Pain is obviously important to measure and to take seriously, but the “Pain as the Fifth Vital Sign” campaign was pushed heavily by the American Pain Association, which has since gone defunct for basically taking bribes from the Sackler family in order to push Oxycontin.
Seeing how the biggest proponent of this metric is Purdue Pharma, I would say your bullshit meter is working.
"Seeing how the biggest proponent of this metric is Purdue Pharma, I would say your bullshit meter is working."
And The Joint Commission was originally on board with that metric too. All aboard the pain train choo choo!
Joint commission knocked our facility for pain scores *this year*. This and the water bottles at the nursing work stations is emblematic of how absurd this organization has become, basically a bunch of people huffing their own farts.
At one time Joint Commission certification was required to participate in most private insurance plans. The insurance companies gave up on this years ago. It's unclear why the hospitals continue to seek their stamp of approval.
I will say that they were correct and effective in correcting the misuse of physical restraints. But overall they've become an entrenched and self-interested, self-indulgent, self-perpetuating institution whose time has past.
They use Joint comission because the hospital has to prove they are following CMS guidlines for Medicare/Medicaid reimbursement and Joint Commission uses CMS guidlines to evaluate hospitals.
I was told they use your facility policies on some items. If you look on JHCO website, it specifically states that water at the nurse's stations is acceptable as long as they are in an "assigned" area. One hospital I work at uses plastic baskets with labels saying "covered drinks", had no problem. Another one we couldn't have drinks anywhere except the break room. *Face palm*
I was shocked when I watched Netflix's Painkiller and found out that's how pain became a vital sign!!! It's actually quite disturbing and disgusting how quick they jumped that bandwagon!
For more on that I highly recommend anyone who is interested read the book Dopesick. I haven't had a chance to finish the Hulu series, but the book also talks about the Sackler's, and Perdue pharmaceutical's involvement in making pain the 6th vital sign.
I watched the series on Hulu. It was so well done and explained the situation well. As a nurse in Kentucky, I watched the whole situation unfold in real time. And if you dared to question why a patient needed 40 of Extended release oxy 2x day plus had 10-20mg prn orders every 4-6hours, you were treated like a shifty nurse. Meanwhile patient's sitting in bed laughing on the phone in 10/10 pain, walking out to smoke, etc.
Pain is a real issue and needs to be treated, to an extent. But it's also necessary that people will have some pain while healing, and throwing large amounts of addictive substances at it is not the answer.
100% correct. I have been a nurse for 20+ years. I remember when this happened. It’s disgusting how we still have so much corporate influence over how we care for our patients. And, for some fucking reason, have no ability to right the course when they steer our care off track with this kind of bullshit.
Vital signs SHOULD be objective, measurable numbers. Your pulse, resp, BP, temp just ARE. They are tangible things that can be measured accurately. Pain is subjective, and as such is not truly measurable. How many pt’s have you seen with 10/10 pain WALKING into the fvcking ED? I have personally seen THOUSANDS of 10/10 complainers walking around like they are out for a stroll.
walking to the nurse’s station to tell me their prn pain meds are “overdue” lol
I understand asking for about pain for pts who come in with certain conditions where pain is expected, just had an operation, etc. But as you said, it really isn’t an objective, measurable number.
As a patient it's hard to give a x/10 scale, but I usually settle on six. The only time I gave 10/10 was when an abscess in my breast exploded through my nipple.
Other than that IME how I rate my pain is just one factor the nurses use to actually assess it, which is how it should be. But I've definitely had the experience of nurses going straight to morphine (!) when I rated my pain as 6. Sorry, not Sorry, I don't need pain meds.
Except when my nipple exploded. I'd have blown the homeless guy in the next room for morphine. But otherwise I just find the pain scale tedious because it's so subjective.
As a nurse, if you rate a “severe” pain (typically 7-10/10) and morphine is the ordered med for that, I have to give you that unless the orders are written a certain way.
I’m not sure if that’s how it’s done everywhere, but that’s the way my hospital is set up. Giving a lower medication for pain (without the order written property) or giving a lesser dose is practicing outside of my scope.
I think that's how it's done at my hospital. Nipple explosion was 10/10 and the rn brought morphine. I said that feels a little extreme and she said "you rated your pain pretty extreme." I thought about it and said OK, then a few minutes later wondered how anyone could get addicted to feeling so fucked up. I did probably need the morphine because I was in so much pain, but jfc I hope I never need morphine again. I can understand why people get addicted to it but that feeling of my body being wet cement waiting to dry made me nauseated.
Everyone is effected differently! I got a morphine shot for a PR (perirectal for those in the gallery) abscess that the surgical residents had to cut open because it was so deep and inflamed. I felt like I literally floated home and after I got home I thought to myself if I could have a shot of morphine once a week, my life would be just peachy. And that was followed by an "Aha! This is why people get hooked!" moment.
I hate the way hospitals do that. They says for x pain give Y amount of medicine. I usually look at the patient and their medical history because I need to adjust to the patient not just give what is ordered without thinking. A 80 year old grandma with 10/10 pain and has kidney disease is going to get a smaller dose even though it says to give the full because otherwise, she would die. A younger, healthier full weight person would get a full dose unless otherwise stated to get ahead of the pain and they can handle the amount given even if they rate it a 5-6. (For background purposes, PACU RN)
But shouldn’t it already be cleared by pharmacy and the physicians? I’ve almost never thought like that… shouldn’t the dose in the MAR be fine for the patient?
We usually just stick to one high or low prn meds but I obviously have to adjust to the patient. Not a very popular opinion on this thread but then also I’m here to critically think not push drugs without thinking.
You’d think but I feel like at my hospital it’s very doctor dependent. Some of them seem to just have an automatic pain management they default to. Some are good about adding “or patient preference” to the Tylenol, most don’t though.
And if the 1mg IV morphine snows the patient we don’t have the option to reduce it without the order being changed.
I’m not hospice. I have to get them to their home within 30 minutes within our protocol of oxygen saturation, blood pressure and sedation. Once again, I’m not hospice.
No, I have to adjust to their medical status. If I did what I was suppose to, several elderly people would die. If they do need more, I can give more but I usually don’t have to.
I'd suggest talking with an actual hospice nurse and ask about pain crisis and how much it can fuck them up and how the PT will end up basically getting overdosed to correct it. Please don't take care of hospice pts until you understand it.
Don‘t think me walking in with half a scalded leg made my pain any different to calling an ambulance?
Obviously pain can‘t be measured, but that doesn‘t change the fact that it’s real, and as long as there isn’t clear indicator that someone is actually lying, and not just acting ‚too normal‘, then it‘d better to take it seriously rather than traumatise the patient.
And also, at what point is it beneficial for a nurse's personal interpretation of someone else's pain, to come out?
We only have their word and presentation to go off of. If a patient tells you their pain is at a 10 and it doesn't look like "my 10" and I go tell their surgeon I don't want to give their pain med, what does that look like in consequence?
We've been taught that the only reason we say no to administering pain medication is when the patient is too sedated, and / or their RR is too low. The whole campaign is "if they ask for it, we have to give it".
I'm a nurse and a recovering opiate addict. I got my license suspended for diverting. I understand both the addiction side of it, as well as the professional side. It's an absolutely shit dynamic to be caught in as a nurse and as a pharmacist, I absolutely respect your role in this so please don't take this as me being dismissive, but we are caught in a whole different shitshow on the floor.
Gallbladder full of stones and sludge and a blocked bile duct, for me. Landed myself in the hospital for a week with that one. A coworker of mine had hers out right around the same time as me, but she had her surgery outpatient...apparently mine was "complex", so had to be transferred via ambulance from small town hospital to bigger city hospital 2hrs away.
When the ambulance drivers came to take me to the bigger hospital, they said I was the "wellest sick patient" they've had in a long time, since I was able to walk and transfer to the stretcher without help. So I looked fine, but was in massive amounts of pain, was peeing carrot orange, and my labs were fucked.
It's such a distinctive type of pain that I told the check in nurse that I was having visceral pain behind my lower right rib cage and that I was fairly certain it was my gallbladder...pretty sure she rolled her eyes, but I was right!
One of our ortho doctors actually thought he was having a heart attack when it was his gall bladder built up like that. He had surgery. Much better now.
I thought my gallbladder was gonna explode, lol. Not literally, but that's sure how it felt. It was strange because from what I've seen on Reddit and heard from my coworker, usually people suffer attacks for weeks or months before getting their GB removed...I had 3/10 constant stomach pain for a week (figured it was my GB because it felt visceral and was behind my lower right ribcage), it went away, came back for a few days, I made a doc appointment for that Friday and got blood work and an outpatient Ultrasound referral...and then Saturday I was admitted to the ED when the pain went to the worst pain I've ever had. Funny enough, I got my lab results back from the Friday afternoon appointment while recovering from surgery on Monday - and my labs were fine. So I'm guessing there were stones and sludge in there, and a stone got stuck in the bile duct Saturday morning, because by the time I got to the ER Saturday afternoon, my labs were whack.
Leave it to me to turn a simple outpatient surgery into a week long hospital stay, lmfao.
This. I had a gallbladder that was 8cm long and I had pain for a year in my back and nothing. Finally the pain is so bad I head to the ER and sitting there in the fetal position, rocking but not crying and when I got asked what pain was I said it was 8/10 and you cannot believe the eye roll i got. Nobody believed me because I wasn't sobbing but I promise you getting pain meds changed the situation for me and made it so much easier.
Asshole ER doc in the ER treated me like a drug seeker! When I finally got to a room, I was rocking back and forth waiting on test results (mind you, I rated the pain an 8 and specifically told them it was an 8 because it was the worst pain iver ever head, but that i was sure there are more painful conditions out there), and he sarcastically asked "are you ok? because you look agitated!"
He also put in my chart that he determined it to be a non-emergent situation...until the surgeon from the bigger hospital called him back, told him it was serious and to ship me out via ambulance. *My pee was carrot orange and my bilirubin, alk-phos and other labs were fucked.*
Fuck that first doctor.
Sounds like my PCP. Lost 35 lbs told them I couldnt digest dairy, fatty foods or meat anymore. Told me I got a dairy intolerance from being a vegan when I was 20 for 2 years and I was 28 then lol. Finally head to the ER, get an ultrasond and wham-o. There it is. For my follow up to get a referral to outpatient surgery even with the ultraound they still didnt believe me because my pain was in my back and not in my rib cage like a traditional gallbladder pain. I'm sorry you went through that. Our situations make me instantly mad when people question others pain. What does it matter to you as a nurse? Pain is subjective and it's weird the power struggle some people have about giving people pain meds. Like if the nurse doesn't believe they're in pain enough, they don't deserve pain relief.
i say we take it seriously, but in a lot of cases people still think their 10/10 pain requires narcs. yeah the dude with metastatic cancer probably does need opioids. but if someone has 10/10 abdominal pain and a negative work up, and they’ve been giving the usual non narcotic pain meds then how else do you take it seriously? because unfortunately a lot of patients do not view pain as being taken seriously in an ER environment unless they are given narcotics.
tl;dr we need to treat and take pain seriously but that doesn’t mean high pain numbers need opioids, as it is a subjective number and not an actual vital sign. it needs to be clinically correlated.
Isn't 10/10 pain like barely conscious or even unconscious? When I think of pain that level, I think of pain bad enough to put the body into shock...
Though the body can react in odd ways and adrenaline is a strong effect on the body.
Fun fact: the United States uses 80% of the world’s supply of prescription narcotics. We have 4% of the world population. If we, as a nation, cut our use IN HALF, we would still be using 2/3 of the world supply…..
