ASSESSING PAIN:THE FIFTH
VITAL SIGN

LEARNING
OBJECTIVES:
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
• At the end of discussion, the students will be able to:
1. Understand the different classification of pain.
2. Discuss the physiologic responses of pain.
3. Assess pain as the fifth vital sign.
4. Interview a client for their subjective experience of pain.
5. Perform a physical assessment of a client experiencing
pain.
6. Analyse subjective and objective data of a client
experiencing pain.

PAI
N
• PHYSIOLOGIC RESPONSES:
1. anxiety, fear , hopelessness,
sleeplessness, thoughts, of suicide.
2. Focus on pain, reports of pain, cries,
moans, frowns, and facial grimaces.
3. Decrease in cognitive function, mental
confusion, altered temperament, high
somatization, and dilated pupils.
4. Increased heart rate, peripheral, systematic,
and coronary vascular resistance,
increased blood pressure.
5. Increased respiratory rate and sputum
retention, resulting in infection and
atelectasis.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

6.decreased urinary output, resulting to urinary retention,
fluid overload, depression of all immune responses.
7.Increased antidiuretic hormone, epinephrine,
norepinephrine, aldosterone, glucagons, decreased
insulin, testosterone, hyperglycemia,, glucose intolerance,
insulin resistance, protein catabolism.
8.Muscle spasm, resulting in impaired muscle function
and immobility, perspiration.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

CLASSIFICATION OF PAIN BY
CAUSE:
1. NOCICEPTIVE
Ex. Somatic: musculoskeletal( joint
pain, myofascial pain, cutaneous;
often well localized)
Visceral: hollow organs and
smooth muscle: usually referred.
2. NEUROPATHIC:
Ex. Include but are not limited to, diabetic
neuropathy, postherpetic neuralgia, spinal
cord injury pain, phantom
limb(postamputation)pain, and post stroke
central pain.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

3. INFLAMMATORY
Ex. Appendicitis, rheumatoid arthritis, inflammatory
bowel disease and herpes zoster.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

CLASSIFICATION BY DURATION AND
ETIOLGY:
1. ACUTE PAIN:
2. CHRONIC NONMALIGMANT
PAIN:
3. CANCER PAIN:
4. INTRACTABLE PAIN:
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

CLASSIFICATION BY PAIN
LOCATION:
1. CUTANEOUS PAIN:
2. VISCERAL PAIN:
3. DEEP SOMATIC PAIN:
PAIN LOCATION whether PERCEIVED at the site of
the pain:
1. RADIATING:
2. REFERRED:
3. PHANTOM PAIN:
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

CANCER
PAIN
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
FACTS:
1. It can be acute(sudden and severe) or chronic( lasting more
than 3 months)
2. Its types include somatic pain, visceral pain, and neuropathic
pain.
3. It causes breakthrough pain (brief, severe pain that occurs in
spite of pain medication) in many clients.
4. It depends on many factors, including the type and stage
of the cancer.
5. It may be triggered by blocked blood vessels or pressure on a
nerve from a tumor.
6. Side effects of cancer treatments- such as surgery ,
radiation, and chemotherapy- may include pain.

7. About 90% of clients with advanced cancer
experienced severe pain, which clients with advanced
cancer experience severe pain, which often is
undertreated.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
8. Cancer pain can result
from:

THE SEVEN DIMENSIONS
OF PAIN
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
• PHYSICAL DIMENSION
• SENSORY DIMENSION
• BEHAVIORAL
DIMENSION
• SOCIOCULTURAL
DIMENSION
• COGNITIVE DIMENSION
• AFFECTIVE DIMENSION
• SPIRITUAL DIMENSION

Questt principles for pain in
children:
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
MNEMONI
CS
• Q-
• U-
• E-
• S-
• T-
• T –

HEALTH
ASSESSMENT
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
I. COLLECTING SUBJECTIVE DATA: THE NURSING
HEALTH HISTORY
• Pain assessment questions includes:
• location intensity, quality, pattern precipitating factors
and pain relief as well as the effect of the pain on daily
activities, what coping strategies have been used and
emotional responses of the pain.
• Past experience with pain, in addition to past and
current therapies, are explored.

