A patient is admitted to the ICU. His VAS score is 8, blood pressure is 130/80 mm Hg, and pulse rate is 66 b/m. Which is the fifth vital sign?

1. A

   Respiration

2. B

   Blood pressure

3. C

   Pain

4. D

   Temperature

Appeared in: NORCET 2 - 2021 (shift-1)

Explanation

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• Pain is established in modern healthcare as the 'fifth vital sign,' complementing the four traditional vital signs (temperature, pulse, respiration, and blood pressure).
• The question provides a Visual Analogue Scale (VAS) score of 8, a direct measurement of the patient's pain intensity, reinforcing its role as a vital sign to be assessed.
• Systematic assessment of pain ensures it is managed promptly and effectively, which is crucial for patient comfort, recovery, and preventing adverse physiological consequences.

Why Other Options Were Wrong

• Option A: Respiration is one of the four cardinal (traditional) vital signs, not the fifth. It measures the number of breaths a person takes per minute.
• Option B: Blood pressure is one of the four traditional vital signs, measuring the pressure of blood against the walls of the arteries. It is not considered the fifth vital sign.
• Option D: Temperature is a core vital sign used to monitor for fever or hypothermia. It is one of the original four vital signs, not the fifth.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Identification of the fifth vital sign in patient assessment in acute care settings.
• In an ICU setting, a VAS score of 8 signifies severe pain that demands immediate nursing intervention, such as administering prescribed analgesics and reassessing the patient's response.
• Uncontrolled severe pain can lead to adverse physiological outcomes, including tachycardia, hypertension, increased myocardial oxygen demand, and delayed healing.
• What if? If the patient were unconscious or non-verbal, the nurse would use an objective, behavioral pain scale like the Critical-Care Pain Observation Tool (CPOT) or the Behavioral Pain Scale (BPS) to assess pain, as the VAS is a subjective tool requiring patient input.

How to Approach the Question

• First, identify the core of the question, which is to name the 'fifth vital sign'.
• Recall the four traditional (cardinal) vital signs: temperature, pulse, respiration, and blood pressure.
• Recognize that 'pain' has been formally designated as the fifth vital sign in modern nursing to ensure it is assessed and managed with the same priority.
• Note the clinical cue provided: a 'VAS score is 8'. The Visual Analogue Scale (VAS) is a tool specifically used to measure pain, which strongly points to pain being the answer.
• Eliminate the other options (Respiration, Blood pressure, Temperature) as they are the original four vital signs.
• Select the option that correctly identifies the fifth vital sign.

Concept Tested & Keywords

• Concept Tested: Identification of the fifth vital sign in patient assessment.
• Stem keywords: ICU, VAS score, fifth vital sign
• Lead-in keywords: Which is
• Clinical cues: VAS score is 8: This indicates severe pain, which requires immediate assessment and intervention.

Question ID

QL-itcuCbLLAc5jVCqka7n

Copy ID

Reference Book

E6 Pharmacology Nursing Lilley 11e Part 1 p. 173-175

E6 Nursing Vital Signs p. 137-139