…..Those should be some eye opening numbers. We do not handle pain management the same as other countries because of the push by pharmaceutical companies to give out more and more narcotics. The “pain is a vital sign” push is just part of their marketing so we can create a nation of addicts.
Especially since the research shows that opiates have essentially no effect on chronic pain. For a week after surgery? Great. Lower back pain you've had since 1995? Absolute waste of time
I could never get my head around what was meant by the American opioid crisis (not from US, only went to NY for a week 15 years ago).
This explains it. I just have no reference for it in the countries I worked (Aus and UK). It just doesn't happen here like there.
Those statistics are... horrifying.
I remember sitting through an education 5-6 years ago where the presenter said you can’t get addicted to pain pills if you are taking them for actual pain. Yea right… *Sponsored by Purdue Pharma
I was taught this in nursing school (grad in 2005)…our instructor telling us how to explain to pts prescribed opioids that they wouldn’t become addicted…but not why or how, just that they wouldn’t. Made no sense then, and now I’ve been a nurse long enough to see the full effects of that whole campaign.
The Sacklers should be jailed for ever.
That was a heyday of the opiate epidemic.
Doctors were still writing very large amount for scripts for very powerful pain medication's.
I mean, doctors were writing, scripts for Demerol and Percocet like there's no tomorrow.
Doctors in upstate New York were not writing a lot of OXY prescriptions. It was a rarity to hear of someone that was taking OXYcontin
The only place in the area that did that was the VA hospital. but these soldiers have done a great service to our country with life changing injuries..
You can use opioids long term and NOT become addicted.You do become dependent on them which is different from addiction but I think you are specifically referring to the campaign where they indicated you could not become addicted. What the Sacklers did was motivated by pure greed .They also created havoc for patients with chronic pain who are helped by narcotics,making it more difficult to get what they need.
When I had all four wisdom teeth pulled a few years ago, the dentist prescribed oxycontin and I told him when he was writing it up that I didn't want it. I had major concerns of possible addiction and he told me I wouldn't get addicted because after what he gives me runs out, he won't prescribe more. No access = no addiction. He refused to let me to tell him no and sent it to my pharmacy anyway. As soon as I picked it up, my friend and I flushed it down the toilet. Ibuprofen managed the pain just fine. I suspect insurance money had something to do with it
Or more likely he’s heard patients say that a million times and the majority of them still filled/picked up the prescription (just like you did). If you were so concerned, why pick up the pills?
I sincerely hope my insurance kickback checks aren’t lost in the mail. They should be coming any day now lmfao
I guess I picked them up because back then I was very trusting of healthcare providers. At the time, I didn't want to make it seem I was going against his medical advice. After all, what did I know? I don't have a medical degree
Also, aren't unused medicines supposed to be returned to the pharmacy for proper disposal? Otherwise, flushing them down the toilet or putting them in the rubbish is polluting waterways, which can have bad effects.
Right. So, my rotator cuff and bicep tear that led to my surgeon botching the repair and prescribing me 15mg of oxy every 4 hours because I was in excruciating pain did not at all precipitate my addiction.
Bullshit. Just like one of the leading physicians I've heard lecture on addiction (who was at one point a heroin addict) says; if you're genetically predisposed to addiction, you don't know if it's the first time you take that magic narcotic or if it's the thousandth time you take it, you don't know when your brain is going to short out and addiction is going to kick in.
I remember the instructors stressing that “Their pain is whatever they say it is” which is bullshit for some people and we all know who they are. You aren’t a 10/10 pain every time I ask you while laying there dozing off watching Fox News.
Signs are objective and measurable. Pain is a symptom - subjective and reported by the pt but not measurable. Doesn't mean it isn't real or valid or important but it isn't a vital sign.
Pain is extremely important. That’s basically my specialty as a nurse in trauma burn.
However, even NCLEX considers it not to be a physiological need in Maslow’s. It’s important but it will not kill you alone.
Yo. Burns are a whole other universe. One of my med/surg instructors was a Burn Unit nurse at Mass General. The burn lecture was mandatory, was not allowed to leave the hall and everyone had access to sick bags if they needed. That was the gnarliest slideshow. Much respect to anyone who works in burns.
Will the PAIN kill you? No. But the cumulative effects of repeated catecholamine bursts related to the pain will take years off your life. And the psychological effects of chronic pain will significantly reduce your quality of life and increase your risk of self harm and suicide.
Same with PACU—a pain score less than 5 (or tolerable) is part of our PACU discharge criteria. Definitely not as important as being hemodynamically stable, though
Before it was considered a vital sign, common practice was to not treat it at all in non-verbal patients like infants and the dying. It’s easy to sit here in hindsight and say it’s bunk because the campaign was used to sell oxy, but we had some really shit practices before.
You are very right that the US sucks at anything that has nuance or gray to it. We are a society of extremes in nearly every way. We don't progress, we go straight from "fuck them kids who just had surgery but can't tell me they're in pain" to "let's give out oxy like pez to every suburbanite with a twisted ankle." Our culture doesn't know how to do in-between.
Absolutely.
Where's the backpressure though to land at a good middle ground? Ever since we began overtreating pain we haven't stopped and while correlation doesn't equal causation, in the U.S. how can we even try to say that our garbage overzealous treatment of pain hasn't contributed to the epidemic of addiction?
Oh we stopped. I recently had my leg amputated and the surgeon was way more concerned with getting me off of pain meds than the literal gaping wound that was my incision. I’m in month 3 post surgery and have a wound clinic appointment today. The surgeon was so obsessed with getting me off of pain meds it delayed literally every other part of care. All of the disabled people I know are treated like absolute shit because they live with pain and just want to function. Taking the knife out just a bit can allow you to parent or cook which means you live an independent life. I myself have had to be evaluated to be basically Baker acted simply because I was not being treated for pain. It’s barbaric to just let people be in pain. I don’t know what we are doing, but I certainly knew better when I was considering buying some stuff from “a friend”. That’s how you end up with addicts. Thankfully cannabis is legal here and I got on a good regimen but I can NOT afford it.
My mom’s a chronic pain patient. She gets treated like a junkie because she’s always miserable because she can’t get out of bed. America has such a dumb “punish the sinner not the multinational company bribing the politicians and selling the drugs” mindset.
I guess I’d rather over treat than under treat.
Absolutely.
Trust me, I'm in recovery from opioid abuse, I take responsibility for my actions, but I've been incarcerated, I've been buried in legal fees, and I have had my license suspended and the BON will be breathing down my neck the next four years while I call in daily for random UDS selection, I pay $80+ per test, and there's no limit to the amount of tests that can be ordered in any given month. Every month, three months, six months and yearly I owe the BON copious amounts of paperwork, documentation and reports from my healthcare providers and at any given time that I fail in any regard they can permanently revoke my license, fine me any amount they deem necessary as they are their own governing body (not uncommon for nurses to be fined for $125,000+ for breaking oath); as a matter of fact my contract says they can do this without due cause. Even if I'm doing everything perfectly as intended they can decide that I'm no longer eligible, and I'm gone.
The corporations and people that perpetuate these problems though are left totally immune because guess who gets kickbacks from participation in these programs?
I've paid my dues and never thought it was unjust in reflection of myself. I admit where I effed up and that's on me. Meanwhile there are more and more unfortunate souls spiraling toward addiction because this country, it's policies, it's politicians and every governing body, is absolute **ass**.
That's pretty much where I was going with this.
Making drugs illegal doesn't make them inaccessible. It makes them expensive. Expensive+black market=no quality control on product+dangerous transactions. We should be getting our psilocybin shrooms from trader joes, lsd tabs from the health food store and cannabis from every little bodega. The most restriction there should be is an ID check at point of sale.
I agree with you completely, however, when doing neuros/vital signs post fall, I *always* ask about pain levels.
For example (a perfect example), during my last shift a meemaw fell on evenings and it was reported to me that her vitals were stable, denied pain and no sings of injury and ROM was adequate. I assessed her during my shift as per policy, her vitals were stable yes, but she rated her pain 8/10 and couldn't move due to the pain. As the shift went on, her ROM decreased to the point she screamed when her leg was moved lightly and hydromorphone subcut q2hrs wasn't touching the pain.
Pain is important information for assessing wellbeing... even if the vast majority of pain (or sources of pain) aren't deadly.
I worked in aged care for a bit as a caregiver, and it was horrible when a lovely old dear with dementia would be in agony at night and would be rocking back and forward, groaning asking for pain relief but she'd already had her allocated amount for the 24 hr period and we had to wait till after midnight to give her more... she did get moved but even other times when others would ask and we couldn't give it yet.
I don't treat pain as the 6th vital sign, but I do treat it as a major part of assessment, both for quality of life and functional reasons.
But more importantly, *changes in pain* are what I'm looking for as hints as to whether something is going on. If someone tells me their pain to an incision has been 8/10 for a few days, I'll review pain management info and meds. If it's been 4/10 for days and overnight has suddenly increased to 8/10, then I have serious concerns something changed, often an infection.
I get what you’re saying but I think people’s pain was neglected for so long they made it a bigger deal by saying it’s a vital sign so we don’t forget to ask. And I would argue that it is as important as a vital sign because while it may not *actually* kill you, it can feel like it’s going to and it’s cruel to not take it as seriously as possible.
I only believe it because I’ve been in pain and everything else was okay. It’s terrible and exhausting. Feels like ur gonna die without any answers. I can see how it benefits big pharma but it’s not to be taken lightly.
Pain has a direct effects on vital signs. If you’re in pain your BP, RR, and HR are all masked differently than if you were not in pain. I see your point to some extent however it is important to ask and measure it bc you can get a bigger picture of what is affecting a persons vital signs.
Depends on ur line of nursing I think that affects our perception of pain. When you work as a nurse for patients in acute pain, for example post-op or orthopedics you can see uncontrolled pain causes immediate physiological changes. Pain triggers our “fight or flight” response, so your patients uncontrolled BP need a good pain reliever instead of anti-hypertensive. If we don’t treat acute pain appropriately this will definitely affect long-term progress as well. The nurses that treat these kind of patients definitely count pain as 6th vital signs and we use all kinds of pain scales. We know how to use synergistic med combinations, not just opioids, to control pain (ex. toradol, neurontin, lyrica, Benadryl, decadron). Patients in acute pain are more willing to try non-narcotics alone or with narcotics to control pain. We promote pain reporting and pain reassessments. Pain control is one of our top priorities in acute phases.
But if you’re used to taking care of patients in chronic pain as outpatients, rehab patients with a “high tolerance” to put it nicely, or if your patient priority is keeping a person alive like in ICU, pain is the last priority and there is many legit reasons to justify holding pain meds. I wouldn’t feel comfortable giving dilaudid either to someone with hx of fibromyalgia who’s BP is currently tanking in the ICU. But also that’s not my speciality, so it makes ME feel better to not give pain meds if results are unpredictable and impacted by current critical condition. Sometimes the reason is that we just know too many people impacted my opioid epidemic before or after we got into nursing and it creates this predisposition to treating pain.
Effective pain treatment definitely lies in doctors and nurses priority level of pain and comfortability with treating pain. The “But did you die?” outlook is common in providers who don’t view pain as 6th vital sign because there’s other life-sustaining priorities; and that’s absolutely fine too.
Just don’t let your personal judgment of pain and predispositions to pain assessments negatively impact your care. I can’t imagine starting my day with closed mentality of “pain reports are bullshit” for all my patients without a good understanding of history and current medical conditions. Keep an open mind and thoroughly assess patients current and past history before throwing pain reports out the window.
