Assessing Pain: The Fifth Vital

Sign
• Overview
• Everyone experiences pain at some point in life.
Because pain is such a private and personal
experience, it may be difficult to describe or explain to
others. The amount of pain and responses to it vary
from person to person; therefore interpreting pain
solely on actions or behaviors can be misleading.

• Pain is generally related to some type of tissue

damage and serves as a warning signal. Although pain
is familiar to most people, it is so complex that there
is no single, universal treatment.
• Definitions of Pain
• Pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage.
• In their classic work, McCaffery and Pasero (1999) offered a more
personal explanation of pain when they stated that pain is whatever the
experiencing person says it is and exists whenever he or she says it does.
• This understanding of pain requires that the patient be seen as the
authority on the pain and as the only one who can define the
experience.
• In other words, self-report is always the most reliable indication of
pain. Nurses who approach pain from this perspective can help the
patient achieve effective pain management by advocating for proper
control.
• Of course, if the patient cannot communicate, self-report is not possible.
In this case, a variety of methods and observation of nonverbal
indicators are used to assess the pain.
Other definitions
Pain is an unpleasant, subjective sensory and
emotional experience associated with actual or
potential tissue damage or described in terms of
such damage. (Association for the Study of Pain
(IASP), 2011)

 Pain is a subjective response to both physical and

psychological stressors.

Basic scientific definition: Pain is a sensation caused

by some noxious stimuli
• Scope of the Problem
• Pain is also a major economic problem and a leading cause of disability that
hampers the lives of many people, especially older adults. Chronic pain is
the most common cause of long-term disability, affecting millions of
Americans and others throughout the world.
• Pain is not adequately treated in all areas of health care. Populations at the
highest risk are older adults, substance abusers, and those whose primary
language differs from that of the health care professional. Older adults in
nursing homes are especially at risk because of lack of professional staff
and communication problems. In patients who are substance abusers,
unrelieved pain can contribute to relapses or increased substance use.
• Inadequate pain management can lead to many consequences affecting
the patient and family members. These consequences often affect the
patient’s and family’s quality of life. Therefore, as a nurse, you have a legal
and ethical responsibility to ensure that patients receive adequate pain
control. In 2000, The Joint Commission (TJC) published pain standards
approved by the American Pain Society. TJC states that patients in all health
care settings, including home care, have a right to effective pain
management.
IMPACT OF UNRELIEVED PAIN
• Physiologic Impact
-Prolongs stress response
-Increases heart rate, blood pressure, and oxygen deman
-Decrease GI motility
-Causes immobility
-Decreases immune response
-Delays healing
-Increases risk for chronic pain
• Quality of life impact
-Interferes with ADL
-Causes anxiety, depression, hopelessness, fear, anger, and
sleeplessness
-Impairs family, work, and social relationships
• Financial Impact
-Costs Americans billions of dollars per year
-Increases hospital lengths of stay
-Leads to lost income and product
Transduction
- conversion of chemical information at the cellular level into electrical impulses
that move toward the spinal cord
Transmission
- stimuli move from the peripheral nervous system toward the brain
Perception
- occurs when the pain threshold is reached
Modulation
- associated with pain reduction

A-delta primary afferent fibers

- myelinated and conduct impulses rapidly (0.1 sec)
- resulting in pain being described as sharp or stabbing
C fibers
- unmyelinated, slower (1 sec)
- cause pain that is achy and ongoing
Physiologic Responses to Pain
- Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide

- Focus on pain, reports of pain, cries and moans, frowns and facial
grimaces

- Decrease in cognitive function, mental confusion, altered

temperament, high somatization, and dilated pupils
- Increased heart rate and blood pressure + peripheral, systemic, and
coronary vascular resistance
- - Increased respiratory rate and sputum retention, resulting in
infection and atelectasis (complete or partial collapse of a lung / lobe)
- Decreased gastric and intestinal motility

- Decreased urinary output, resulting in urinary retention, fluid

overload,
- Depression of all immune responses

- Increased antidiuretic hormone, epinephrine, norepinephrine,

aldosterone, glucagons, decreased insulin, testosterone
- Hyperglycemia, glucose intolerance, insulin resistance, protein
catabolism

- Muscle spasm resulting in impaired muscle function and immobility,

perspiration
Definition of Pain according duration and etiology:
Acute Pain
Usually associated with a recent injury.

