PAIN- THE FIFTH VITAL SIGN

1. “The fifth
vital sign”

2. PAIN

3.  “The fifth vital sign” –
American Pain Society2003
 Identifying pain as the fifth
vital sign suggests that the
assessment of pain should
be as automatic as taking a
client’s BP and pulse

4.  “whatever the person says
it is, existing whenever
the experiencing person
says it does”

5.  Pain is the most
COMMON reason
clients seek medical
advice
 Pain is a protective
mechanism or a
warning to prevent
further injury

8. TYPES OF PAIN
BASED ONTHE DURATION:
 Acute Pain – usually of sudden onset and
commonly associated with specific injury;
lasting from seconds to 6 months
 Chronic Pain – constant or intermittent pain
that persists beyond the expected healing time
and seldom attributed to a specific cause or
injury; lasts for 6 months or longer

9. BASED ON LOCATION:
1. Shooting pain/localized pain:
Shooting pain is characterized as a discomfort
that originates at a certain spot or region and
will manifest near or at that region.
1. Radiating pain:
Radiating pain is different because the pain
usually manifests not directly on the affected
area. As such, radiating pain is characterized as a
spreading type of pain that expands outwards
thereby forming a wider area of hurt.

10. According to severity:
1. Mild pain
2. Moderate pain
3. Severe pain
4. Profound or unbearable pain

12. FACTORS INFLUENCING PAIN
RESPONSE

13.  Past experience
 Anxiety and Depression
 Culture
 Gender
 Genetics
 Placebo effect

14. PAIN ASSESSMENT

15.  Obtain a Pain History
 Ask about previous pain experience and what
measures have been effective as well as
those who have not
 UseWHAT’S UP format or PQRSTor
OLDCART in assessing pain

16.  W – where is the pain (Location)?
Be specific.Use drawing of body if
necessary
 H – how does the pain feel? Is it shooting,
burning, dull, sharp?
 A – aggravating and alleviating factors.What
makes the pain better?Worse?
 T – timing.When did the pain start? Isit
intermittent?Continuous?

17.  S – severity. How bad is the pain on a 0 to 10
(0 to 5; faces) scale
 U – useful other data. Are you experiencing
any other symptoms associated with the pain
or pain treatment?
Itching, nausea, sedation, constipation?
 P – perception.What is the client’sperception
of what caused the pain?

20. Sample (PQRST)
 With continuous, drilling, bilateral knee pain
that occurs upon ambulation; rated as 8/10 in
the numeric pain rating scale, with 0 as no
pain and 10 as excruciating pain.

21. Sample (OLDCART)
 With continuous, penetrating, right flank pain
that occurred 1 hour prior to admission while
client was consuming fried dried fish; rated as
9/10 in the numeric pain rating scale with 0 as
no pain and 10 as excruciating pain in the pain
rating scale; radiating on the left shoulder;
aggravated with ambulation and
consumption of salty foods such as dried fish
and corned beef and alleviated with rest,
deep breathing exercises, and guided
imagery.

22. Visual Analogue Scales
 Useful in assessing the intensity of pain
 Includes a horizontal 10cm line, with anchors
indicating the extremes of pain
 The client is asked to place a mark indicating
where the current pain lies on the line
 Left: none or no pain
 Right: severe or worst possible pain

23. Wong-Bakers Faces Pain Scale
 This instrument has six faces depicting
expressions that range from contentedto
obvious distress
 The client is asked to point to the face that most
closely resembles the intensity of his or her pain

24. Numeric Pain Scale
Moderate Pain
[4,5,6]
0 1 2 3 4 5 6 7 8 9 10
No Mild Pain Severe Pain Unbearable
Pain
[1,2,3] [7,8,9,10]
Pain
May use FACES Scale if patienthas
difficulty with use of numeric scale
For use in adults, adolescents &
cognitively-appropriate pediatric patients
No Pain Distressing Pain WORST Pain

25. FLACC Pain RatingScale For infants to 7 years of age
Category Scoring
0 1 2
Face No particular expression Occasional grimace or frown Frequent-constant quiver or
smile withdrawn, disinterested chin, clenched jaw
Legs Normal position, relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, normal Squirming, shifting back & Arched, rigid or jerking
position, moves easily forth, tense
Cry No cry (awake or asleep) Moans or whimpers; Crying steadily, screams,
occasional complaint sobs; frequent complaint
Consolabilty Content, relaxed Reassured by occasional Difficult to console or
touching, hugging, or being comfort
talked to, distractible