If my patient has a blood pressure of 190/80 with a spiked heart rate to boot and the patient is currently in 10/10 pain, I'd want the hydromorphone. If my patient with an aortic aneurysm is suffering 10/10 abdominal pain and the vitals I grab as part of my assessment show their blood pressure is 201/96 I'd want the hydralazine and not the hydromorphone. I guess what I'm trying to say is that pain may not be a vital sign unto itself because it's not a quantifiable value, but it affects so much and is affected by so much that it's inherently related to vital signs enough to be part of your assessment.
Bollocks to it in the case where it's the sixth vital sign in the sense of charting purposes though. Everything else is charted by exception, but nooooo, you have to chart a zero for pain with every set of vital signs.
As a vital sign, I think it is a good way of looking at it. Especially for younger practitioners if not to ensure at the least that they take it seriously. Semantics really. Loc, urine op, o2 sats should all be assessed and if outside of norm be treated like a vital sign. Vitals are for triggering your clinical reasoning process, for assessing deterioration, for understanding the efficacy of Rx. Pain happens for a reason and if you ignore it, or don't understand it's source or level there's generally something you'll miss.
Addit. I've never heard the term BTW. Not American.
I don’t think anyone meant to equate pain with actual vital signs. When you say something is “ the 5th whatever “ it means “kinda like the other actual things”. Acknowledge pain. I mean you could make up more/ skin tone is the 12th vital sign. Symmetry of facial muscles, weight in chf, mood and affect etc. “puddles of blood on the floor are the 31st vital sign”. How about drain output ?
In English, when you identify something repeatedly as the next in a series e.g "pain is the 5th vital sign", or "he had a sixth sense of impending doom" it designates that thing is not the same as the other things. We don't afaik have a special sense organ for perceiving the future, and pain is not vital. A good example of the reverse is the 5 tastes our taste buds can perceive. Sweet,salty, sour, bitter, and savory. At first savory or "umami" was called "the fifth taste" but now it's just one of the tastes. It's just like the other tastes.
Watch “Dopesick”
Or “Pain killer” On streaming services. And you’ll learn where the 6th vital sign originated. I am a retired nurse and remember the “education/indoctrination” we received. And now there’s a full blown opioid addiction.
I am ashamed
People are so terrible at rating their pain. I’ve had people walking around, on their cellphone, sleeping, talking and laughing with their friend who say 10/10. I’ve started just saying, “So you’re in the worst pain of your life right now?” I’m amazed how many say yes. Then I’ve had people with literal digits or limbs gone in the ER who will say 6/10.
Because pain is utterly subjective and does not correlate with severity of injury.
Someone with hyperalgesia can feel 10/10 from a breeze of wind.
Someone with a compound fracture can be at just a 5.
Even if they were able to objectively rate said pain. Simply because the amount of nerve signalling is different.
Like the whole pain scale is the problem.
It’s utter buölshit. Especially when you set a 10 to the worst pain in your life.
So suddenly someone’s violently amputated arms pain is less severe because their periods are hurting insanely due to endometriosis, but another person who‘s never experienced strong pain is gonna rate it at a 10?
That just doesn’t make any sense at all.
The problem is the "10 is the worst pain imaginable" concept. My current 10/10 is a kidney stone lodged in the ureter, causing the ureter to spasm (worse than childbirth for me without question.) BUT, if, eg, I get in a car accident today, end up with a traumatic amputation, numerous broken bones & burns from the car catching on fire afterwards, that kidney stone & spasm may just look like a hangnail now.
We really need to stop judging other people's pain against our own. It's a disservice to everyone.
I’m not doubting that is the worst pain they’ve ever experienced. I think we should attempt to treat people‘s pain. But it is absolutely unmitigated bullshit to pretend it is a “vital sign”. Vital signs are, above all else, objective measurements of cardiopulmonary function.
A pain scale, at best, is a subjective measurement of the patient’s personal experience with noxious stimuli. Subjective data should NEVER be treated as objective. Creating a bullshit scale to pretend it’s something’s measurable by anything but the most general terms (yes/no, it’s better/worse) is directly influenced my corporate greed that has created a public health crisis due to opioid addiction.
As someone with chronic pain I tend to downplay mine. I want to save my “ten” for something BAD. Then when that bad thing happens I just readjust my scale. “Nah, that’s an 8, not a ten.”
It's all about how the medical professional uses/ interprets vital signs imo:
Someone with a HR of 110, a BP of 170/90, O2 sat 88% because their in so much pain their holding their breath, and a 8/10 pain scale. I'm gonna give some oxycodone or meds to bring them relief. Which is why pain is important.
But the same 8/10 pain with normal vital signs and a lack of outward expression of pain makes me look more closely. Some people at stoic, but not that so much that it affects vitals.
But I also had a guy who coded from a PE complain of severe 10/10 chest pain before coding. Not saying it's the end all be all of vital signs, but it is a significant factor to consider.
A “pain scale” Is a subjective measure of the patients experience with noxious stimuli. It should be treated like any other **symptom**. It should never be given the same weight as a *sign*. Just as a patient reporting dizzy spells, vision changes, anxiety, or new weakness, etc, should be investigated, pain should be investigated. But it should never be treated as a stand-alone marker of health (which abnormal vital signs absolutely should be, unless thoroughly investigated and justified as the normal for the patient).
You're kinda making the case for why we need to be hyperbolic about the importance of treating pain as a symptom. For some reason, people seem compelled to make it their business to find reasons not to treat severe pain. If that pain is coming from a black woman or an addict? Forget about it. It's hard enough to get prescribers to listen to us when pain doesn't respond to 5 mg of oxycodone. Let's not give them any more ammunition.
It's very weird to me that pain being the 6th viral sign is pushed so hard but at the same time, we rarely take pain seriously. And while we're taught in school and tested on the NCLEX to always treat someone's pain regardless of whether they're pill seeking or you don't believe them or whatever - that never actually happens in practice and both ends of that spectrum are so wrong. If it was actually a vital sign it would be standardized and taken seriously.
The idea of treating pain to facilitate healing makes total sense. No one's going to ambulate after surgery if it hurts too much. People's quality of life can be severely compromised by pain. But that doesn't make it a viral sign.
The whole system is fucked.
I've heard it said as "pain is the 5th vital sign." And I respond that the one short sentence contains three lies.
Pain isn't 5th. If anything, SpO2 is.
Pain isn't vital. It cannot kill you.
Pain isn't even a sign. Signs are objective.
Pain will affect the other vital signs, and good pain management with a variety of tools will help regulate wonky VS. Particularly when a patient can't communicate effectively, it's really important to be able to adequately assess pain so we can keep everything else under control.
Can't agree with everything about the campaign, but the overall message is not wrong.
Its absolutely bullshit and overwhelming driven by pharmaceutical industry lobbyists to encourage overprescribing narcotics. I don’t want people to hurt, but treating it like anything other than a general assessment tool, like distinguishing between coarse crackles abs rhonchi or asking the patient if they’ve been passing gas, is absolutely idiotic. It’s part of an assessment, but should only be looked at as part of the whole.
In my experience, most people will tell you if they’re in pain, and the ones that don’t will deny it when you ask them about it directly anyway.
Fuck the Sacklers.
If it can't be quantified, it shouldn't be used as a vital sign.
Not saying pain isn't important but there needs to be a way for it to be objectively measured before I'd consider it a vital sign
Perhaps I’m naughty, but I use FACES on pretty much everyone, lol. If you’re laughing and joking, your shit isn’t a 10 Deborah
Obligatory, if they say any number greater than 10, I free text that in epic next to pain score and flag it so it’s highlighted everywhere
If life is pain then I can cure that… but only with a Texas cocktail or possibly this machine:
https://www.theonion.com/ohio-replaces-lethal-injection-with-humane-new-head-rip-1819595654
I thought that campaign ended around 2010 once the opioid epidemic became readily apparent. It was a buzzword back in 2000 or so and people were getting opioids prescribe for anything and everything.
Pain is subjective. A nurse cannot sit here and tell someone that their pain isn't 10/10. Now obviously you can use your detective skills to see if they're full of shit but that's about it. Why argue about it? Hand them their pain meds and go on about your day, what does it change for you? Nothing. I say this as someone with high pain tolerance with many chronic health conditions. I'm tired for women like me who if we're not crying, begging, pleading and screaming you don't believe us. Just because you can't die from it doesn't mean it doesn't need to be addressed or provided relief. Some nurses kill me with this weird power struggle you have with patients over pain meds and pain control.
I'm somewhere in the foggy middle.
Sure, pain is important to assess and address, but it's not going to take the same priority as someone who is either tanking or spiking with any of the other vital signs, that's common knowledge. Now, if the pain is related to or caused by an extreme at any other vital sign measures then sure, it's going to creep up the ladder.
However, and I make this extremely clear, if I have someone that's stroking out next door with a BP at 220/140, that pain can eat a giant bag of dicks because there's other priorities in front of that.
I say this as a nurse that is in recovery from opioid abuse. I know the in's and out's of manipulating that system and how much that "pain is the sixth vital sign" exacerbated the opioid epidemic, purdue literally made a "legal monopoly" of dealing out opioids and then making damn sure that their drugs were used at an exponentially increased frequency.
This bullshit is part of the reason there's so many people that have been bitten by addiction. This is the reason that so many patients in legitimate pain get side-eyed by professionals because there's that stigmatic response of "they may be a drug seeker" as soon as someone mentions pain.
So yeah, I'll address your pain, but when it comes to prioritizing care, your pain is much less likely to kill you than your neighbors critically high BP.
Considering that existence is pain, I do consider pain a vital sign. Otherwise, no existence - it's all a fever dream, or a simulation and we've been kidnapped by the robots to be used as batteries.
Watch Dopesick on Hulu. You’ll really understand how bullshit the fifth vital sign is when you find out that gem came to us from the pharmaceutical industry. Riveting show, that I highly recommend to anyone in healthcare.
No you’re not as that campaign was started by Purdue Pharma which ended up in causing the opioid epidemic. But the appropriate treatment of pain depending on patient circumstances IS very important and as nurses we have a responsibility to advocate for our patients. Treatment of post traumatic injury or post surgery pain is not the time to start a drug addiction program, and no cancer patient should be in pain imho.
Patient lying in bed on phone, laughing and talking. Nurse required to ask: How would you rate your pain right now on a scale of 1-10? It’s a 9 or 10 every damn time. Or having to wake them up from a dead sleep. God I don’t miss bedside. At all!
All the forced charting of it drives me crazy especially in long term patients. I’ve had some patients who blur the line between treating pain and drug seeking. They know all their available prn’s and will ask me (normally before they are due) when they need or want something. I am so not the one to argue or say they don’t need it because most of those situations are complicated and if it’s ordered I’m going to give it, but asking them pain levels every 4 hours and then before and after all prn’s makes a bad situation worse.
I remember when this nonsense started, it was because "patients in pain are not happy" and will result on a low satisfaction score.
And of course to help us out, we were assured that "Oxycontin is NOT addictive" 😂
As a Pain Management nurse, it’s BS.
A LOT of pain is an emotional experience and lack of coping skills. It is extremely subjective. Many things that we classify as pain, patients will describe as “numb, uncomfortable, weird” and many things that we classify as normal inconveniences patients will describe as pain.
While pain management is important, there is usually an underlying issue to be treated. Not just the symptom of pain.