Chronic Nonmalignant Pain

Usually associated with a specific cause or injury and described
as a constant pain that persists for more than 6 months.

Cancer Pain
Often due to the compression of peripheral nerves or meninges,
or from the damage to these structures following surgery,
chemotherapy, radiation, or tumor growth and infiltration.
Pain Location Classifications
Cutaneous pain: skin or subcutaneous

Visceral pain: abdominal cavity, thorax, cranium: crampy or gnawing

Deep somatic pain: ligaments, tendons, bones, blood vessels, nerves

Radiating: perceived both at the source and extending to other tissues

Referred: perceived in body areas away from the pain source

Phantom pain: perceived in nerves left by a missing, amputated, or
paralyzed body part
Neuropathic pain: causes an abnormal processing of pain messages
and results from past damage to peripheral or central nerves due to
sustained neurochemical levels: burning, painful numbness, or tingling

Nociceptive: response to noxious insult or injury of tissues such as skin,

muscles, visceral organs, joints, tendons, or bones

Inflammatory: a result of activation and sensitization of the nociceptive

pain pathway by a variety of mediators released at a site of tissue
inflammation

Intractable: is defined by its high resistance to pain relief.

Seven Dimensions of Pain (Silkman, 2008)
Physical:
- effect of anatomic structure and physiologic functioning on the
experience of pain
- patient's perception of the pain and the body's reaction to the
stimulus.
What medical conditions do you have?
Sensory:
- qualitative and quantitative descriptions of pain
- patient's perception of the pain's location, intensity, and
quality.
Feels like? Rate? How long?
Behavioral:
- verbal and nonverbal behaviors that the patient demonstrates in
response to the pain.
I notice that you are ...? Do you have a pain?
Sociocultural:
- effect of social and cultural backgrounds on the experience of pain
What is your country of origin? How do you manage your pain at
home?
Cognitive:
- thoughts, beliefs, attitudes, intentions, and motivations related to
the experience of pain
What do you think is causing your pain? What do you think will relieve
it?
Affective:
- feelings and emotions that result from pain
How does the pain affect your overall daily life and activities?
Personal relationships?
Spiritual:
-pain, self, others, and the divine
How do your religious or spiritual beliefs influence your health
care decisions?
How would you describe the support you receive from friends
and loved ones?

- ultimate meaning and purpose attributed to

QUESTT Principles for Pain in Children (Baker, Wong,
1987)
Question the child.
Use pain-rating scales.
Evaluate behavior and physiologic changes.
Secure parents' involvement.
Take cause of pain into account.
Take action and evaluate results.
Cultural Expressions of Pain
Asian and Asian American
• Pain is natural.
• Use mind over body; positive thinking.
• Pain is honorable.
• Pain may be caused by past transgressions and
helps to atone and achieve higher spirituality.
• Stigma against narcotic use may result in
underreporting of pain.
African American
• Pain is a challenge to be fought.
• Pain is inevitable and is to be endured.
• Pain is stigmatized, resulting in inhibition in expressing
pain or seeking help.
• Pain may be a punishment from God.
• God and prayer will help more than medicine.

