1. Nurses no longer pay attention to vital signs; they simply ask
the patient for their estimate of pain - even to the point of waking a
sleeping patient to ask them how the rate their pain.
2. When I get called for a patient "with uncontrolled pain", I
always ask for their vital signs, reasoning that if the pulse and blood
pressure aren't up, there is likely a disconnect between the patient and
the evaluating nurse. Invariably, the nurse calling does not have the
vitals available and has to go check - they haven't even evaluated the
patient. After all, an over-medicated patient doesn't ring the nurse
call button much!
3. The pain scale has resulted in the hospital creating a "Pain
Team" to specifically deal with patients who complain of "uncontrolled
pain". Physicians who have grown weary of the numerous nursing calls
for "uncontrolled pain", based on their pain scale assessment, can now
just write an order for the Pain Team to be consulted "as needed". This
results in significant additional costs to the patient, who typically
just gets her analgesic changed to Dilaudid with Toradol.
4. A postoperative patient in our hospital continued to complain
of excruciating pain based on the pain scale and was repeatedly given
narcotics without appropriate monitoring and was later found dead
secondary to respiratory arrest.
a. During a review of this case, a point was made regarding the
contribution of the pain scale to this patient's demise, but despite
this, the solution was not to re-address the scale, but rather to get
more oximeters with louder alarms so that patients with respiratory
depression secondary to analgesic therapy would be detected before they
die...
--
Lynn D. Montgomery, M.D.
Obstetrics & Gynecology, Maternal-Fetal Medicine
The Birth Center/Rocky Mountain Women's Health
1211 S. Reserve St.
Missoula, Montana, 59801
406-549-0978
fax 406-549-0987
e-mail: apgar10@thebirthcentermt.com
________________________________
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
________________________________
Charlie Chambers
Sent: Wednesday, November 21, 2007 10:25 AM
To: Multiple recipients of list OB-GYN-L
Subject: Re: ACOG Antepartum Record - Pain Scale?
Pain is not a vital sign. It's a symptom. The key is what is the cause,
not to go to endless lengths to document the symptom. No one ever died
or suffered sequelae from pain alone. I have issues with our current
society believing that everything should be painless. No, I don't think
people should suffer needlessly, but the idea that we should be able to
treat all pain till absent seems hopeless. Plus, it just contributes to
all the oxycontin, methadone, etc addiction that exists.
On Nov 21, 2007, at 8:34 AM, ainsron wrote:
It also reflects the recommendation/requirement of the nursing and
medical
boards of California that pain be assessed on any patient whose vital
signs
are recorded:
"It is now required that all health care staff record pain assessment
each
time that vital signs are recorded for each patient. If the institution
is
using the zero to ten pain assessment scale, a recording of pain 2/10,
fulfills the requirements of this law. The Board reminds RNs that pain
assessment is based on patient self-report and that patient's can be
asleep
and still experience significant pain; appropriate charting would be to
write "asleep" for the pain rating. Registered nurses will continue to
be
required to monitor all five vital signs and take appropriate action
based
on deviations from normal. In other words, a competent registered nurse
intervenes when the patient's pain is not being managed according to the
agreed upon comfort level."
Ronald E. Ainsworth, MD, FACOG
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
ainsron
Sent: Wednesday, November 21, 2007 8:26 AM
To: Multiple recipients of list OB-GYN-L
Subject: Re: ACOG Antepartum Record - Pain Scale?
It probably reflects JCAHO's position that pain is the "fifth vital
sign."
Ronald E. Ainsworth, MD, FACOG
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Don
Miller
Sent: Wednesday, November 21, 2007 6:31 AM
To: Multiple recipients of list OB-GYN-L
Subject: ACOG Antepartum Record - Pain Scale?
Just took a look at the latest ACOG Antepartum record and noticed that
they slipped in a new column in the obstetric flowsheet for "Pain
Scale". Considering that things that ACOG publishes tend to be held up
as a standards of care (especially by lawyers), I'm wondering where this
item came from.
Where is the overwhelming evidence of benefit to the patient or a
multitude of references to elevate such an item to suggest routine
documentation at every prenatal visit? I've done a cursory look through
PubMed and the ACOG website and haven't found anything.
If there is such data, could someone please illuminate me as to the
value of this new column and the proper response to patients who
repeatedly say they have pain? What are the next diagnostic steps to
defend oneself when a patient reports and you document continual pain?
OR, is this designed to be defensive legal strategy to counteract
patients with bad outcomes who said they were always in pain and there
was no documentation of such (or the absence of pain)?
My worst fear is that this was a pet project or self-serving agenda
lobbied by someone on the committee that creates the form and is not
evidence-based and adds one more task, one more question.. This is in
the face of real evidence that suggests that urine dipstick testing for
sugar and protein provides no benefit and probably should be dropped
from routine prenatal care and from all prenatal forms.
So, what's the story?
--
Donald W. Miller, Jr., MD, FACOG
eNATAL, LLC
http://www.eNATAL.com
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Charlie Chambers
Hood River, OR
cchamber@alumni.rice.edu
"Almost anything you do will seem insignificant but it is very important
that you do it....You must be the change you wish to see in the world"
-- Mahatma Ghandi.
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