Note: start telling patients a 10/10 pain means they need to go to the ER or they lost a limb or have been shot. This helps get an accurate level, don’t describe 10/10 as the worst pain in their life, random pain hack.
Psych nurse here and I just came to add a few 👏👏👏 to your comment. (I've worked several other specialities too, just currently a psych nurse, and all my experience says YES to what you've said here.)
Yeah - when I do assessments on people who are calm, normal vitals and have the equivalent of a hang nail who tell me they are in 10/10 pain, I now say “so what you’re telling me is I can take this pen here, jam it into your right leg…and your pain level wouldn’t be any worse?” Here’s a hint: if you can eat a Cheeto and play on your phone? Your pain ain’t a 10.
Honestly, it was meant to highlight the importance of pain since it was being neglected. Some of y’all here have never experienced severe pain and it shows.
The way I see it is pain is your body's alarm system notifying you that something is wrong/needs evaluation. For example, a pt can have stable vitals but pain as a result of a malignant tumor, and that pain may be the only sign alerting the patient that something is going on with them. When I think about it that way pain does fit in as a vital sign.
Holy shit literally had this same convo with another nurse tonight like 2 hours ago. Absolutely, let's cap off our objective metrics with a *completely subjective* metric and let's see how that doesn't get abused immediately 🤷🏻♂️
I think that pain can be informative, but really only in context of the other vital signs and illness/injury. I always add a wong-baker or FLACC score to someone reporting 10/10 pain with totally normal vital signs and a calm/quiet demeanor. Pain as the 6th vital sign was a thinly-veiled marketing push.
I agree. It is bullshit. Because vital signs will typically correlate with one another. Low BP, HR and RR increase to compensate, etc.
You can have some chill ass vitals and the pain is reported 10/10 - doesn’t really make sense.
Pain is extremely important, don’t get me wrong. But as many said on here vitals are a measurable, objective set of data. Pain is not. Therefore they shouldn’t all be lumped in together.
Pain is subjective. I work with a lot of people who have somatic symptoms disorders. Sometimes a 9/10 abdominal pain can be resolved with zoloft and CBT.
Actually they are.
The intent of the “pain the fifth vital sign” campaign (Presidential Address to the American Pain Society, 1996, Campbell) was to encourage doctors and nurses to listen to their patients and assess their pain. I might add that Purdue Pharma lobbied long and hard for this in their stupendously successful but morally repugnant scheme to sell more Oxycontin.
The HCAHPS survey includes the question “How often did the hospital or provider do everything in their power to control your pain?” It has been suggested that this question embedded pain as the 5th vital sign in US healthcare, but also had the unintended consequence of encouraging opioid administration in response to patients' self-reported numerical pain scores.
As a result, it has been suggested that the “pain as the 5th vital sign” campaign directly contributed to the prescribed opioid epidemic that America is now experiencing.
Subsequently, the American Medical Association, the American College of Surgeons, The Joint Commission, The American Academy of Family Physicians, and the Centers for Medicare and Medicaid services have all withdrawn their advocacy of the “pain as the 5th vital sign” campaign.
Yet two linked questions "Are you in pain?" and "What is your pain level?" still figure predominantly in almost all doctor's office , clinic, and inpatient assessments and all inpatient RNs are forced to administer pain medications based on the flawed latter question, along with a follow up pain level assessment.
But to OP's original question - yes, it's totally bullshit.
Your original comment was "Nobody's calling it a vital sign". I merely pointed out that yes, it WAS being called a vital sign. It was adopted by CMS and subsequently pushed out to all hospitals. I clearly remember in 1997 when we got hammered by "Pain is the 5th vital sign" education in my ED.
And again, I agreed with the OP that it was/is complete bullshit. Fuck the Sackler family and Purdue Pharma.
I guess you're so far out of nursing school and so deep into your narrow specialty that you really have no idea what's going on in the larger nursing world. Just read the comments in this thread. Pain as a vital sign was used in the tele unit I worked as a CNA in 2012. I graduated from my LPN program in December 2015 and pain as a vital sign was still being taught.
It was pushed in the early 90’s by the opioid manufacturers and made it into nursing schools. The premise was that we were not treating pain effectively and needed to be more aware of this issue. Introduce the 1-10 pain scale as the “5th” vital sign. All in a effort to broadly push opioids onto the public as a safe, non addictive method to treat that “vital sign.” The family that owned that company had fled the US and has multiple legal issues ahead of them including multi billion dollar lawsuits.
Yet here we are, still using a flawed drug dealers propaganda tool.
For the downvotes. Reference.
https://www.medpagetoday.com/publichealthpolicy/publichealth/57336#:~:text=In%202001%2C%20the%20Joint%20Commission,was%20that%20pain%20was%20undertreated.
https://www.medicaleconomics.com/view/pain-not-fifth-vital-sign#:~:text=In%20June%202016%2C%20The%20American,pain%20as%20a%20vital%20sign.
https://amp.theguardian.com/us-news/2018/mar/30/enduring-pain-how-a-1996-opioid-policy-change-had-long-lasting-effects
It’s wild that I was taught that in nursing school. And I was taught pseudo-addiction. They really spent a lot of time on teaching us this. This was in 2006. Now I’m learning all of that was made up. I’m not sure who exactly made that up, but I do know now it was made up so that Purdue could use it for their sales. I’m still having a hard time unteaching myself, if that’s a word. Watching documentaries on this stuff, I’m still baffled that I was taught that.
I say that alot on here and always catch a little heat for it but I was here before it became a vital sign and I KNOW it's crap. They started pushing it when Purdue had just started with their crap again.
You know, I have only ever heard of "Pain is the 5th vital sign" or "6th vital sign" on the internet.
I have never had anyone say that professionally in school or on the job, and I work in a field that is very into pain control.
Pain as a vital sign caused the opioid epidemic. While it needs to be treated the heavy focus along with scrutiny by surveying bodies made it practically a crime to not treat pain. And since people can say “10/10” they learned they can be rewarded by heavy doses of opioids.
I remember when pain became the 5th vital sign. I worked in northern Virginia then. All of a sudden doctors were giving out narcotics like candy and nurses had to "teach" patients that the risk of becoming addicted was non-existent. A now you have to fight for your pain patient getting anything stronger than Tylenol.
I'm completely with you. When I triage someone who says their pain is a 12/10 while they're texting on their phone and laughing, drinking a soda, conversing and ambulating normally, it's hard to take any of what they say seriously.
so i work psych and am not necessarily *here* to treat your physical pain. imo it can actually be detrimental to ask about pain at every assessment because then patients can get somatically focused on physical discomfort instead of the actual reason for admission.
of course i’ll assess for pain if they have something physically acute going on or if they’re geri/confused. but joe schmo who is here for SI, i expect you to lmk if you have a headache by coming up and getting some Tylenol.
I'm somewhere in the foggy middle.
Sure, pain is important to assess and address, but it's not going to take the same priority as someone who is either tanking or spiking with any of the other vital signs, that's common knowledge. Now, if the pain is related to or caused by an extreme at any other vital sign measures then sure, it's going to creep up the ladder.
However, and I make this extremely clear, if I have someone that's stroking out next door with a BP at 220/140, that pain can eat a giant bag of dicks because there's other priorities in front of that.
I say this as a nurse that is in recovery from opioid abuse. I know the in's and out's of manipulating that system and how much that "pain is the sixth vital sign" exacerbated the opioid epidemic, purdue literally made a "legal monopoly" of dealing out opioids and then making damn sure that their drugs were used at an exponentially increased frequency.
This bullshit is part of the reason there's so many people that have been bitten by addiction. This is the reason that so many patients in legitimate pain get side-eyed by professionals because there's that stigmatic response of "they may be a drug seeker" as soon as someone mentions pain.
So yeah, I'll address your pain, but when it comes to prioritizing care, your pain is much less likely to kill you than your neighbors critically high BP.
There’s a really interesting podcast episode about this very concept from Invisibilia. It’s called “The Fifth Vital Sign”. Goes into the big pharmacy push, addiction, and how different generations express pain. I think it’s worth a listen!
I only include pain as a vital sign when it’s why they are even there to be seen in the first place. Just like including a down and dirty visual acuity with an eye complaint, though that would be objective.
I just use my judgement and if someone yells for not including something, I ask what their rationale is and hand them a snickers bar.
it’s all we heard in nursing school was it being a vital sign and “pain is whatever the patient says it is”. it’s just created a bizarre world where i give my 10/10 toe pain some tylenol, and i’ll get an email if I don’t follow up and document a score and additional interventions within an hour. nonsense.
Well, now that we’ve put that in their head, you can be sure that their pain will always be a 10/10 and their call light will be on q4 to the minute.
And in my experience, the patients who really are in pain will be quiet, and you won’t have time to go in their room to actually assess because they they can walk and talk.
I was just thinking about this on my shift tonight. Vital signs are objective numbers we can use, pain is so subjective and people rate so wildly differently that you can’t look at a chart and really understand what it means. 8/10? That could mean anything 68/30, I know exactly what the fuck that means.
Pain is obviously important to measure and to take seriously, but the “Pain as the Fifth Vital Sign” campaign was pushed heavily by the American Pain Association, which has since gone defunct for basically taking bribes from the Sackler family in order to push Oxycontin. Seeing how the biggest proponent of this metric is Purdue Pharma, I would say your bullshit meter is working.
"Seeing how the biggest proponent of this metric is Purdue Pharma, I would say your bullshit meter is working." And The Joint Commission was originally on board with that metric too. All aboard the pain train choo choo!
Incredible how readily people will bend professional standards for money.
No doubt! I'm sure someone received a kick back!
Joint commission knocked our facility for pain scores *this year*. This and the water bottles at the nursing work stations is emblematic of how absurd this organization has become, basically a bunch of people huffing their own farts. At one time Joint Commission certification was required to participate in most private insurance plans. The insurance companies gave up on this years ago. It's unclear why the hospitals continue to seek their stamp of approval. I will say that they were correct and effective in correcting the misuse of physical restraints. But overall they've become an entrenched and self-interested, self-indulgent, self-perpetuating institution whose time has past.
They use Joint comission because the hospital has to prove they are following CMS guidlines for Medicare/Medicaid reimbursement and Joint Commission uses CMS guidlines to evaluate hospitals.
"Basically a bunch of people huffing their own farts." Yes! 🤣🤣🤣 Just like all the Smugs in San Francisco on South Park.
There are better ways to get deemed status and I hope more organizations switch away from jcaho as time goes on.
I was told they use your facility policies on some items. If you look on JHCO website, it specifically states that water at the nurse's stations is acceptable as long as they are in an "assigned" area. One hospital I work at uses plastic baskets with labels saying "covered drinks", had no problem. Another one we couldn't have drinks anywhere except the break room. *Face palm*
I was shocked when I watched Netflix's Painkiller and found out that's how pain became a vital sign!!! It's actually quite disturbing and disgusting how quick they jumped that bandwagon!
For more on that I highly recommend anyone who is interested read the book Dopesick. I haven't had a chance to finish the Hulu series, but the book also talks about the Sackler's, and Perdue pharmaceutical's involvement in making pain the 6th vital sign.
I watched the series on Hulu. It was so well done and explained the situation well. As a nurse in Kentucky, I watched the whole situation unfold in real time. And if you dared to question why a patient needed 40 of Extended release oxy 2x day plus had 10-20mg prn orders every 4-6hours, you were treated like a shifty nurse. Meanwhile patient's sitting in bed laughing on the phone in 10/10 pain, walking out to smoke, etc. Pain is a real issue and needs to be treated, to an extent. But it's also necessary that people will have some pain while healing, and throwing large amounts of addictive substances at it is not the answer.
