This document discusses pain assessment tools and guidelines. It defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain should be assessed in all patients as the 5th vital sign using appropriate tools based on a patient's age, such as the FACES scale for children ages 3-7 or the MOH pain scale for adults. Nurses and other medical staff should assess pain at regular intervals, after interventions, and whenever a patient reports pain in order to effectively treat and document pain levels.

1. PAIN ASSESSMENT
&
TOOL
BY:
KJ AZNIE WATTY BINTI AZMI

2. DEFINITION
 Pain is an
unpleasant sensory
& emotional
experience
associated with
actual & potential
tissue damage or
described in term of
such damage
InternationalAssociation fortheStudy ofPain1996

3. WHAT DO YOU
UNDERSTAND
ABOUT PAIN ?
What we understand
…
 Unpleasant
 Emotions are
important
 The cause is not
always visible

4. Pain is what the patient
says
SAKIT!!
DEFINITION
TO THE PATIENT

5. • Temperature (T)
• Pulse (P)
• Respiration (R)
• Blood pressure (B/P)
Prior to 5th
Nursing Observation:
Before
... Only 4 vital signs monitored

6. After
...
Pain as 5th Vital Sign
Mandatory to carry out
Pain as 5th vital sign
To provide routine
assessment, treatment
and documentation

7. Promote client satisfaction
4
6 Reduce
psychological
distress
1 Enhance healing, reduce length of
stay
2 Reduce health care cost
3 Promote staff- patient
interaction
BENEFITS OF PAIN AS 5TH VITAL SIGN
5 Improve quality Of life ,
sleep & appetite

8. WHY ASSESS / MEASURE
PAIN?
• Produce a baseline to assess therapeutic interventions
e.g. administration of analgesic drugs
• Facilitate communications between staff looking
after the patient
• For documentation

9. CLINICAL TECHNIQUES FOR
MEASUREMENT OF PAIN
• Self reporting by the patient
• Gold standard
• Best method
• Observer assessment
• Observation of behaviour and vital signs
• Functional assessment

10. HOW TO ASSESS PAIN:
 Important to :
listen and believe the
patient
 Take a pain history :
“Tell me about your
pain…”

11. HOW TO ASSESS PAIN:
P: Place or site of pain
“Where does it hurt?”
(record on a body chart)
A: Aggravating factors
“What makes the pain worse?”
I : Intensity
“How bad is the pain?”
N: Nature and neutralizing factors
“What does it feel like” “What makes the pain better?”

12. SELECTION OF
PAIN ASSESSMENT TOOL
• Use the standard tool for pain assessment
• Use appropriate scale
• Appropriate for age, learning, development
*Always use the same tool for the same patient

13. •
AGE TOOL (Scale)
Adult MOH pain scale
Paediatrics
1 month-3 years FLACC scale
3 -7 years Faces scale
> 7 years MOH pain scale
SELECTION OF PAIN
ASSESSMENT TOOL
Based on MOH standard

14. 10
@~ ~[§@&~DLJ&~
3 4 56 7 8
Adopted from IASP 2017
“On a scale of ‘0’ – ‘10’ (show the pain scale), if ‘0’ = no
pain and ‘10’ = worst pain you can imagine, what is your pain
score now?”
Pesakit akan ditanya tahap kesakitan yang dialami
berdasarkan nombor pada skala tersebut iaitu dari 0-10.
9
2
MOH Pain Scale 2018

15. PAIN MEASUREMENT
Scales used in children / infants and
in cognitively impaired patients
 Faces Scale
 FLACC scale

16. FLACC SCALE
F
L
A
C
C

17. FACESSCALE
-3-7years
- Cognitive impaired patients

18. • Verbal response from the patient according
to the 6 faces
• The children will be asked the pain score
by point to the Faces Scale
FACES SCALE

19. Cont…
1. At regular intervals – as the 5th
vital sign during routine observation of
BP
, HR, RR and temperature
This can be 4 hourly, 6 hourly or 8
hourly
2. On admission of patient
3. On transfer-in of patient
WHEN SHOULD PAIN BE
ASSESSED ?

20. 4. At other times apart from
scheduled observations:
▪ 1/2 to 1 hour after administration of
analgesics and nursing intervention for
pain relief
▪ During and after any painful procedure in
the ward e.g. wound dressing.
▪ Whenever the patient complains of pain
Cont… WHEN SHOULD PAIN BE
ASSESSED ?

21. WHO SHOULD BE ASSESSED?
ALL PATIENTS
• Patient in labour room
• Operating theatre (recovery room)
• ICU/ HDU/CCU
• Ambulatory day care units
• Clinics

22. WHO DOES PAIN ASSESSMENT?
EVERYONE
• All nurses/ paramedics
• All doctors
• All student nurses
• All medical students
• All allied health personnel

23. How to do Pain Assessment
1 . Greet patient / salam
2. Inform the purpose : to get the
patient’scorrect pain score for proper
treatment
3. Show and teach patient pain assessment
tool
“If ‘0’(no expression) – no pain
‘10’(most frowning face) – worst pain imaginable,
What is your pain score now?”

24. PAIN?
UNABLE TO ASSESS
Record ‘Unable to Score’ for :
1) Unconscious patients
2) Sedated patients
BUT Ventilated but conscious is still able
to
give a pain score!

25. Patient’s Name :
Age :
Ward :
Pain Score
DATE TIME BP PR RR T°C PS NURSING
INTERVENTION
Nursing Observation {Vital Sign
Chart} PS.KKM.1/2014

26. CONCLUSION
 Infants and young children can and do feel pain
 Untreated pain can have a negative impact and long
term consequences
 Pain needs to be recognised and managed
 Tools for assessment is dependent not only on age
but also other factors.
 We need to treat patients in a more humane manner
and be responsible to eliminate or assuage pain.

28. gohsk.2009