Pain As The 5Th Vital Sign Toolkit - VA.gov Home
Pain as the 5Th Vital Sign ToolkitOctober 2000Revised EditionGeriatrics and Extended Care Strategic Healthcare GroupNational Pain Management Coordinating CommitteeVeterans Health Administration810 Vermont Avenue NWWashington, DC 20420
PREFACEThis toolkit has been prepared as a resource manual for use by Veterans Health Administration(VHA) managers and staff in implementing the VHA National Pain Management Strategy.More specifically, the toolkit has been designed to promote Pain as the 5th Vital Sign and to offerguidelines for the completion of comprehensive pain assessments. These are the initial steps inpromoting and improving pain management for veterans receiving care within the VHA system.This information is intended for reference only and is provided for use in the development oflocal pain assessment procedures.Copyright permission has been granted by the American Pain Society to use the phrase: "Pain:the 5th Vital Sign" as a portion of the VA take 5 logo as displayed on the front cover.Page 1Pain as the 5th Vital Sign Toolkit
CONTENTSPreface1Contents2Acknowledgements4Toolkit Task Force4Content Reviewers4Section 1: Introduction5Veterans Health Administration (VHA) National Pain Management Strategy5Why Pain as the 5th Vital Sign5Overview of the Toolkit6Section 2: An Overview of the VHA National Pain Management StrategyImplementing the Pain as the 5th Vital Sign MandateSection 3: Barriers to Pain Screening and Assessment7711Healthcare Professionals11Patients11Healthcare System12Section 4: The Pain Screening Process13Keys to Successful Pain Screening13The Numeric Rating Scale (NRS)13Tips for Successful Use of the Numeric Rating Scale14Suggested Script and Answers to Questions Patient's Frequently Ask15Alternatives to the Numeric Rating Scale16When to Screen for Pain17Documenting Pain Scores17Interpreting Pain Scores18Page 2Pain as the 5th Vital Sign Toolkit
Section 5: Comprehensive Pain Assessment20Assessing the “Person with Pain”20Overview of the Comprehensive Pain Assessment Process20Components of the Comprehensive Pain Assessment Interview21Documenting the Comprehensive Pain Assessment21Footnotes in Sections 1 through 522Section 6: Educational and Resource Information23VHA National Pain Management Policy23VHA National Pain Management Strategy Coordinating Committee25VISN Pain Management Points of Contact (POCs)29Education Service Representatives (ESRs)32Electronic Documentation of Pain Scores33Examples of Paper Documentation Forms39Examples of Local Facility Pain Assessment Tools and Templates41Pain Assessment Resources43Joint Commission on Accreditation of Healthcare Organizations (JCAHO)Standards Related to the Assessment and Treatment of Pain51Page 3Pain as the 5th Vital Sign Toolkit
ACKNOWLEDGEMENTSToolkit Task ForcePain as the 5th Vital Sign Toolkit is the result of substantial effort by members of the ToolkitTask Force who are listed below. We are particularly indebted to Loretta Wasse and BonnieRyan for creating the initial draft of the toolkit and to Robert D. Kerns for subsequent revisions.John Booss, MDDirector, Neurology Service (200)Field BasedVA Connecticut Healthcare SystemWest Haven, CT 06516Audrey Drake, RN, MSN, CNAAProgram Director (118)Nursing Strategic Healthcare GroupVA Headquarters810 Vermont Avenue, NWWashington, DC 20420Robert D. Kerns, PhDChief, Psychology ServiceVA Connecticut Healthcare SystemWest Haven, CT 06516Bonnie Ryan, RN (Co-Chair)Chief, VA Home and Community-Based Care (114)VA Headquarters810 Vermont Avenue, NWWashington, DC 20420Loretta Wasse, CRNA, MEd (Co-Chair)Deputy Director, Headquarters Anesthesia Service (111L)Puget Sound Health Care System, Seattle Division1660 South Columbian WaySeattle, WA 98108Content ReviewersNumerous individuals both within and beyond the VHA healthcare system contributed time andtalent as reviewers of the original draft of this Pain as the 5th Vital Sign Toolkit. We gratefullyacknowledge their contributions, specifically recognizing the members of the VHA NationalPain Management Strategy Coordinating Committee, members of the VISN 1 Pain ManagementSubcommittee, and staff of the Comprehensive Pain Management Center at the VA ConnecticutHealthcare System.Page 4Pain as the 5th Vital Sign Toolkit
SECTION 1: INTRODUCTIONVeterans Health Administration (VHA)National Pain Management StrategyVHA has initiated a comprehensive national strategy for pain management. The overall goal ofthe new VHA National Pain Management Strategy is to prevent pain and suffering in personsreceiving care in the veterans healthcare system. The specific objectives of this strategy are to: Provide a system-wide VHA standard of care for pain management that will reducesuffering from preventable pain. Assure that pain assessment is performed in a consistent manner. Assure that pain treatment is prompt and appropriate. Include patients and families as active participants in pain management. Provide for continual monitoring and improvement in outcomes of pain treatment. Provide for an interdisciplinary, multi-modal approach to pain management. Assure that clinicians practicing in the VHA healthcare system are adequately prepared toassess and manage pain effectively.Why Pain as the 5th Vital