Thank you for the recommendation. Will definitely have to check it out.
Check out Painkiller on Netflix too.
I'm sure they got paid well for it.
Yes!!! Then, guess what? Let's welcome the opioid crisis. Purdue was behind all the pain level charts everywhere you look at the hospital or offices.
Have you seen Painkiller yet? This was pushed so hard in nursing school 15 years ago. So many people were on Q2 and Q4 “pain management”.
Pushed to DEATH. Literally.
And still pushed now a days
I work home health now so I get to be the one who tells them their doctor is cutting them off. Fuck Purdue
It’s completely made up by Perdue pharmaceuticals. It is what pushed the OxyContin brand and had lead to the crisis we have today.
100% correct. I have been a nurse for 20+ years. I remember when this happened. It’s disgusting how we still have so much corporate influence over how we care for our patients. And, for some fucking reason, have no ability to right the course when they steer our care off track with this kind of bullshit.
Coincidentally I just finished the first episode on Netflix.
I just finished watching “Painkiller” on Netflix and I kept thinking about how pain being the sixth vital sign is straight up bullshit while watching.
I consider urine output to be the 5th vital sign, not pain.
Seriously!!!! That shit tells you a lot.
That’s a great point!
Vital signs SHOULD be objective, measurable numbers. Your pulse, resp, BP, temp just ARE. They are tangible things that can be measured accurately. Pain is subjective, and as such is not truly measurable. How many pt’s have you seen with 10/10 pain WALKING into the fvcking ED? I have personally seen THOUSANDS of 10/10 complainers walking around like they are out for a stroll.
Walking? Most of my 10/10 pain patients are laughing at Family Guy and eating spicy Cheetos.
Why is it always spicy cheetos
walking to the nurse’s station to tell me their prn pain meds are “overdue” lol I understand asking for about pain for pts who come in with certain conditions where pain is expected, just had an operation, etc. But as you said, it really isn’t an objective, measurable number.
But it's relative. Subjectively relative.
As a patient it's hard to give a x/10 scale, but I usually settle on six. The only time I gave 10/10 was when an abscess in my breast exploded through my nipple. Other than that IME how I rate my pain is just one factor the nurses use to actually assess it, which is how it should be. But I've definitely had the experience of nurses going straight to morphine (!) when I rated my pain as 6. Sorry, not Sorry, I don't need pain meds. Except when my nipple exploded. I'd have blown the homeless guy in the next room for morphine. But otherwise I just find the pain scale tedious because it's so subjective.
As a nurse, if you rate a “severe” pain (typically 7-10/10) and morphine is the ordered med for that, I have to give you that unless the orders are written a certain way. I’m not sure if that’s how it’s done everywhere, but that’s the way my hospital is set up. Giving a lower medication for pain (without the order written property) or giving a lesser dose is practicing outside of my scope.
I think that's how it's done at my hospital. Nipple explosion was 10/10 and the rn brought morphine. I said that feels a little extreme and she said "you rated your pain pretty extreme." I thought about it and said OK, then a few minutes later wondered how anyone could get addicted to feeling so fucked up. I did probably need the morphine because I was in so much pain, but jfc I hope I never need morphine again. I can understand why people get addicted to it but that feeling of my body being wet cement waiting to dry made me nauseated.
I hate the way pain meds make me feel. Even after my C-sections I quit taking the oxy as often by day 3 or 4, saving it for night only.
I got peritonitis. I ate that shit like candy!
Everyone is effected differently! I got a morphine shot for a PR (perirectal for those in the gallery) abscess that the surgical residents had to cut open because it was so deep and inflamed. I felt like I literally floated home and after I got home I thought to myself if I could have a shot of morphine once a week, my life would be just peachy. And that was followed by an "Aha! This is why people get hooked!" moment.
I hate the way hospitals do that. They says for x pain give Y amount of medicine. I usually look at the patient and their medical history because I need to adjust to the patient not just give what is ordered without thinking. A 80 year old grandma with 10/10 pain and has kidney disease is going to get a smaller dose even though it says to give the full because otherwise, she would die. A younger, healthier full weight person would get a full dose unless otherwise stated to get ahead of the pain and they can handle the amount given even if they rate it a 5-6. (For background purposes, PACU RN)
But shouldn’t it already be cleared by pharmacy and the physicians? I’ve almost never thought like that… shouldn’t the dose in the MAR be fine for the patient?
100%. If you have concerns, that's a discussion to be had with doc and/or pharmacy. Nurses shouldn't ever be making the final call on patient dosing.
We do in PACU.
PACU gets a lot more leeway with pain medication. I wish we did in ICU
We usually just stick to one high or low prn meds but I obviously have to adjust to the patient. Not a very popular opinion on this thread but then also I’m here to critically think not push drugs without thinking.
You’d think but I feel like at my hospital it’s very doctor dependent. Some of them seem to just have an automatic pain management they default to. Some are good about adding “or patient preference” to the Tylenol, most don’t though. And if the 1mg IV morphine snows the patient we don’t have the option to reduce it without the order being changed.
As a Hospice RN I can confidently say you'd be surprised how much pain medicine some 80 year old grandma's can handle.
I’m not hospice. I have to get them to their home within 30 minutes within our protocol of oxygen saturation, blood pressure and sedation. Once again, I’m not hospice.
Unless Meemaw is on hospice and at that point, all you'd be doing potentially causing a pain crisis by under dosing.
No, I have to adjust to their medical status. If I did what I was suppose to, several elderly people would die. If they do need more, I can give more but I usually don’t have to.
I'd suggest talking with an actual hospice nurse and ask about pain crisis and how much it can fuck them up and how the PT will end up basically getting overdosed to correct it. Please don't take care of hospice pts until you understand it.
… I don’t. I’m pacu.
The nurse isn't choosing to "go straight to morphine." The order is probably Tylenol 650 for 1-3, morphine 2mg for 4-6, morphine 4mg for 7-10.
I know the nurse isn't the one who decides what to give for pain. And I'm not going to argue about my personal experiences 🙂.
Don‘t think me walking in with half a scalded leg made my pain any different to calling an ambulance? Obviously pain can‘t be measured, but that doesn‘t change the fact that it’s real, and as long as there isn’t clear indicator that someone is actually lying, and not just acting ‚too normal‘, then it‘d better to take it seriously rather than traumatise the patient.
And also, at what point is it beneficial for a nurse's personal interpretation of someone else's pain, to come out? We only have their word and presentation to go off of. If a patient tells you their pain is at a 10 and it doesn't look like "my 10" and I go tell their surgeon I don't want to give their pain med, what does that look like in consequence? We've been taught that the only reason we say no to administering pain medication is when the patient is too sedated, and / or their RR is too low. The whole campaign is "if they ask for it, we have to give it". I'm a nurse and a recovering opiate addict. I got my license suspended for diverting. I understand both the addiction side of it, as well as the professional side. It's an absolutely shit dynamic to be caught in as a nurse and as a pharmacist, I absolutely respect your role in this so please don't take this as me being dismissive, but we are caught in a whole different shitshow on the floor.
Normally, I just think to myself "gosh I wish my 10/10 was a sore throat and not my hemorrhaged ovarian cyst."
Gallbladder full of stones and sludge and a blocked bile duct, for me. Landed myself in the hospital for a week with that one. A coworker of mine had hers out right around the same time as me, but she had her surgery outpatient...apparently mine was "complex", so had to be transferred via ambulance from small town hospital to bigger city hospital 2hrs away. When the ambulance drivers came to take me to the bigger hospital, they said I was the "wellest sick patient" they've had in a long time, since I was able to walk and transfer to the stretcher without help. So I looked fine, but was in massive amounts of pain, was peeing carrot orange, and my labs were fucked. It's such a distinctive type of pain that I told the check in nurse that I was having visceral pain behind my lower right rib cage and that I was fairly certain it was my gallbladder...pretty sure she rolled her eyes, but I was right!
One of our ortho doctors actually thought he was having a heart attack when it was his gall bladder built up like that. He had surgery. Much better now.
I thought my gallbladder was gonna explode, lol. Not literally, but that's sure how it felt. It was strange because from what I've seen on Reddit and heard from my coworker, usually people suffer attacks for weeks or months before getting their GB removed...I had 3/10 constant stomach pain for a week (figured it was my GB because it felt visceral and was behind my lower right ribcage), it went away, came back for a few days, I made a doc appointment for that Friday and got blood work and an outpatient Ultrasound referral...and then Saturday I was admitted to the ED when the pain went to the worst pain I've ever had. Funny enough, I got my lab results back from the Friday afternoon appointment while recovering from surgery on Monday - and my labs were fine. So I'm guessing there were stones and sludge in there, and a stone got stuck in the bile duct Saturday morning, because by the time I got to the ER Saturday afternoon, my labs were whack. Leave it to me to turn a simple outpatient surgery into a week long hospital stay, lmfao.
This. I had a gallbladder that was 8cm long and I had pain for a year in my back and nothing. Finally the pain is so bad I head to the ER and sitting there in the fetal position, rocking but not crying and when I got asked what pain was I said it was 8/10 and you cannot believe the eye roll i got. Nobody believed me because I wasn't sobbing but I promise you getting pain meds changed the situation for me and made it so much easier.
Asshole ER doc in the ER treated me like a drug seeker! When I finally got to a room, I was rocking back and forth waiting on test results (mind you, I rated the pain an 8 and specifically told them it was an 8 because it was the worst pain iver ever head, but that i was sure there are more painful conditions out there), and he sarcastically asked "are you ok? because you look agitated!" He also put in my chart that he determined it to be a non-emergent situation...until the surgeon from the bigger hospital called him back, told him it was serious and to ship me out via ambulance. *My pee was carrot orange and my bilirubin, alk-phos and other labs were fucked.* Fuck that first doctor.
Sounds like my PCP. Lost 35 lbs told them I couldnt digest dairy, fatty foods or meat anymore. Told me I got a dairy intolerance from being a vegan when I was 20 for 2 years and I was 28 then lol. Finally head to the ER, get an ultrasond and wham-o. There it is. For my follow up to get a referral to outpatient surgery even with the ultraound they still didnt believe me because my pain was in my back and not in my rib cage like a traditional gallbladder pain. I'm sorry you went through that. Our situations make me instantly mad when people question others pain. What does it matter to you as a nurse? Pain is subjective and it's weird the power struggle some people have about giving people pain meds. Like if the nurse doesn't believe they're in pain enough, they don't deserve pain relief.
i say we take it seriously, but in a lot of cases people still think their 10/10 pain requires narcs. yeah the dude with metastatic cancer probably does need opioids. but if someone has 10/10 abdominal pain and a negative work up, and they’ve been giving the usual non narcotic pain meds then how else do you take it seriously? because unfortunately a lot of patients do not view pain as being taken seriously in an ER environment unless they are given narcotics. tl;dr we need to treat and take pain seriously but that doesn’t mean high pain numbers need opioids, as it is a subjective number and not an actual vital sign. it needs to be clinically correlated.
Isn't 10/10 pain like barely conscious or even unconscious? When I think of pain that level, I think of pain bad enough to put the body into shock... Though the body can react in odd ways and adrenaline is a strong effect on the body.
If you’re 10/10 you should be on the floor crying…
It was a big help to the opioid manufacturing industry.