Hindu
• Pain must be endured as part of preparing for the next
life in the cycle of reincarnation.
• Must remain conscious when nearing death to
experience the events of dying and perhaps rebirth.
Native American
• Pain is to be endured.
• May not ask for medication due to respect for caregivers who
should know their needs.
• Metaphors and images from nature are used to describe pain.
Hispanic
• Pain response is often very expressive, though pain must be
endured to perform gender role duties.
• Pain is natural, but may be the result of sinful or immoral
behavior.
Jewish
• Pain is expressed openly, with much complaining.
• Pain must be shared, recognized, and validated by others so
that the experience is affirmed
Assessing Tools / Scales
For older adults without cognitive impairment:
- Visual Analog Scale (VAS)
• The visual analogue scale or visual analog scale is a psychometric
response scale which can be used in questionnaires. It is a
measurement instrument for subjective characteristics or attitudes
that cannot be directly measured. Wikipedia
- Numeric Pain Intensity Scale (NPI)
Numerical rating scale. A NRS involves asking the patient to rate
his or her pain from 0 to 10 (11 point scale) or from 0 to 100 (101
point scale) with the understanding that 0 is equal to
no pain and 10 or 100 is equal to worst possible pain.
- Numeric Rating Scale (NRS)
- Categorical Rating Scale:
"none“ (0),
"mild" (1),
"moderate“ (2), or
"severe" (3)
Cognitively impaired older adults:
- Faces Pain Scale
- observe behaviors:
facial expressions (frowning, grimacing);
vocal-ization (crying, groaning)
- change in body language
(rocking, guarding);
- behavioral change
(refusing to eat, alteration in usual patterns); -
-physiologic change
(blood pressure, heart rate); and
-physical change
(skin tears, pressure areas).
-Verbal Descriptor Scale
-Verbal Rating Scale
-Simple Descriptive Pain Intensity Scale
-Graphic Rating Scale
The Verbal Descriptor Scale (VDS) is comprised of a series of
descriptive phrases that refer to different levels of pain severity or intensity.
Patients select the phrase that best describes their current pain.
This tool is best suited for use with more articulate patients, due to
the need for patients to understand and respond to the scale in verbal terms.

The VDS is the scale of choice for assessing pain intensity among older
adults, including those with mild to moderate levels of cognitive impairment.

See also Verbal descriptor scale (pain thermometer) and Review of pain
intensity scales.
-Neonatal Pain, Agitation, & Sedation Scale (N-PASS)
The N-PASS is a reliable assessment tool for neonatal pain and
sedation. It is a valid assessment tool for ongoing pain and sedation for
the term and preterm infant. ... Stratification of the data by gestational
age may clarify the low internal consistency at low pain scores.

-FLACC Scale (Face, Legs, Activity, Cry, and Consolability -)

for acute postoperative pain in children 2 months to 7 years old
Cancer Pain Assessment Tool
-Cancer pain assessment is a complex undertaking.
-The evaluation begins with a thorough history of both the pain and the
underlying malignancy as well as their treatment.
-Because of the potential impact of pain on quality of life, it is also
essential to determine the adverse effects of pain on physical and
psychosocial wellbeing, as well as the spiritual impact of the pain.
-Cancer pain may linger after the cancer is removed (as examples,
postmastectomy, postamputation, or postthoracotomy syndrome), and
this may have an important psychological and spiritual impact.
-McCaffrey Initial Pain Assessment Tool
-Brief Pain Inventory
-Initial Pain Assessment for Pediatric Use Only

-Self Assessment: Memorial Pain Assessment Card

• The McCaffrey Initial Pain Assessment Tool can be
used to guide health care professionals through an
initial assessment of patient pain.
• This tool includes diagrams of the human body to help
patients locate the pain they experience as well as
questions to prompt the patient to describe the
intensity, quality, causes, effects, and contributing
factors of the pain.
 to continue to
to continue to

Pain Assessment Frequency

-Pain should be assessed every 4 hours;
-reassessments after the interventions should be
done in 30 minutes after intervention