SignThe phrase “pain as the 5th vital sign” was initially promoted by the American Pain Society toelevate awareness of pain treatment among healthcare professionals.Vital Signs are taken seriously. If pain were assessed with the same zeal as othervital signs are, it would have a much better chance of being treated properly. Weneed to train doctors and nurses to treat pain as a vital sign. Quality care meansthat pain is measured and treated.James Campbell, MDPresidential Address, American Pain SocietyNovember 11, 1996VHA recognizes the importance of making pain “visible” in an organization. Screening,assessing, and documenting pain routinely is an important first step in assuring that unrelievedpain is identified and treated promptly.It is important to emphasize that Pain as the 5th Vital Sign is a screening mechanism foridentifying unrelieved pain. Screening for pain can be administered quickly for most patients ona routine basis. As with any other vital sign, a positive pain score should trigger furtherassessment of the pain, prompt intervention, and follow-up evaluation of the pain and theeffectiveness of treatment.Page 5Pain as the 5th Vital Sign Toolkit
Overview of the ToolkitThis Pain as the 5th Vital Sign Toolkit has been prepared as a resource toolkit for use byhealthcare professionals. It is organized into the following sections:Section 1: Introduction. This section presents the objectives of the VHA National PainManagement Strategy and a synopsis of the major sections of this toolkit.Section 2: An Overview of the VHA National Pain Management Strategy. This sectionhighlights the key components of the strategy and provides recommendations for implementationat individual VHA facilities (or in individual healthcare facilities if it is being used by non-VHAsystems).Section 3: Barriers to Pain Screening and Assessment. This section reviews many of thecommon barriers to reliable pain screening and assessment, including barriers attributable tohealthcare professionals, patients, and the healthcare system. Appreciation of the factors iscritical to the development of an effective program for pain management.Section 4: The Pain Screening Process. This section includes information about the NumericRating Scale (NRS) for pain screening, a description of the tool, tips for using it reliably;guidelines for frequency of screening across diverse clinical settings; and suggestions for usingthe tool within the context of patient/family education on pain and pain management. Thissection also contains information on methods for documenting pain scores in the patient record.Section 5: Conducting a Comprehensive Pain Assessment. This section emphasizes the roleof pain screening as an initial step in the comprehensive assessment of pain. The sectiondiscusses pain as a complex, perceptual phenomenon and provides a rationale for morecomprehensive assessment. Key components and commonly employed methods of painassessment are also described, followed by a description of common barriers to reliable painassessment.Section 6: Educational and Resource Information. This section provides information to assistindividuals and facilities in the successful implementation of the Pain as the 5th Vital Signinitiative.Page 6Pain as the 5th Vital Sign Toolkit
SECTION 2: AN OVERVIEW OFTHE VHA NATIONAL PAIN MANAGEMENT STRATEGYPain as the 5th Vital Sign is just one element of the VHA National Pain Management Strategy. Itis the first step toward assuring that all persons cared for in the VHA healthcare system canreliably count on prompt and appropriate treatment of pain.The VHA Pain as the 5th Vital Sign initiative establishes the routine screening and assessment ofpain and the documentation of a plan for pain reduction as national policy throughout the VHAhealthcare system.The essential components of this initiative are: Routine pain screening for the presence and intensity of pain for all patients using a 0-to10 Numeric Rating Scale (NRS). Documentation of present pain intensity (i.e., “pain score”) for all patients as part of thevital sign record. Completion of a comprehensive pain assessment, as clinically indicated, for patientsreporting a significant level of pain. Documentation of the comprehensive pain assessment, the plan for improved painmanagement, and a timeframe for reassessment.Implementing the Pain as the 5th Vital Sign MandateImplementing Pain as the 5th Vital Sign will require every VHA medical facility to do thefollowing: Develop a comprehensive implementation plan for the facility. Plan and implement methods for pain screening and assessment. Provide for routine documentation of pain scores and assessment. Provide education for healthcare providers, e.g., physicians, nurses. Education shouldinclude instruction on how to use the NRS, documentation procedures, and interpretationof the results; how to conduct a comprehensive pain assessment and documentationrequirements; and how to develop a plan for effective pain management and how todocument it. Educate patients and families about pain screening, assessment, patient rights andresponsibilities related to pain management, and available pain management/treatmentoptions.Page 7Pain as the 5th Vital Sign Toolkit
