Malaysian 5th Vital Sign Implementation: 2008-2010

DR LEE OI WAH PENGARAH HOSPITAL CHANGKAT MELINTANG

5th Vital Sign: Doctors training module: Intruduction

OBJECTIVE:
The purpose of module is to train doctors and nurses on pain assessment and pain management in order to implement pain as a 5th vital sign effectively in OUR hospital

5th Vital Sign: Doctors training module: Intruduction

All types of pain in all parts of the world are inadequately treated, be it acute or chronic, related to malignant or non-malignant etiologies.
Pain can be relieved in up to 90% of cancer patients, yet fewer than 50% receive adequate treatment National APS audit, Malaysia showed that 76% of postlaparotomy patients suffered moderate to severe pain in the 1st 24 hours What about patients in the medical wards or patients who have not had surgery?
5th Vital Sign: Doctors training module: Intruduction

 New

standards in 2001 pain as the 5th vital sign

Record

Joint Commission on Accreditation of Healthcare Organizations. Jt Comm Perspect. 1999;19(5):68. Sklar DP. Ann Emerg Med. 1996;27:412413.

5th Vital Sign: Doctors training module: Intruduction

Pain should be considered the fifth vital sign

Patients should be assessed for pain every time pulse, blood pressure, temperature, and respiration are measured

American Pain Society Quality Improvement Committee. JAMA. 1995;18471880. th

5 Vital Sign: Doctors training module: Intruduction

Promote doctor-patient and nurse-patient interaction

Better communication Better patient satisfaction

Individualised carer Priority to pain assessment Better awareness of pain

Provide better patient care

better management of pain early ambulation faster recovery, reduced length of stay
5th Vital Sign: Doctors training module: Intruduction

Spectrum of Pain
ACUTE PAIN
Healing

NO PAIN

Insidious onset

CHRONIC PAIN
post-surgical, post-trauma syndromes cancer

ACUTE PAIN

CHRONIC PAIN

5th Vital Sign: Doctors training module: Pain Physiology

Pain Pathway
PAG / RAS
Descending inhibitory fibres

Sensory cortex
Thalamus

Ascending ST tracts

Free nerve endings Spinal cord

Dorsal horn Afferent nerve ( A / c)
5th Vital Sign: Doctors training module: Pain Physiology
Courtesy of Prof Ramani Vijayan, MASP

Main effects of severe unrelieved pain

Physiological
Increased stress hormones Negative effects on CVS, RS leading to increased risk of hypoxemia and myocardial ischaemia Increased risk of developing chronic pain conditions

Psychological
Anxiety and sleeplessness

Economic
Increased hospital complications, prolonged length of stay and increased costs

5th Vital Sign: Doctors training module: Pain Physiology

Malaysian 5th Vital Sign Implementation: 20082010

Why measure pain?

Produces a baseline to assess therapeutic interventions e.g. administration of analgesic drugs Facilitates communication between staff looking after the patient For documentation

5th Vital Sign: Doctors training module: Pain Assessment

Clinical techniques for measurement of pain

Self reporting by the patient (best method)

Observer assessment

Observation of behaviour and vital signs Functional assessment

Unidimensional scales

Numerical Rating Scale (NRS) Verbal Analogue Score (VAS) Categorical Scale or Verbal rating scale

Multidimensional scales
(not commonly used here)

Brief Pain Inventory (BPI) McGill Pain Questionnaire (MPQ) Memorial Pain Assessment Card

5th Vital Sign: Doctors training module: Pain

Combination Rating Scale (NRS & VAS) *Recommended for Ministry of Health*

On a scale of 0 10 (show the pain scale), if 0 = no pain and 10 = worst pain you can imagine, what is your pain score now?
Patient is asked to slide the indicator along the scale to show the severity of his/her pain, which is recorded as a number (zero to 10)

5th Vital Sign: Doctors training module: Pain Assessment

Wong-Baker Faces Pain Rating Scale

5th Vital Sign: Doctors training module: Pain Assessment

FLACC SCORE

5th Vital Sign: Doctors training module: Pain Assessment

WHEN SHOULD PAIN BE ASSESSED ?

1. At regular intervals as the 5th vital sign during routine observation of BP, heart rate, respiratory rate and temperature). This can be 4 hourly, 6 hourly or 8 hourly 2. On admission of patient 3. On transfer-in of patient 4. At other times apart from scheduled observations: Half to one hour after administration of analgesics and nursing intervention for pain relief During and after any painful procedure in the ward e.g. wound dressing Whenever the patient complains of pain

5th Vital Sign: Doctors training module: Pain Assessment

Who should be assessed?

All inpatients
Including patients in labour room, recovery room (OT), High dependency units, Coronary Care Units

All patients in Emergency department

Ambulatory care units

Exclusion
Patients in NICU

5th Vital Sign: Doctors training module: Pain

UNABLE TO ASSESS PAIN

Record

Unable to Score for adult cognitively impaired patients and unconscious patients

5th Vital Sign: Doctors training module: Pain Assessment

Observation Chart
Patients Name : Age : Ward :
DATE TIME BP PULSE RESP RATE

RN :

DOA :

TEMP

PAIN SCORE

ACTION TAKEN

COMMENTS

5th Vital Sign: Doctors training module: Pain Assessment

5th Vital Sign: Doctors training module: Pain Assessment

ANALGESIC LADDER: ACUTE PAIN MANAGEMENT

5th Vital Sign: Doctors training module: Pharmacology