made us feel better? In a small nutshell, co-dependency. That needs brought up. Can't neglect that issue altogether.

And lastly, there are medical conditions like sickle cell, acute post op, cancer, et cetera that do benefit from ATC (Around The Clock) medications. That is a separate issue altogether. Not talking about that....just for the record.

[iluvivt, BSN, RN]

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.

Yep Yep Yep I get what you are saying and perhaps I was not clear enough in the point I was trying to make! I get that narcotics (true narcotic derived from opium or synthetic ones ) copy what our naturally present neurotransmitters do in our bodies by binding to opiate receptor sites in the brain, spinal column and in the gut (that's why people get constipated on narcotics). Once activated they go to work and the perception of pain is decreased and euphoria occurs.

But chronic pain patients once stable on a regime and ones that that follow their orders are not walking around like sloppy drunks. Many will tell you they do NOT feel any high sensation at all. That is what I am talking about! Many are fully functioning people leading productive lives!I think that people are not as out of touch with their bodies as you seem to think they are. People know when they feel high. Many are only seeking pain relief and not a high and that is why they do not get addicted. Only 4 percent of chronic pain patients taking narcotics actually get addicted.

[meandmymeds]

This thought has GREAT merit! I have been looking for a topic to do a research paper on and this intrigues me!! Great post!

[nurseswholovenursing]

I have never done guided imagery in all my years of being a nurse, especialIy in oncology, it is bunk. I was talking about repositioning someone with a tumor the size of a basketball coming out of their lady parts, or yes, God forbid, using an ice pack for a head and neck cancer patient who had half of their face/neck removed the day before. Or using a unique recipe for a suckable lozenger that one of our oncologist created (it included anesthetic herbs, clove oil, sichuon peppers, antibacterial herbs, and other things I can't recall) for people that had stomatitis from the tip of their tongue to their end of their orifice from chemotherapy. Doing these things all WHILE I was administering their ordered pain medication.

I can relate to the pain of a child birth, and i am sorry you suffered corneal erosions. But cancer pain is much more. Not taken care of by any one thing, needs to be treated with ALL you've got, and whatever else you can think of. I certainly didn't mean to make you "mad".

And i mis-spoke, saying to use non-pharm interventions 1st , my bad, wrong, wrong, wrong.

You need narcotic analgesics, strong ones, big doses, long acting, short acting, PCA pumps, antidepressants, anticonvusants, nerve blocks, implantable pain relief devices, topicals, steroids, RT, spinals: Some of, or all of those, and more. Our team was very aggressive with pain management for the folks we took care of. Those patients taught us so, so much about pain. And worring about drug seeking behaviors is a dangerous way to think for nurses. Thinking that we have the ability to really know how another person perceives their own world, is not a skill any of us possess.

[Here.I.Stand, BSN, RN]

I have never done guided imagery in all my years of being a nurse, especialIy in oncology, it is bunk. I was talking about repositioning someone with a tumor the size of a basketball coming out of their lady parts, or yes, God forbid, using an ice pack for a head and neck cancer patient who had half of their face/neck removed the day before. Or using a unique recipe for a suckable lozenger that one of our oncologist created (it included anesthetic herbs, clove oil, sichuon peppers, antibacterial herbs, and other things I can't recall) for people that had stomatitis from the tip of their tongue to their end of their orifice from chemotherapy. Doing these things all WHILE I was administering their ordered pain medication.

I can relate to the pain of a child birth, and i am sorry you suffered corneal erosions. But cancer pain is much more. Not taken care of by any one thing, needs to be treated with ALL you've got, and whatever else you can think of. I certainly didn't mean to make you "mad".

And i mis-spoke, saying to use non-pharm interventions 1st , my bad, wrong, wrong, wrong.

You need narcotic analgesics, strong ones, big doses, long acting, short acting, PCA pumps, antidepressants, anticonvusants, nerve blocks, implantable pain relief devices, topicals, steroids, RT, spinals: Some of, or all of those, and more. Our team was very aggressive with pain management for the folks we took care of. Those patients taught us so, so much about pain. And worring about drug seeking behaviors is a dangerous way to think for nurses. Thinking that we have the ability to really know how another person perceives their own world, is not a skill any of us possess.

Thanks for clarifying! I definitely agree there is a place for adjuncts to pain meds. And yes I get that CA pain is much more than corneal erosions, as I'm sure my other examples of sickle cell crises and multiple traumas are. I used that as an example as the most pain I've personally experienced, and was picturing what I thought you meant. Glad I misunderstood! :)

[Brandidrn]

Well I gotta say as an ER nurse and also chronic illness that is very painful at times I am so mad we have gotten to this point where Narcan is basically everywhere now, when I started nursing we never had to give it and now this epidemic has people having a kit like epi! So the people who r in chronic pain and need these meds we need to make sure they have them, pain is subjective and u can not say just suck it up we r all not the same I can't handle pain at times it incapacitates me and maybe u would be fine no one knows so it is our job to be advocates for the patient not their enemy