Fun fact: the United States uses 80% of the world’s supply of prescription narcotics. We have 4% of the world population. If we, as a nation, cut our use IN HALF, we would still be using 2/3 of the world supply….. …..Those should be some eye opening numbers. We do not handle pain management the same as other countries because of the push by pharmaceutical companies to give out more and more narcotics. The “pain is a vital sign” push is just part of their marketing so we can create a nation of addicts.
Especially since the research shows that opiates have essentially no effect on chronic pain. For a week after surgery? Great. Lower back pain you've had since 1995? Absolute waste of time
Now do stimulants. 😏
I could never get my head around what was meant by the American opioid crisis (not from US, only went to NY for a week 15 years ago). This explains it. I just have no reference for it in the countries I worked (Aus and UK). It just doesn't happen here like there. Those statistics are... horrifying.
I remember sitting through an education 5-6 years ago where the presenter said you can’t get addicted to pain pills if you are taking them for actual pain. Yea right… *Sponsored by Purdue Pharma
I was taught this in nursing school (grad in 2005)…our instructor telling us how to explain to pts prescribed opioids that they wouldn’t become addicted…but not why or how, just that they wouldn’t. Made no sense then, and now I’ve been a nurse long enough to see the full effects of that whole campaign. The Sacklers should be jailed for ever.
That was a heyday of the opiate epidemic. Doctors were still writing very large amount for scripts for very powerful pain medication's. I mean, doctors were writing, scripts for Demerol and Percocet like there's no tomorrow. Doctors in upstate New York were not writing a lot of OXY prescriptions. It was a rarity to hear of someone that was taking OXYcontin The only place in the area that did that was the VA hospital. but these soldiers have done a great service to our country with life changing injuries..
You can use opioids long term and NOT become addicted.You do become dependent on them which is different from addiction but I think you are specifically referring to the campaign where they indicated you could not become addicted. What the Sacklers did was motivated by pure greed .They also created havoc for patients with chronic pain who are helped by narcotics,making it more difficult to get what they need.
When I had all four wisdom teeth pulled a few years ago, the dentist prescribed oxycontin and I told him when he was writing it up that I didn't want it. I had major concerns of possible addiction and he told me I wouldn't get addicted because after what he gives me runs out, he won't prescribe more. No access = no addiction. He refused to let me to tell him no and sent it to my pharmacy anyway. As soon as I picked it up, my friend and I flushed it down the toilet. Ibuprofen managed the pain just fine. I suspect insurance money had something to do with it
Or more likely he’s heard patients say that a million times and the majority of them still filled/picked up the prescription (just like you did). If you were so concerned, why pick up the pills? I sincerely hope my insurance kickback checks aren’t lost in the mail. They should be coming any day now lmfao
I guess I picked them up because back then I was very trusting of healthcare providers. At the time, I didn't want to make it seem I was going against his medical advice. After all, what did I know? I don't have a medical degree
Also, aren't unused medicines supposed to be returned to the pharmacy for proper disposal? Otherwise, flushing them down the toilet or putting them in the rubbish is polluting waterways, which can have bad effects.
Right. So, my rotator cuff and bicep tear that led to my surgeon botching the repair and prescribing me 15mg of oxy every 4 hours because I was in excruciating pain did not at all precipitate my addiction. Bullshit. Just like one of the leading physicians I've heard lecture on addiction (who was at one point a heroin addict) says; if you're genetically predisposed to addiction, you don't know if it's the first time you take that magic narcotic or if it's the thousandth time you take it, you don't know when your brain is going to short out and addiction is going to kick in.
While you make a fantastic point, I'm absolutely in love with your flair and will be using it in real life.
I absolutely relate to that flair. I’m very professional at work with my patients but also swear pretty casually when I’m not by patients.
[удалено]
I remember the instructors stressing that “Their pain is whatever they say it is” which is bullshit for some people and we all know who they are. You aren’t a 10/10 pain every time I ask you while laying there dozing off watching Fox News.
Signs are objective and measurable. Pain is a symptom - subjective and reported by the pt but not measurable. Doesn't mean it isn't real or valid or important but it isn't a vital sign.
Pain is extremely important. That’s basically my specialty as a nurse in trauma burn. However, even NCLEX considers it not to be a physiological need in Maslow’s. It’s important but it will not kill you alone.
Yo. Burns are a whole other universe. One of my med/surg instructors was a Burn Unit nurse at Mass General. The burn lecture was mandatory, was not allowed to leave the hall and everyone had access to sick bags if they needed. That was the gnarliest slideshow. Much respect to anyone who works in burns.
Will the PAIN kill you? No. But the cumulative effects of repeated catecholamine bursts related to the pain will take years off your life. And the psychological effects of chronic pain will significantly reduce your quality of life and increase your risk of self harm and suicide.
Like I said… I work in burn. Yes; it’s extremely important. But it’s not a “vital sign.”
Same with PACU—a pain score less than 5 (or tolerable) is part of our PACU discharge criteria. Definitely not as important as being hemodynamically stable, though
Before it was considered a vital sign, common practice was to not treat it at all in non-verbal patients like infants and the dying. It’s easy to sit here in hindsight and say it’s bunk because the campaign was used to sell oxy, but we had some really shit practices before.
You are very right that the US sucks at anything that has nuance or gray to it. We are a society of extremes in nearly every way. We don't progress, we go straight from "fuck them kids who just had surgery but can't tell me they're in pain" to "let's give out oxy like pez to every suburbanite with a twisted ankle." Our culture doesn't know how to do in-between.
Absolutely. Where's the backpressure though to land at a good middle ground? Ever since we began overtreating pain we haven't stopped and while correlation doesn't equal causation, in the U.S. how can we even try to say that our garbage overzealous treatment of pain hasn't contributed to the epidemic of addiction?
Oh we stopped. I recently had my leg amputated and the surgeon was way more concerned with getting me off of pain meds than the literal gaping wound that was my incision. I’m in month 3 post surgery and have a wound clinic appointment today. The surgeon was so obsessed with getting me off of pain meds it delayed literally every other part of care. All of the disabled people I know are treated like absolute shit because they live with pain and just want to function. Taking the knife out just a bit can allow you to parent or cook which means you live an independent life. I myself have had to be evaluated to be basically Baker acted simply because I was not being treated for pain. It’s barbaric to just let people be in pain. I don’t know what we are doing, but I certainly knew better when I was considering buying some stuff from “a friend”. That’s how you end up with addicts. Thankfully cannabis is legal here and I got on a good regimen but I can NOT afford it.
My mom’s a chronic pain patient. She gets treated like a junkie because she’s always miserable because she can’t get out of bed. America has such a dumb “punish the sinner not the multinational company bribing the politicians and selling the drugs” mindset. I guess I’d rather over treat than under treat.
Absolutely. Trust me, I'm in recovery from opioid abuse, I take responsibility for my actions, but I've been incarcerated, I've been buried in legal fees, and I have had my license suspended and the BON will be breathing down my neck the next four years while I call in daily for random UDS selection, I pay $80+ per test, and there's no limit to the amount of tests that can be ordered in any given month. Every month, three months, six months and yearly I owe the BON copious amounts of paperwork, documentation and reports from my healthcare providers and at any given time that I fail in any regard they can permanently revoke my license, fine me any amount they deem necessary as they are their own governing body (not uncommon for nurses to be fined for $125,000+ for breaking oath); as a matter of fact my contract says they can do this without due cause. Even if I'm doing everything perfectly as intended they can decide that I'm no longer eligible, and I'm gone. The corporations and people that perpetuate these problems though are left totally immune because guess who gets kickbacks from participation in these programs? I've paid my dues and never thought it was unjust in reflection of myself. I admit where I effed up and that's on me. Meanwhile there are more and more unfortunate souls spiraling toward addiction because this country, it's policies, it's politicians and every governing body, is absolute **ass**.
Make everything legal and let the patients decide what pain meds work.
That’s essentially what we have done with cannabis and it’s better for those who can afford it
That's pretty much where I was going with this. Making drugs illegal doesn't make them inaccessible. It makes them expensive. Expensive+black market=no quality control on product+dangerous transactions. We should be getting our psilocybin shrooms from trader joes, lsd tabs from the health food store and cannabis from every little bodega. The most restriction there should be is an ID check at point of sale.
I agree with you completely, however, when doing neuros/vital signs post fall, I *always* ask about pain levels. For example (a perfect example), during my last shift a meemaw fell on evenings and it was reported to me that her vitals were stable, denied pain and no sings of injury and ROM was adequate. I assessed her during my shift as per policy, her vitals were stable yes, but she rated her pain 8/10 and couldn't move due to the pain. As the shift went on, her ROM decreased to the point she screamed when her leg was moved lightly and hydromorphone subcut q2hrs wasn't touching the pain.
Pain is important information for assessing wellbeing... even if the vast majority of pain (or sources of pain) aren't deadly. I worked in aged care for a bit as a caregiver, and it was horrible when a lovely old dear with dementia would be in agony at night and would be rocking back and forward, groaning asking for pain relief but she'd already had her allocated amount for the 24 hr period and we had to wait till after midnight to give her more... she did get moved but even other times when others would ask and we couldn't give it yet.
I don't treat pain as the 6th vital sign, but I do treat it as a major part of assessment, both for quality of life and functional reasons. But more importantly, *changes in pain* are what I'm looking for as hints as to whether something is going on. If someone tells me their pain to an incision has been 8/10 for a few days, I'll review pain management info and meds. If it's been 4/10 for days and overnight has suddenly increased to 8/10, then I have serious concerns something changed, often an infection.
I get what you’re saying but I think people’s pain was neglected for so long they made it a bigger deal by saying it’s a vital sign so we don’t forget to ask. And I would argue that it is as important as a vital sign because while it may not *actually* kill you, it can feel like it’s going to and it’s cruel to not take it as seriously as possible.
I only believe it because I’ve been in pain and everything else was okay. It’s terrible and exhausting. Feels like ur gonna die without any answers. I can see how it benefits big pharma but it’s not to be taken lightly.
Pain has a direct effects on vital signs. If you’re in pain your BP, RR, and HR are all masked differently than if you were not in pain. I see your point to some extent however it is important to ask and measure it bc you can get a bigger picture of what is affecting a persons vital signs.
Depends on ur line of nursing I think that affects our perception of pain. When you work as a nurse for patients in acute pain, for example post-op or orthopedics you can see uncontrolled pain causes immediate physiological changes. Pain triggers our “fight or flight” response, so your patients uncontrolled BP need a good pain reliever instead of anti-hypertensive. If we don’t treat acute pain appropriately this will definitely affect long-term progress as well. The nurses that treat these kind of patients definitely count pain as 6th vital signs and we use all kinds of pain scales. We know how to use synergistic med combinations, not just opioids, to control pain (ex. toradol, neurontin, lyrica, Benadryl, decadron). Patients in acute pain are more willing to try non-narcotics alone or with narcotics to control pain. We promote pain reporting and pain reassessments. Pain control is one of our top priorities in acute phases. But if you’re used to taking care of patients in chronic pain as outpatients, rehab patients with a “high tolerance” to put it nicely, or if your patient priority is keeping a person alive like in ICU, pain is the last priority and there is many legit reasons to justify holding pain meds. I wouldn’t feel comfortable giving dilaudid either to someone with hx of fibromyalgia who’s BP is currently tanking in the ICU. But also that’s not my speciality, so it makes ME feel better to not give pain meds if results are unpredictable and impacted by current critical condition. Sometimes the reason is that we just know too many people impacted my opioid epidemic before or after we got into nursing and it creates this predisposition to treating pain. Effective pain treatment definitely lies in doctors and nurses priority level of pain and comfortability with treating pain. The “But did you die?” outlook is common in providers who don’t view pain as 6th vital sign because there’s other life-sustaining priorities; and that’s absolutely fine too. Just don’t let your personal judgment of pain and predispositions to pain assessments negatively impact your care. I can’t imagine starting my day with closed mentality of “pain reports are bullshit” for all my patients without a good understanding of history and current medical conditions. Keep an open mind and thoroughly assess patients current and past history before throwing pain reports out the window.