ASSESSMENT OF PAIN TO UNCONSCIOUS,
COGNITIVELY IMPAIRED, ELDERS WITH
DEMENTIA, INTUBATED, INFANTS, PREVERBAL
TODDLERS: HIERARCHY OF PAIN ASSESSMENT
TECHNIQUES( Mccaffery & pasero, 1999)
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
1. SELF REPORT
2. Searchfor potential causes of pain
3. Observe patient behaviors
4. Surrogate reporting (family members, parents,
caregivers) of pain and behavior/ activity changes
Note: Discrepancies may exist between self report of
pain and surrogate reports and between surrogates and
health care providers on judgments of pain and its
intensity.
5.Attempt an analgesic trial

PREPARING THE
CLIENT:
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
PAIN ASSESSMENT
TOOLS:
1. Visual Analog Scale
2. Numeric Rating
Scale
3. Numeric Pain
Intensity
4. Verbal descriptor
Scale

• 5. Simple descriptive Pain Intensity Scale
• 6. Graphic rating Scale
• 7. Verbal rating Scale
• 8. Faces Pain Scales( Wong-Baker FACES Pain rating
Scale) Pls. read your book pg. 151 Chapter 9.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

HISTORY OF PRESENT HEALTH
CONCERN (COLDSPA)
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
C- CHARACTER
-Describe the pain in your own
words O- ONSET
-When did the pain
start? L- LOCATION
- Where is it? Does it radiate or spread ? Does it
occur anywhere else?

• D-DURATION
Rationale: this is also to help identify the nature of the
pain.
• S- SEVERITY
Rationale: Using a standardized tool helps to determine
how much the pain worsens or improves.
• P-PATTERN
Rationale: Understanding the course of the pain
provides a pattern that may help to determine the
source.
•A- ASSOCIATED FACTORS/ HOW IT AFFECTS THE
CLIENT Rationale: Accompanying symptoms also help to
identify the possible source. For ex. Right lower quadrant
pain is associated
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

- What factors relieve your pain?
- What factors increase your pain?
- Has this pain been treated with any medication, therapy,
or surgery ( prescribed medications or therapies,
complimentary or alternative medications or therapies?
- Have any of these decreased or increased your pain?
- This helps in formulating the future plan of care,
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

- Does this pain have any special meaning to you?
- Is there anything you would like to add?
Rationale: An open- ended allows the client to
mention anything that has been missed or the
issues that were not fully addressed by the above
questions.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

PERSONAL HEALTH
HISTORY
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
• Have you had previous experience with pain?
• Have you taken any medications?
Rationale: Types of medications, pattern of use, and
doses may provide evidence of effectiveness or potential
addiction to pain medications.

Family
history
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
• Does anyone in you family experience pain?
• How does pain affect your family?
Rationale: This helps assess the extent the pain is
interfering with
the client’s family

Lifestyle and health
practices
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
• What are your concerns about pain?
• How does you pain interfere with the
following?
- General activity
- Mood/ emotions
- Concentration
- Physical ability
- Work
- Relations with other people
- Sleep
- Appetite
- Enjoyment of life

II. Collecting Objective Data: Physical
Examination During examination:
• Choose an assessment tool reliable and valid to the client’s
culture.
• Explain to the client the purpose of rating the intensity of pain.
• Ensure the client’s privacy and confidentiality.
• Respect the client’s behaviour toward pain and the terms
used to
express it.
• Understand that different pain threshold and expectation.
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

GENERAL ROUTINE SCREENING OR
FOCUSED SPECIALTY
ASSESSMENT FOR PAIN
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
Observe posture
Observe facial expression
Inspect joints and muscles
Observe skin for scars, lesions, rashes changes, or
discoloration.
Measure heart rate
 measure respiratory rate
Measure blood pressure.

ASSESSMENT
PROCEDURE:
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
GENERAL IMPRESSION:
INSPECTION
1. Observe posture
- Inattentive and agitated
- Might be guarding affected area and have
tachypnea or guarded respirations.
2. Observe facial expression
Normal findings: smiles, makes and maintains eye
contact and conversation, asks and answers questions
appropriately facial expressions, and maintains
adequate eye contact.

• Abnormal findings: Clients facial expressions
indicate distress and discomfort, including frowning,
moans, cries, and grimacing.
• Eye contact is not maintained, indicating
discomfort. Nodding up and down or saying.
3.Assess face , legs activity, cry, and consolability
using Assessment tool ( FLACC behavioural
Scale)
4. Inspect joints and muscles
5.Observe skin for scars, lesions, rashes,
changes or discoloration
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

VITAL SIGNS WHEN IN
PAIN:
• INSPECTION
1. Measure heart rate
2. Measure respiratory
rate
3. Measure Blood
pressure
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.

VALIDATING AND DOCUMENTING
FINDINGS:
Weber, Janet R., Kelly, Jane H. (2018). Health
Assessment
in Nursing. 6th edition. Lippincott Williams & Wilkins.
• Validate findings with other caregivers and family
members, especially if the client is reluctant to express
pain.
• Document the assessment data following the health
care facility or agency policy.