PAIN AS THE FIFTH VITAL SIGN
MUST BE ASSESED EACH TIME VITAL SIGNS
CLIENT SPECIFIC : PAIN IS WHAT PATIENT
SAY IT IS
MEASURE ON 0 – 10 SCALE
0MEANS NO PAIN AND 10 MEANS WORST
GOAL FOR PAIN CONTROL IS 2
DOCUMENTATION : ABDOMINAL PAIN 5/10,
PATIENT DECLINED MEDICINE.
Pain is called the fifth vital sign, in
conjuction with temperature, pulse,
respiration & blood pressure.
Pain can reveal a tremendous
amount about the health status of
Pain also affects on such things as
mood, activity, appetite, sleep,
hygiene and the ability to focus
THE FIFTH VITAL SIGN
To achieve adequate pain control it
is necessary to understand how
to assess pain.
Pain is totally subjective and what
causes excruciating pain to one
person, may only be perceived as
moderate pain to someone else.
•There are several pain assessment tools
used by health care professional to help
assess the pain levels. This include the
Wong Baker faces Pain Rating Scale
which have several faces from a smiling
face (represent no pain) to face with tears
and scowl (represent the worst pain
VERBAL PAIN SCALE
A verbal pain scale uses colour from blue to
red and a series of vertical lines stretching
from blue representing pain, to deep red
representing severe pain.
NUMERICAL PAIN SCALE
Numerical pain scale uses number from
0 to 10 , where 0 represent no pain
and 10 represent worst pain
In addition to the pain scales, nurses will
ask questions to determine the quality
of the pain and how its affect patient’s
*Where is the pain?
*When did it start?
*What make it worse?
*What helps to ease it?
*Is it sharp, dull, aching, throbbing,
How does the pain affect your life?
Mood and emotions
Does the pain affect patient’s
physical appearance / sexual
function / energy levels?
Medication will not cure or eliminate pain
Medications work in many ways to help to
ease patient’s pain, by improving patient’s
flexibility by treating underlying factors
causing the pain, or by reducing
inflammation or swelling. Medications help
to ease pain by changing how brains
perceives the pain.
Rating scale is recommended for
persons age 3 years and older
Brief instructions : Point to each
face using the words to
describe the pain intensity.
Ask the child to choose face
that best describes own pain
and record the appropriate
0 1 2
Face No particular
Occasional grimace or
chin, clenched jaw.
Legs Normal position
Uneasy, restless, tense Kicking or legs
Activity Lying quietly,
Squirming, shifting back and
Arched, rigid or
Cry No cry ( awake /
Moans or whimpers;
scream or sobs,
Consolability Content, relaxed Reassured by occasional
touching, hugging or being
talked to distractable
Difficult to console
FLACC Rating Scale to be use for
children less than 3 years old of age
or other patients who cannot self
report. Can also be used in
cognitively impaired or demented
Each of the five categories Face, Legs,
Activity, Cry and Consolabilityis
scored from 0 – 2, resulting in total
range of 0 - 10
Provokes What provokes the pain (exertion,
spontaneous onset, stress(
Location Where does it hurt?
Radiation or relief Does it travel anywhere? ( to the
jaw, back, arms, etc( what makes it
better? ( position / being still (
What make it worse? ( inspiration /
Onset When did it start?
Severity or Signs &
Are they any associated signs and
symptoms? (nausea, anxiety,
dizziness, dyspnea, SOB, pallor(
Provide comfort Positioning, rest & relaxation
response to pain
Relieve anxiety and
Set aside time with patient
Rhythmic breathing, guided
Massage, heat & cold
Bright light, noise &