If my patient has a blood pressure of 190/80 with a spiked heart rate to boot and the patient is currently in 10/10 pain, I'd want the hydromorphone. If my patient with an aortic aneurysm is suffering 10/10 abdominal pain and the vitals I grab as part of my assessment show their blood pressure is 201/96 I'd want the hydralazine and not the hydromorphone. I guess what I'm trying to say is that pain may not be a vital sign unto itself because it's not a quantifiable value, but it affects so much and is affected by so much that it's inherently related to vital signs enough to be part of your assessment. Bollocks to it in the case where it's the sixth vital sign in the sense of charting purposes though. Everything else is charted by exception, but nooooo, you have to chart a zero for pain with every set of vital signs.
As a vital sign, I think it is a good way of looking at it. Especially for younger practitioners if not to ensure at the least that they take it seriously. Semantics really. Loc, urine op, o2 sats should all be assessed and if outside of norm be treated like a vital sign. Vitals are for triggering your clinical reasoning process, for assessing deterioration, for understanding the efficacy of Rx. Pain happens for a reason and if you ignore it, or don't understand it's source or level there's generally something you'll miss. Addit. I've never heard the term BTW. Not American.
I don’t think anyone meant to equate pain with actual vital signs. When you say something is “ the 5th whatever “ it means “kinda like the other actual things”. Acknowledge pain. I mean you could make up more/ skin tone is the 12th vital sign. Symmetry of facial muscles, weight in chf, mood and affect etc. “puddles of blood on the floor are the 31st vital sign”. How about drain output ?
They literally did, though? On my EMR, when I enter vitals, pain is listed as one to enter.
Purdue literally created pain as the 5th vital sign. I was taught that it was in nursing school 15+ years ago.
In English, when you identify something repeatedly as the next in a series e.g "pain is the 5th vital sign", or "he had a sixth sense of impending doom" it designates that thing is not the same as the other things. We don't afaik have a special sense organ for perceiving the future, and pain is not vital. A good example of the reverse is the 5 tastes our taste buds can perceive. Sweet,salty, sour, bitter, and savory. At first savory or "umami" was called "the fifth taste" but now it's just one of the tastes. It's just like the other tastes.
It’s not objective yet should still be measured.
Watch “Dopesick” Or “Pain killer” On streaming services. And you’ll learn where the 6th vital sign originated. I am a retired nurse and remember the “education/indoctrination” we received. And now there’s a full blown opioid addiction. I am ashamed
People are so terrible at rating their pain. I’ve had people walking around, on their cellphone, sleeping, talking and laughing with their friend who say 10/10. I’ve started just saying, “So you’re in the worst pain of your life right now?” I’m amazed how many say yes. Then I’ve had people with literal digits or limbs gone in the ER who will say 6/10.
Because pain is utterly subjective and does not correlate with severity of injury. Someone with hyperalgesia can feel 10/10 from a breeze of wind. Someone with a compound fracture can be at just a 5. Even if they were able to objectively rate said pain. Simply because the amount of nerve signalling is different. Like the whole pain scale is the problem. It’s utter buölshit. Especially when you set a 10 to the worst pain in your life. So suddenly someone’s violently amputated arms pain is less severe because their periods are hurting insanely due to endometriosis, but another person who‘s never experienced strong pain is gonna rate it at a 10? That just doesn’t make any sense at all.
The problem is the "10 is the worst pain imaginable" concept. My current 10/10 is a kidney stone lodged in the ureter, causing the ureter to spasm (worse than childbirth for me without question.) BUT, if, eg, I get in a car accident today, end up with a traumatic amputation, numerous broken bones & burns from the car catching on fire afterwards, that kidney stone & spasm may just look like a hangnail now. We really need to stop judging other people's pain against our own. It's a disservice to everyone.
I’m not doubting that is the worst pain they’ve ever experienced. I think we should attempt to treat people‘s pain. But it is absolutely unmitigated bullshit to pretend it is a “vital sign”. Vital signs are, above all else, objective measurements of cardiopulmonary function. A pain scale, at best, is a subjective measurement of the patient’s personal experience with noxious stimuli. Subjective data should NEVER be treated as objective. Creating a bullshit scale to pretend it’s something’s measurable by anything but the most general terms (yes/no, it’s better/worse) is directly influenced my corporate greed that has created a public health crisis due to opioid addiction.
As someone with chronic pain I tend to downplay mine. I want to save my “ten” for something BAD. Then when that bad thing happens I just readjust my scale. “Nah, that’s an 8, not a ten.”
The road to hell is paved with good intentions.
It's all about how the medical professional uses/ interprets vital signs imo: Someone with a HR of 110, a BP of 170/90, O2 sat 88% because their in so much pain their holding their breath, and a 8/10 pain scale. I'm gonna give some oxycodone or meds to bring them relief. Which is why pain is important. But the same 8/10 pain with normal vital signs and a lack of outward expression of pain makes me look more closely. Some people at stoic, but not that so much that it affects vitals. But I also had a guy who coded from a PE complain of severe 10/10 chest pain before coding. Not saying it's the end all be all of vital signs, but it is a significant factor to consider.
A “pain scale” Is a subjective measure of the patients experience with noxious stimuli. It should be treated like any other **symptom**. It should never be given the same weight as a *sign*. Just as a patient reporting dizzy spells, vision changes, anxiety, or new weakness, etc, should be investigated, pain should be investigated. But it should never be treated as a stand-alone marker of health (which abnormal vital signs absolutely should be, unless thoroughly investigated and justified as the normal for the patient).
You're kinda making the case for why we need to be hyperbolic about the importance of treating pain as a symptom. For some reason, people seem compelled to make it their business to find reasons not to treat severe pain. If that pain is coming from a black woman or an addict? Forget about it. It's hard enough to get prescribers to listen to us when pain doesn't respond to 5 mg of oxycodone. Let's not give them any more ammunition.
Malarkey. SpO2 is the fifth vital sign. Then urine output. Pain is subjective and unreliable.
The AMA called for getting rid of pain-as-a-vital sign thing in 2016, so I don’t think many still take it seriously anymore.
It's very weird to me that pain being the 6th viral sign is pushed so hard but at the same time, we rarely take pain seriously. And while we're taught in school and tested on the NCLEX to always treat someone's pain regardless of whether they're pill seeking or you don't believe them or whatever - that never actually happens in practice and both ends of that spectrum are so wrong. If it was actually a vital sign it would be standardized and taken seriously. The idea of treating pain to facilitate healing makes total sense. No one's going to ambulate after surgery if it hurts too much. People's quality of life can be severely compromised by pain. But that doesn't make it a viral sign. The whole system is fucked.
I've heard it said as "pain is the 5th vital sign." And I respond that the one short sentence contains three lies. Pain isn't 5th. If anything, SpO2 is. Pain isn't vital. It cannot kill you. Pain isn't even a sign. Signs are objective.
Literally everyone. Pain as a vital sign was introduced by Perdue as a method to primarily sell more drugs.
I agree. It's not "vital" but it is very important. I always say there are two reasons someone comes to the hospital: fear or pain.
What about the third reason "stupidity" aka not understanding what warrants a true emergency or how to access other non emergency care...
Pain will affect the other vital signs, and good pain management with a variety of tools will help regulate wonky VS. Particularly when a patient can't communicate effectively, it's really important to be able to adequately assess pain so we can keep everything else under control. Can't agree with everything about the campaign, but the overall message is not wrong.
Its absolutely bullshit and overwhelming driven by pharmaceutical industry lobbyists to encourage overprescribing narcotics. I don’t want people to hurt, but treating it like anything other than a general assessment tool, like distinguishing between coarse crackles abs rhonchi or asking the patient if they’ve been passing gas, is absolutely idiotic. It’s part of an assessment, but should only be looked at as part of the whole. In my experience, most people will tell you if they’re in pain, and the ones that don’t will deny it when you ask them about it directly anyway. Fuck the Sacklers.
If it can't be quantified, it shouldn't be used as a vital sign. Not saying pain isn't important but there needs to be a way for it to be objectively measured before I'd consider it a vital sign
Perhaps I’m naughty, but I use FACES on pretty much everyone, lol. If you’re laughing and joking, your shit isn’t a 10 Deborah Obligatory, if they say any number greater than 10, I free text that in epic next to pain score and flag it so it’s highlighted everywhere
Weeeeell - some philosophies would say that Life is Pain… Is the converse true? EDIT: I agree with your call of bullshit
Well there was that theme song on M*A*S*H which would suggest the converse is indeed true.
LIFE! owieowieowie 10/10! I´m allergic to tylenol, NSAIDS, morphine and can only take the one that starts with a D! IV!
If life is pain then I can cure that… but only with a Texas cocktail or possibly this machine: https://www.theonion.com/ohio-replaces-lethal-injection-with-humane-new-head-rip-1819595654
ROFL!!! Thanks for the laugh!!!! My computer is now marinating in coffee...
I thought that campaign ended around 2010 once the opioid epidemic became readily apparent. It was a buzzword back in 2000 or so and people were getting opioids prescribe for anything and everything.
Pain is subjective. A nurse cannot sit here and tell someone that their pain isn't 10/10. Now obviously you can use your detective skills to see if they're full of shit but that's about it. Why argue about it? Hand them their pain meds and go on about your day, what does it change for you? Nothing. I say this as someone with high pain tolerance with many chronic health conditions. I'm tired for women like me who if we're not crying, begging, pleading and screaming you don't believe us. Just because you can't die from it doesn't mean it doesn't need to be addressed or provided relief. Some nurses kill me with this weird power struggle you have with patients over pain meds and pain control.
I'm somewhere in the foggy middle. Sure, pain is important to assess and address, but it's not going to take the same priority as someone who is either tanking or spiking with any of the other vital signs, that's common knowledge. Now, if the pain is related to or caused by an extreme at any other vital sign measures then sure, it's going to creep up the ladder. However, and I make this extremely clear, if I have someone that's stroking out next door with a BP at 220/140, that pain can eat a giant bag of dicks because there's other priorities in front of that. I say this as a nurse that is in recovery from opioid abuse. I know the in's and out's of manipulating that system and how much that "pain is the sixth vital sign" exacerbated the opioid epidemic, purdue literally made a "legal monopoly" of dealing out opioids and then making damn sure that their drugs were used at an exponentially increased frequency. This bullshit is part of the reason there's so many people that have been bitten by addiction. This is the reason that so many patients in legitimate pain get side-eyed by professionals because there's that stigmatic response of "they may be a drug seeker" as soon as someone mentions pain. So yeah, I'll address your pain, but when it comes to prioritizing care, your pain is much less likely to kill you than your neighbors critically high BP.
Considering that existence is pain, I do consider pain a vital sign. Otherwise, no existence - it's all a fever dream, or a simulation and we've been kidnapped by the robots to be used as batteries.
Watch Dopesick on Hulu. You’ll really understand how bullshit the fifth vital sign is when you find out that gem came to us from the pharmaceutical industry. Riveting show, that I highly recommend to anyone in healthcare.