Develop an implementation plan for your facility. Designate a person or team who will be responsible for implementing Pain as the 5th VitalSign. Establish an action plan with timelines and assigned responsibilities. Implementing Painas the 5th Vital Sign in all sites of care should be approached as the first step in acomprehensive plan to continuously improve pain management. It will be necessary todevelop further guidelines and procedures for more comprehensive pain assessment andfollow-up for patients for whom pain is identified as a problem. Share the plan with your VISN Pain Management Point of Contact (POC). See pages 2931 in Section 6 of this toolkit for a list of VISN POCs.Plan methods for pain screening and assessment at all sites of care. Review the VHA National Pain Management Policy and the JCAHO Standards Relatedto the Assessment and Treatment of Pain, both in Section 6 of this toolkit. Identify procedures and guidelines for pain screening and assessment that are currentlybeing used in your facility and/or VISN. Keep in mind that the NRS is simply an initialscreening tool and is only the first step toward achieving consistent pain assessment forall patients. You may already have more comprehensive pain assessment procedures inplace in some sites of care. Identify local pain management experts to assist in developing and reviewing policies andprocedures. Review pain screening and assessment resources (see Section 6). Establish policies and procedures for your facility. Incorporate pain screening and assessment procedures into appropriate facility manuals,handbooks, publications, and other facility reference materials as is needed. Develop an implementation plan for documenting pain scores in the medical record (seeSection 4). Develop an implementation plan for documentation of comprehensive pain assessmentsand care plans.Educate healthcare providers on pain assessment. The Employee Education System (EES) can provide valuable assistance in developingeducational materials and coordinating educational programs. Include your VISNEducation Service Representative (ESR) as well as your facility and VISN educationcommittee in planning for educational activities. See page 32 in Section 6 of this toolkitfor an ESR contact list and the Web address for updates. Each facility has an Education Point of Contact Person (POC) who can be identified byreviewing the list in Outlook under “VHA Education POCs.”Page 8Pain as the 5th Vital Sign Toolkit
Identify the target audience for Pain as the 5th Vital Sign, e.g., physicians, nurses, nursesaides, medical technicians, pharmacists, therapists, chaplains, social workers. Consider abroad audience for initial, basic education. Remember that one objective of this initiativeis to raise awareness of the importance of pain assessment and pain managementthroughout the organization. All members of the healthcare team should be able tounderstand and use the NRS. Professional staff who will have responsibility forconducting comprehensive pain assessments and for the development of plans for painmanagement/treatment will necessarily require additional specialized training. Identify educational resources (see Section 6). A wide array of published materials isavailable, as well as information on the Internet that can be readily adapted for use instaff education. Identify local pain management experts to assist in the development of employeeeducation programs and materials. Develop an educational plan with a timetable and assigned responsibilities. Keep in mindthat this is an ongoing project. Consider starting with the basics and building moredetailed and comprehensive educational programs over time. Ask: What does staff needto know? Who needs to know? When, where, and how should training be provided? Incorporate pain assessment into the initial orientation and ongoing education of allappropriate staff. Share your education plan with your VISN Pain Management Point of Contact (POC)and your VISN Education Service Representative (ESR). See lists in Section 6 of thistoolkit.Educate patients and families. Identify the contact person for patient education in your facility and/or your VISN patienteducation committee. Enlist their assistance in coordinating your patient educationactivities. A listing of local “Patient Education Contacts” is available in Outlook. Identify patient and family education materials on pain assessment and pain managementthat are already in use in your facility and/or VISN. Identify local experts to assist with the development of patient and family educationmaterials. Identify educational resources (see Section 6). There is an abundance of publishedmaterials, as well as information on the Internet designed for patient and family educationrelated to pain assessment and treatment. Review the JCAHO Standards Related to the Assessment and Treatment of Pain providedin Section 6 of this toolkit, paying particular attention to the chapters on “Rights andEthics” and “Education.” Develop a plan for educating patients and families on pain assessment and management.Again, keep in mind that this is an ongoing effort. Establish priorities and a realisticPage 9Pain as the 5th Vital Sign Toolkit