Timeframe for reaseessment

1 hour for oral medication and
30 minutes for IV medication.
Pathophysiology of Pain
• The pathophysiologic phenomena of pain is associated with
central and peripheral nervous system.
• Peripheral and Central Nervous System perception of pain . The
source of pain stimulates peripheral nervous systems
(nociceptors), which transmits the sensation to the central
nervous systems.
• Nociceptors are located at the peripheral ends of both
myelinated neve endings of type A fibers or unmyelinated type
C fibers.
There are three types that are stimulated by different stimuli:
1. Mechanosensitive nociceptors (of A delta fibers) Sensitive
to intense mechanical stimulation (e.g. pliers, pinching
skin)
2. Temperature sensitive (thermosensititive) nociceptors (of
Delta fibers), sensitive to intense heat ad cold and
3. Polymodal nociceptors ( of C fibers), sensitive to noxious
stimuli of mechanical thermal or chemical nature. Some
nociceptors may respond to more than one type of
stimulus.
• Nociceptors are distributed in the body, skin, subcutaneous
tissues, skeletal muscles, joints, peritoneal surfaces, pleural
membranes, dura mater, and blood vessel walls, They are
not located in the parenchyma of visceral organs.

• Physiologic processes involved in pain perception (or

nociception) include:
1. Transduction
2. Transmission
3. Perception and
4. Modulation
 THE PAIN PROCESS
Dr. David Thompson
• Pain involves an incredibly complicated myriad of
physiochemical responses leading to the perception of
an unpleasant sensation arising from actual or
potential tissue damage. While the full complexities of
the pain process are beyond the scope of this
discussion, an understanding of the terminology and
basic neurophysiology involved is helpful in preventing
and treating discomfort in our patients.
• Pain can be classified as
• physiologic, which refers to the body’s protective
mechanism to avoid tissue injury,
• or pathologic, which arises from tissue injury and
inflammation or damage to a portion of the nervous system.
• Pathologic pain can be further divided into categories such
as nociceptive (peripheral tissue injury),
• neuropathic (damage to peripheral nerves or spinal cord),
• visceral (stimulation of pain receptors in the thoracic or
abdominal viscera), and
• somatic (injury to tissues other than viscera, such as bones,
joints, muscles and skin).
It can also be defined temporally as
acute (arising from a sudden stimulus such as surgery or trauma) or
chronic (persisting beyond the time normally associated with tissue
injury).
Nociception refers to the processing of a noxious stimulus resulting in
the perception of pain by the brain. The components of nociception
include transduction, transmission, modulation and perception
Transduction is the conversion of a noxious stimulus
(mechanical, chemical or thermal) into electrical energy by a
peripheral nociceptor (free afferent nerve ending). This is the
first step in the pain process, and can be inhibited by NSAID’s,
opioids and local anesthetics.
TRANSDUCTION of pain begins when a mechanical, thermal, or
chemical stimulus results in tissue injury or damage stimulating the
nociceptors, which are the primary afferent nerves for receiving painful
stimuli.
• Transmission describes the propagation through the peripheral
nervous system via first-order neurons. Nerve fibers involved include
A-delta (fast) fibers responsible for the initial sharp pain, C (slow)
fibers that cause the secondary dull, throbbing pain, and A-beta
(tactile) fibers , which have a lower threshold of stimulation.
Transmission can be reduced by local anesthetics and alpha-2
agonists.
Modulation occurs when first-order neurons synapse with
second-order neurons in the dorsal horn cells of the spinal
cord. Excitatory neuropeptides (including, but not limited to,
glutamate, aspartate and substance P) can facilitate and
amplify the pain signals in ascending projection neurons. At
the same time, endogenous (opioid, serotonergic and
noradrenergic) descending analgesic systems serve to dampen
the nociceptive response. Modulation can be influenced by
local anesthetics, alpha-2 agonists, opioids, NSAID’s, tricyclic
antidepressants (TCA’s) and NMDA receptor antagonists.
Perception is the cerebral cortical response to nociceptive
signals that are projected by third-order neurons to the brain.
It can be inhibited by general anesthetics, opioids and alpha-2
agonists.
Hyper responsiveness (increased sensitivity) is a hallmark
feature of both acute and chronic pathologic pain. This is a
result of changes in the nervous system response
(neuroplasticity) at peripheral and central locations.
Peripheral sensitization occurs when tissue inflammation
leads to the release of a complex array of chemical mediators,