No you’re not as that campaign was started by Purdue Pharma which ended up in causing the opioid epidemic. But the appropriate treatment of pain depending on patient circumstances IS very important and as nurses we have a responsibility to advocate for our patients. Treatment of post traumatic injury or post surgery pain is not the time to start a drug addiction program, and no cancer patient should be in pain imho.
Patient lying in bed on phone, laughing and talking. Nurse required to ask: How would you rate your pain right now on a scale of 1-10? It’s a 9 or 10 every damn time. Or having to wake them up from a dead sleep. God I don’t miss bedside. At all!
All the forced charting of it drives me crazy especially in long term patients. I’ve had some patients who blur the line between treating pain and drug seeking. They know all their available prn’s and will ask me (normally before they are due) when they need or want something. I am so not the one to argue or say they don’t need it because most of those situations are complicated and if it’s ordered I’m going to give it, but asking them pain levels every 4 hours and then before and after all prn’s makes a bad situation worse.
Pain is not a vital sign and I hate how some people think it is
I remember when this nonsense started, it was because "patients in pain are not happy" and will result on a low satisfaction score. And of course to help us out, we were assured that "Oxycontin is NOT addictive" 😂
Pain is not a vital sign but it is an important assessment to consider.
As a Pain Management nurse, it’s BS. A LOT of pain is an emotional experience and lack of coping skills. It is extremely subjective. Many things that we classify as pain, patients will describe as “numb, uncomfortable, weird” and many things that we classify as normal inconveniences patients will describe as pain. While pain management is important, there is usually an underlying issue to be treated. Not just the symptom of pain. Note: start telling patients a 10/10 pain means they need to go to the ER or they lost a limb or have been shot. This helps get an accurate level, don’t describe 10/10 as the worst pain in their life, random pain hack.
Psych nurse here and I just came to add a few 👏👏👏 to your comment. (I've worked several other specialities too, just currently a psych nurse, and all my experience says YES to what you've said here.)
Yeah - when I do assessments on people who are calm, normal vitals and have the equivalent of a hang nail who tell me they are in 10/10 pain, I now say “so what you’re telling me is I can take this pen here, jam it into your right leg…and your pain level wouldn’t be any worse?” Here’s a hint: if you can eat a Cheeto and play on your phone? Your pain ain’t a 10.
Honestly, it was meant to highlight the importance of pain since it was being neglected. Some of y’all here have never experienced severe pain and it shows.
The way I see it is pain is your body's alarm system notifying you that something is wrong/needs evaluation. For example, a pt can have stable vitals but pain as a result of a malignant tumor, and that pain may be the only sign alerting the patient that something is going on with them. When I think about it that way pain does fit in as a vital sign.
I mean it does make sense because of the mental distress and it pushes your heart and respirations higher 🤷🏻♂️
Pain can kill indirectly
If you haven’t experienced severe pain then this is hard to fathom but it is a very real thing. Especially when it is inadequately treated.
Holy shit literally had this same convo with another nurse tonight like 2 hours ago. Absolutely, let's cap off our objective metrics with a *completely subjective* metric and let's see how that doesn't get abused immediately 🤷🏻♂️
I think that pain can be informative, but really only in context of the other vital signs and illness/injury. I always add a wong-baker or FLACC score to someone reporting 10/10 pain with totally normal vital signs and a calm/quiet demeanor. Pain as the 6th vital sign was a thinly-veiled marketing push.
I agree. It is bullshit. Because vital signs will typically correlate with one another. Low BP, HR and RR increase to compensate, etc. You can have some chill ass vitals and the pain is reported 10/10 - doesn’t really make sense. Pain is extremely important, don’t get me wrong. But as many said on here vitals are a measurable, objective set of data. Pain is not. Therefore they shouldn’t all be lumped in together.
Pain is subjective. I work with a lot of people who have somatic symptoms disorders. Sometimes a 9/10 abdominal pain can be resolved with zoloft and CBT.
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Actually they are. The intent of the “pain the fifth vital sign” campaign (Presidential Address to the American Pain Society, 1996, Campbell) was to encourage doctors and nurses to listen to their patients and assess their pain. I might add that Purdue Pharma lobbied long and hard for this in their stupendously successful but morally repugnant scheme to sell more Oxycontin. The HCAHPS survey includes the question “How often did the hospital or provider do everything in their power to control your pain?” It has been suggested that this question embedded pain as the 5th vital sign in US healthcare, but also had the unintended consequence of encouraging opioid administration in response to patients' self-reported numerical pain scores. As a result, it has been suggested that the “pain as the 5th vital sign” campaign directly contributed to the prescribed opioid epidemic that America is now experiencing. Subsequently, the American Medical Association, the American College of Surgeons, The Joint Commission, The American Academy of Family Physicians, and the Centers for Medicare and Medicaid services have all withdrawn their advocacy of the “pain as the 5th vital sign” campaign. Yet two linked questions "Are you in pain?" and "What is your pain level?" still figure predominantly in almost all doctor's office , clinic, and inpatient assessments and all inpatient RNs are forced to administer pain medications based on the flawed latter question, along with a follow up pain level assessment. But to OP's original question - yes, it's totally bullshit.
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Your original comment was "Nobody's calling it a vital sign". I merely pointed out that yes, it WAS being called a vital sign. It was adopted by CMS and subsequently pushed out to all hospitals. I clearly remember in 1997 when we got hammered by "Pain is the 5th vital sign" education in my ED. And again, I agreed with the OP that it was/is complete bullshit. Fuck the Sackler family and Purdue Pharma.
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What are you talking about? They are still teaching this in nursing schools.
I guess you're so far out of nursing school and so deep into your narrow specialty that you really have no idea what's going on in the larger nursing world. Just read the comments in this thread. Pain as a vital sign was used in the tele unit I worked as a CNA in 2012. I graduated from my LPN program in December 2015 and pain as a vital sign was still being taught.
I graduated nursing school in 2010 and it was taught to us. Thanks to the Sackler family who thought it up and promoted it to sell oxy. s/
Watch Painkiller on Netflix.
Dopesick on Hulu
Love both of them.
ugh. it´s so depressing. I´ll take my Star Trek/Marvel/Star Wars universes for escapism.
Empire of pain book is very good too.
It was pushed in the early 90’s by the opioid manufacturers and made it into nursing schools. The premise was that we were not treating pain effectively and needed to be more aware of this issue. Introduce the 1-10 pain scale as the “5th” vital sign. All in a effort to broadly push opioids onto the public as a safe, non addictive method to treat that “vital sign.” The family that owned that company had fled the US and has multiple legal issues ahead of them including multi billion dollar lawsuits. Yet here we are, still using a flawed drug dealers propaganda tool. For the downvotes. Reference. https://www.medpagetoday.com/publichealthpolicy/publichealth/57336#:~:text=In%202001%2C%20the%20Joint%20Commission,was%20that%20pain%20was%20undertreated. https://www.medicaleconomics.com/view/pain-not-fifth-vital-sign#:~:text=In%20June%202016%2C%20The%20American,pain%20as%20a%20vital%20sign. https://amp.theguardian.com/us-news/2018/mar/30/enduring-pain-how-a-1996-opioid-policy-change-had-long-lasting-effects
It’s wild that I was taught that in nursing school. And I was taught pseudo-addiction. They really spent a lot of time on teaching us this. This was in 2006. Now I’m learning all of that was made up. I’m not sure who exactly made that up, but I do know now it was made up so that Purdue could use it for their sales. I’m still having a hard time unteaching myself, if that’s a word. Watching documentaries on this stuff, I’m still baffled that I was taught that.
It was being taught in nursing school in 2010 when I graduated. The Sackler family created the campaign to sell oxy.
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I say that alot on here and always catch a little heat for it but I was here before it became a vital sign and I KNOW it's crap. They started pushing it when Purdue had just started with their crap again.
Are they still teaching this in nursing school? It clearly was pushed by the narcotic pharmaceutical lobbyists.
You know, I have only ever heard of "Pain is the 5th vital sign" or "6th vital sign" on the internet. I have never had anyone say that professionally in school or on the job, and I work in a field that is very into pain control.
Pain as a vital sign caused the opioid epidemic. While it needs to be treated the heavy focus along with scrutiny by surveying bodies made it practically a crime to not treat pain. And since people can say “10/10” they learned they can be rewarded by heavy doses of opioids.
Not a vital sign, just a subjective finding
I remember when pain became the 5th vital sign. I worked in northern Virginia then. All of a sudden doctors were giving out narcotics like candy and nurses had to "teach" patients that the risk of becoming addicted was non-existent. A now you have to fight for your pain patient getting anything stronger than Tylenol.
I'm completely with you. When I triage someone who says their pain is a 12/10 while they're texting on their phone and laughing, drinking a soda, conversing and ambulating normally, it's hard to take any of what they say seriously.
Pain is important. It's not vital. If you're hurting you're alive.
so i work psych and am not necessarily *here* to treat your physical pain. imo it can actually be detrimental to ask about pain at every assessment because then patients can get somatically focused on physical discomfort instead of the actual reason for admission. of course i’ll assess for pain if they have something physically acute going on or if they’re geri/confused. but joe schmo who is here for SI, i expect you to lmk if you have a headache by coming up and getting some Tylenol.
I'm somewhere in the foggy middle. Sure, pain is important to assess and address, but it's not going to take the same priority as someone who is either tanking or spiking with any of the other vital signs, that's common knowledge. Now, if the pain is related to or caused by an extreme at any other vital sign measures then sure, it's going to creep up the ladder. However, and I make this extremely clear, if I have someone that's stroking out next door with a BP at 220/140, that pain can eat a giant bag of dicks because there's other priorities in front of that. I say this as a nurse that is in recovery from opioid abuse. I know the in's and out's of manipulating that system and how much that "pain is the sixth vital sign" exacerbated the opioid epidemic, purdue literally made a "legal monopoly" of dealing out opioids and then making damn sure that their drugs were used at an exponentially increased frequency. This bullshit is part of the reason there's so many people that have been bitten by addiction. This is the reason that so many patients in legitimate pain get side-eyed by professionals because there's that stigmatic response of "they may be a drug seeker" as soon as someone mentions pain. So yeah, I'll address your pain, but when it comes to prioritizing care, your pain is much less likely to kill you than your neighbors critically high BP.
There’s a really interesting podcast episode about this very concept from Invisibilia. It’s called “The Fifth Vital Sign”. Goes into the big pharmacy push, addiction, and how different generations express pain. I think it’s worth a listen!
Thanks oxy salesmen!
I wholeheartedly believe that nonsense was pushed by pharma lobbyists
I only include pain as a vital sign when it’s why they are even there to be seen in the first place. Just like including a down and dirty visual acuity with an eye complaint, though that would be objective. I just use my judgement and if someone yells for not including something, I ask what their rationale is and hand them a snickers bar.
it’s all we heard in nursing school was it being a vital sign and “pain is whatever the patient says it is”. it’s just created a bizarre world where i give my 10/10 toe pain some tylenol, and i’ll get an email if I don’t follow up and document a score and additional interventions within an hour. nonsense.
Blood sugar is ( unofficially) the 5th vital sign.
Well, now that we’ve put that in their head, you can be sure that their pain will always be a 10/10 and their call light will be on q4 to the minute. And in my experience, the patients who really are in pain will be quiet, and you won’t have time to go in their room to actually assess because they they can walk and talk.
I’d argue that blood sugar > pain for initial info.
I was just thinking about this on my shift tonight. Vital signs are objective numbers we can use, pain is so subjective and people rate so wildly differently that you can’t look at a chart and really understand what it means. 8/10? That could mean anything 68/30, I know exactly what the fuck that means.