timeline based on an assessment of needs and resources available. Consider starting witha simple instruction tool for use of the NRS for rating pain intensity. Share your plan for patient and family education with your VISN Pain Management Pointof Contact (POC), listed in Section 6 of this toolkit.Use the Numeric Rating Scale (NRS) to teach patients and families. Define the word “pain.” For example, you might describe “pain” as a physicaldiscomfort that may have various characteristics such as aching, pulling, tightness,burning, or pricking, and you might explain that pain may be mild to severe. To verify that the patient understands how the word “pain” (or other word preferred bythe patient) is used, ask the patient to give examples of pain he or she has experienced. Ifthe patient is already in pain, use the present situation as the example. Emphasize to the patient and family that the patient's self-report of pain is the single mostreliable indicator of how much pain the patient is experiencing. Explain that the patientmust volunteer information. Although caregivers will ask about pain regularly, they donot know when the patient has pain unless the patient reports it. This information helpsstaff establish pain relief satisfactory to the patient. Emphasize also that the patient'sreport about his/her pain level is always what is recorded in the patient's record. Show the patient and family the NRS and explain that its primary purpose is to providequick, consistent communication between the patient and caregivers, including nurse andphysician. Explain that 0 represents no pain, while 10 represents the worst possible pain.If the patient does not understand, select another pain intensity scale. If the patient reports more than one site or painful condition, discuss the importance ofproviding a single, global measure of pain intensity. The patient should be encouraged totake into account a primary site of pain (e.g., surgical wound) but also to consider allother relevant sites of pain, as well. Ask the patient to practice using the NRS by rating his/her present painful experiences orthose that he/she remembers. Ask the patient what pain rating would be acceptable or satisfactory to him/her. Thishelps set a realistic, initial goal. Zero pain is not always possible. Once the initial goal isachieved, the possibility of better pain relief can then be considered. Emphasize to thepatient that satisfactory pain relief is a level of pain that is not distressing, and one thatenables the patient to sleep, eat, and perform other required physical activities.Page 10Pain as the 5th Vital Sign Toolkit
SECTION 3: BARRIERS TO PAIN SCREENING AND ASSESSMENTBefore presenting the key parameters of the pain screening and assessment process, it isimportant to consider the numerous obstacles to this process.The patient's subjective pain experience may be difficult to communicate because the patient andprovider have different languages, experiences, expectations, and frames of reference. Prior toassessment, it is important that the provider be aware of and sensitive to these types of barriers.A range of additional barriers attributable to healthcare professionals, patients, and the healthcaresystem have also been articulated and deserve special attention in promoting reliable painassessment and optimal pain management.Traditional patterns of professional practice may be among the most difficult barriers toovercome. Healthcare providers and institutions must address these barriers in their practicesettings to assure that all patients receive quality pain care.1Healthcare ProfessionalsHow we think about pain influences the way we go about evaluating a person who reports thepresence of pain. Assessment of pain is also influenced by learned behavioral responses from agiven culture or subculture. It is important that all practitioners be aware of how their ownbiases may influence pain assessment. The following may affect practitioners’ responses topatients’ reported pain: Attitudes - Fear of patient addiction. Concern that attention to pain may encourageadditional complaints of pain and medication seeking. Skills - Inadequate knowledge and experience related to pain assessment andmanagement. Knowledge - Concern about
Pain as the 5 th Vital Sign Toolkit Page 6 Overview of the Toolkit This Pain as the 5 th Vital Sign Toolkit has been prepared as a resource toolkit for use by healthcare professionals. It is organized into the following sections: Section 1: Introduction.
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
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pain”, “more pain” and “the most pain possible”. Slightly older children can also say how much they are hurting by rating their pain on a 0-10 (or 0-100) scale. Zero is no pain and 10 (or 100) is the worst possible pain. What a child is doing Often children show their pain by crying, making a “pain” face, or by holding or rubbing .
Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được
Short-term pain, such as when you suffer a sprained ankle, is called 'acute' pain. Long-term pain, such as back pain that persists for months or years, is called 'chronic' pain. Pain that comes and goes, like a headache, is called 'recurrent' pain. It is not unusual to have more than one sort of pain or to have pain in several places