resulting in reduced nociceptor thresholds. This causes an
increased response to painful stimuli (primary hyperalgesia).
Central sensitization refers to an increase in the
excitability of spinal neurons, mediated in part by the
activation of NMDA receptors in dorsal horn neurons.
The net effect is expanded receptor fields (pain in
neighboring areas not subjected to injury, or secondary
hyperalgesia) and painful responses to normally
innocuous stimuli (mediated by A-beta fibers and
referred to as allodynia). The combination of
peripheral and central sensitization results in an
increase in the magnitude and duration of pain.
Because the pain response is extremely complex and can
involve multiple mechanisms in the same animal
(inflammatory and neuropathic, acute and chronic), no one
drug at one dose can be expected to be effective in every
patient.
Two important concepts should be kept in mind when treating
pain. Preemptive analgesia involves initiating treatment
before the nociceptive response is triggered, in an effort to
inhibit the development of peripheral and central
sensitization.
Multimodal analgesia is the strategy of combining two
or more analgesic drugs to achieve an additive or
synergistic effect. This reduces the individual drug
dosages (lowering the risk of side effects) and works
best when each drug has a different mechanism of
action (blocks a different portion of the nociceptive
response).
 • Classification of Pain
Classifying pain is helpful to guide assessment and
treatment. There are many ways to classify pain and the
common types of pain include:
• Nociceptive: represents the normal response to noxious
insult or injury of tissues such as skin, muscles, visceral
organs, joints, tendons, or bones.
• Examples include:
• Somatic: musculoskeletal (joint pain, myofascial pain),
cutaneous; often well localized
• Visceral: hollow organs and smooth muscle; usually
referred
• Neuropathic: pain initiated or caused by a primary lesion or
disease in the somatosensory nervous system.
• Sensory abnormalities range from deficits perceived as
numbness to hypersensitivity (hyperalgesia or allodynia),
and to paresthesias such as tingling.
• Examples include, but are not limited to, diabetic
neuropathy, postherpetic neuralgia, spinal cord injury
pain, phantom limb (post-amputation) pain, and post-
stroke central pain.
• Inflammatory: a result of activation and sensitization of the
nociceptive pain pathway by a variety of mediators released at a site
of tissue inflammation.
• The mediators that have been implicated as key players are pro
inflammatory cytokines such IL-1-alpha, IL-1-beta, IL-6 and TNF-
alpha, chemokines, reactive oxygen species, vasoactive amines,
lipids, ATP, acid, and other factors released by infiltrating
leukocytes, vascular endothelial cells, or tissue resident mast cells
• Examples include appendicitis, rheumatoid arthritis, inflammatory
bowel disease, and herpes zoster.
• Clinical Implications of classification: Pathological processes never
occur in isolation and consequently more than one mechanism may
be present and more than one type of pain may be detected in a
single patient; for example, it is known that inflammatory
mechanisms are involved in neuropathic pain.
• There are well-recognized pain disorders that are not easily
classifiable. Our understanding of their underlying mechanisms is still
rudimentary though specific therapies for those disorders are well
known; they include
• cancer pain,
• migraine and
• other primary headaches and
• wide-spread pain of the fibromyalgia type.
• Pain Intensity: Can be broadly categorized as:
• mild,
• moderate and
• severe.
• It is common to use a numeric scale to rate pain intensity where
0= no pain and
10 = is the worst pain imaginable:
• Mild: <4/10
• Moderate: 5/10 to 6/10
• Severe: >7/10
• Time course: Pain duration
• Acute pain: pain of less than 3 to 6 months duration
• Chronic pain: pain lasting for more than 3-6 months, or persisting beyond the
course of an acute disease, or after tissue healing is complete.
• Acute-on-chronic pain: acute pain flare superimposed on underlying chronic
pain.
Myths & Misconceptions
• Regular use of analgesics, especially narcotics, leads to addiction
• Drug abusers overreact to pain
• Minor illnesses and injuries are less painful than severe ones
• Healthcare workers are the expert in interpreting the patient’s pain,
not the patient
PQRST Assessment Tool
• P - Precipitating/provoking factors; what causes pain
• Q – Quality; describe the pain
• R - Region/Radiation; where is the pain
• S – Severity; rate intensity of the pain
• T – Timing; onset, duration
Inquire about aggravating and relieving factors
Inquire regarding treatment
Categorizing PainThe two major types of pain are acute and chronic

