1. Salcido, Richard "Sal MD"

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THE PREVALENCE OF CHRONIC, painful conditions in the United States is enormous: An estimated 80 million persons live with chronic pain. Millions more undergo surgery or suffer a painful injury, making pain one of the most common reasons for medical treatment.


Various organizational and regulatory bodies, including the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), 1 have declared that pain should be treated as vital sign. The American Pain Society, 2 in fact, coined the phrase "Pain: The Fifth Vital Sign" to elevate awareness of pain treatment among health care professionals.


It's the Standard

Most health care organizations have followed this lead, and evaluating complaints of pain is now the standard of care; it must be documented in the patient record, along with any treatments used to ameliorate the pain. According to standards developed by JCAHO, 1 health care providers are required to:


* recognize their patients' right to assessment and management of pain


* assess the nature and intensity of pain in all patients


* establish safe medication prescription and ordering procedures


* ensure staff competency and orient new staff in pain assessment and management


* monitor patients following procedures and reassess patient problems appropriately


* educate patients on the role of pain management in treatment


* address patients' need for symptom management in the discharge planning process


* collect data to monitor performance.



Stumbling Toward Our Goal

I agree with this goal. We should measure and treat our patients' pain with the same degree of urgency as we do the other vital signs.


The stumbling block may be the definition of a sign. The traditional vital signs-pulse, blood pressure, respiration, and temperature-are called signs for a reason: They follow the medical axiom that signs must be objective, measurable, and quantifiable. Pain is not a sign; it is a symptom. Symptoms are what patients describe, subjectively, as a feeling, and feelings are not easy to quantify.


In practice, though, we attempt to make this subjective phenomenon more objective. We ask patients to rate their pain using various scales-typically, 1 to 10, with 1 being the least pain and 10 being the worst pain. We also ask about qualitative facets of the pain: the location, the time of onset, the duration, and the nature of the pain (sharp, burning, stabbing, shooting, dull, aching, throbbing, and pressure, to name a few). This gives us some data to work with, which is a start.


Pain as a Sign and Symptom

Although pain is not a clinical sign in the traditional sense, it is a patient's early warning system that an underlying problem-one that may be life threatening-does exist. As health care providers, we need to pay attention to this warning, including when evaluating and treating chronic wounds. Unfortunately, we have little guidance in the chronic wound care literature. 3,4,5


In my experience, pain is undertreated. This is not surprising: As a society, we face significant challenges in the area of adequately treating pain. 6 Barriers thrown up by our health care systems, other health care professionals, laws and regulatory issues, the attitude of patients and families, and society itself thwart our ability to provide adequate pain relief. Sadly, patients who do not report pain and health care providers who fail to assess for pain are major contributors to this problem. 6


Given the complexity of the issue and the impact on the quality of life for our patients, I believe that considering pain a vital sign is more than appropriate. In my view, pain is both a sign and a symptom.


If we refer to pain as the fifth vital sign, we must resolve to measure and treat it. I am gratified that this issue of our journal has a seminal paper 7 that may start us on the right path by critically examining for us the existing pain assessment tools and their use in managing chronic leg ulcers.




1. Chapman CR. New JCAHO standards for pain management: carpe diem! APS Bulletin, July/August 2000; available online at Accessed September 2, 2003. [Context Link]


2. American Pain Society. Pain: the fifth vital sign; available online at Accessed September 2, 2003. [Context Link]


3. Freedman G, Cean C, Duron V, Tarnovskaya A, Brem H. Pathogenesis and treatment of pain in patients with chronic wounds. Surg Technol Int 2003; 11:168-79. [Context Link]


4. Reddy M, Keast D, Fowler E, Sibbald RG. Pain in pressure ulcers. Ostomy Wound Manage 2003; 49(4 Suppl):30-5. [Context Link]


5. Taylor A. Managing pressure ulcers: the need for pain assessment. Community Nurse 2000; 6( 3):45-6. [Context Link]


6. Lynch M. Pain as the fifth vital sign. J Intraven Nurs 2001; 24:85-94. [Context Link]


7. Nemeth KA, Graham ID, Harrison MB. The measurement of leg ulcer pain: identification and appraisal of pain assessment tools. Adv Skin Wound Care 2003; 16:260-7. [Context Link]