26. Guidelines for Using Pain
Assessment Scale
 Written pain scale may not be possible if a
person is seriously ill, is in severe pain, or has
just returned from surgery
 The scale should be used consistently
 The nurse teaches the client how to use the
pain scale before the pain occurs

27.  Numerical rating should be documented and
used to assess the effectiveness of pain relief
interventions
 Pain scale may help assess the effectiveness
of the interventions if the scale is used before
and after the interventions are implemented

30. NON PHARMACOLOGIC
INTERVENTIONS

31.  Non-pharmacologic nursing activities can
assist in pain relief
 Not a substitute for medication
 Combining nonpharmacologic interventions
with medications may be the most effective
way to relieve pain

32. Cutaneous stimulation and
massage
 The gate control theory of pain proposes that
stimulation of fibers that transmit nonpainful
sensations can block or decrease the
transmission of pain impulses
 Rubbing the skin and using heat & cold are
based on this theory

33. Thermal therapies
 Proponents believe that ice and heat
stimulate the nonpain receptors in the same
receptor field as the injury
 Ice should be placed on the injury site
immediately after injury or surgery
 Ice therapy after joint surgery can
significantly reduce the amount of analgesic
medication required

34.  Assess skin first before applying ice
 Ice should be applied on an area for no longer
than 15 to 20 minutes at a time and should be
avoided in clients with compromised
circulation
 Application of heat increases circulation to an
area and contributes to pain reduction by
speeding healing

35.  Both ice and heat therapy must be applied
carefully and monitored closely to avoid
injuring the skin
 Neither therapy should be applied to areas
with impaired circulation or used in clients
with impaired sensation

36. Transcutaneous electrical nerve
stimulation (TENS)
 Uses a battery-operated unit with electrodes applied to the
skin to produce a tingling, vibrating, or buzzing sensation in
the area of pain
 Decreases pain by stimulating the nonpain receptors in the
same area as the fibers that transmit pain

37. Distraction Techniques
 Involves focusing the client’s
attention on something other
than the pain
 Thought to reduce the
perception of pain by
stimulating the descending
control system
 Effectiveness depends on the
client’s ability to receive and
create sensory input other
than pain

38. Relaxation techniques
 Believed to reduce pain by relaxing tense
muscles that contribute to the pain
 Consists of abdominal breathing at a slow,
rhythmic rate
 The client may close both eyes and breathe
slowly and comfortably

40. Guided imagery
 Using one’s imagination in a special way to
achieve a specific positive effect, consist of
combining slow, rhythmic breathing with a
mental image of relaxation and comfort
 The client is asked to practice guided imagery
for about 5 minutes, three times a day

41. Hypnosis
 Has been effective in relieving or decreasing
the amount of analgesic agents required in
clients with acute and chronic pain
 Mechanism is unclear
 Induced by specially skilled people

42. Music therapy
 An inexpensive and effective therapy for the
reduction of pain and anxiety

43. PHARMACOLOGIC INTERVENTIONS

44. Premedication assessment
 The nurse should ask the client about
allergies to medications and the nature of any
previous allergic responses
 The nurse obtains the client’s medication
history, along with a history of health
disorders

45. APPROACHES FOR USING
ANALGESIC AGENTS

46. Balanced analgesia
 Refers to the use of more than one form of
analgesia concurrently to obtain more pain
relief with fewer side effects
 Using two or three types of agents
simultaneously can maximize pain relief while
minimizing the potentially toxic effects of any
one agent

47. Pro re nata
 The nurse waits for the client to complain of
pain and then administer analgesia

48. Patient controlled analgesia
 Used to manage postoperative pain as well as
persistent pain
 Allows clients to control the administration of
their own medication within predetermined
safety limits
 Most nonopioids have antipyretic effects
 Works primarily at the site of injury, or
peripherally

49. Nonopioids
Examples
 aspirin
 Ibuprofen
 acetaminophen
Opioids
Examples
•Morphine
•Fentanyl
Steroids
 May reduce pain
by decreasing
inflammation
andtheresultant
compression of
healthy tissues
Benzodiazepines
Midazolam
 These drugs do not provide
pain relief except in the
treatment of muscle spasms
 May cause sedation