Acute Pain vs. Chronic Pain

• Acute pain is usually of short duration, lasts no longer than 6 months.
Acute pain often results from sudden, accidental trauma (e.g., fractures,
burns, lacerations) or from surgery, ischemia, or acute inflammation.
• Acute pain occurs when tissue injury or potential injury initiates
nociceptors
• Examples: surgery, infection, trauma, inflammation
Chronic pain or persistent pain is further divided into two subtypes.
Chronic cancer pain is pain associated with cancer or another progressive
disease such as acquired immune deficiency syndrome (AIDS). The cause of
pain is usually life threatening.
Chronic non-cancer pain is associated with tissue injury that has healed or is
not associated with cancer, such as arthritis or chronic back pain. This type of
pain is the most common.
• ARACTERISTICS OF ACUTE PAIN AND CHRONIC PAIN
Acute
• Has short duration
• Usually has a well-defined
causes
• Decreases with healing
• iss reversible
• Serves a biologic purpose
(warning signs)
• Ranges from mild to severe
intensity
• May be accompanied by anxiety
and restless
Chronic/Persistent
• Lasts longer than 3 mos
• ay or may not have well-defined
ca
• Begins gradually and persists
• Is exhausting and serves no
biologic purpose
• Ranges from mild to severe
intensity
• May be accompanied by
depression and fatigue, as well
as decreased functional ability
• The nurse’s primary role in pain management is to advocate
for the patient by believing reports of pain and acting
promptly to relieve it, while respecting the patient’s
preferences and values (Quality and Safety Education for
Nurses [QSEN], 2011). Even though some nurses with many
years of experience think that they can identify patients in
pain, it is sometimes not easy to do.
• In response to mandates by The Joint Commission and other
organizations, many hospitals and other health care agencies
in the United States have interdisciplinary pain teams, also
known as analgesia teams, who consult with staff and
prescribers on how best to control the patient’s pain. The
team typically consists of one or more nurses, pharmacists,
case managers, and physicians. In larger facilities, pain teams
may specialize by type of pain (e.g., cancer pain team).
Although a large part of the team’s plan may center on drug
therapy, this group also recommends nonpharmacologic
measures as appropriate.
The 5th Vital Sign-Pain
• Pain is usually unwelcome and uncomfortable
• Pain is also protective – warning of potentially
health-threatening conditions
• Pain is the most common reason for seeking
healthcare
• The symptom most associated with describing
oneself as ill is pain
• Pain affects the whole body
Summary
• It is important to remember every person deserves a thorough pain
assessment
• Pain is what the patient says it is (subjective)
• Tools should be utilized to objectively assess, intervene and evaluate
outcomes
• Healthcare workers must be familiar with organizational standards
regarding pain
Analyze how you feel about pain
• Know the subjective and the objective
• Educate yourself, your patients and their support groups
• Pain is continually untreated, undertreated and misdiagnosed
• Don’t let that happen to your patients or to yourself.

Resources and Websites American Chronic Pain Association –

www.theacpa.org • American Pain Foundation –
www.painfoundation.org • American Pain Society –
www.ampainsoc.org • American Society of Pain Management Nursing -
www.aspmn.org