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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
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Malaysian 5th Vital Sign Implementation: 2008-2010
5th Vital Sign: Doctors’ training module: Intruduction
DR LEE OI WAHPENGARAH HOSPITAL CHANGKAT MELINTANG
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
OBJECTIVE:OBJECTIVE:
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 post-laparotomy 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
Record pain as the 5th vital sign
Joint Commission on Accreditation of Healthcare Organizations. Jt Comm Perspect. 1999;19(5):6–8.Sklar DP. Ann Emerg Med. 1996;27:412–413.
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;1847–1880.
5th Vital Sign: Doctors’ training module: Intruduction
Promote doctor-patient and nurse-patient interaction
• Better communication
• Better patient satisfaction Provide better patient care
• Individualised carer
• Priority to pain assessment
• Better awareness of pain better management of pain early ambulation faster recovery, reduced length of stay
5th Vital Sign: Doctors’ training module: Intruduction
Spectrum of PainSpectrum of Pain
ACUTE PAIN
CHRONICPAIN
ACUTE PAIN
Healing
NO PAIN
CHRONICPAIN
Insidious onset
post-surgical, post-trauma syndromes cancer
5th Vital Sign: Doctors’ training module: Pain Physiology
Pain PathwayPain Pathway
Free nerve endings
Afferent nerve – ( A / c)
Spinal cord
Sensory cortex
Thalamus
Descending inhibitory fibres
Dorsal horn
PAG / RAS
Ascending ST tracts
Courtesy of Prof Ramani Vijayan, MASP5th Vital Sign: Doctors’ training module: Pain Physiology
Main effects of severe unrelieved painMain effects of severe unrelieved pain
PhysiologicalIncreased stress hormonesNegative effects on CVS, RS leading to increased risk of hypoxemia and myocardial ischaemiaIncreased risk of developing chronic pain conditions
PsychologicalAnxiety and sleeplessness
EconomicIncreased hospital complications, prolonged length of stay and increased costs
5th Vital Sign: Doctors’ training module: Pain Physiology
Why measure pain?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 Clinical techniques for measurement of painmeasurement 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 Assessment
Combination Rating Scale (NRS & VAS)*Recommended for Ministry of Health*
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)
“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 Wong-Baker Faces Pain Rating Scale
5th Vital Sign: Doctors’ training module: Pain Assessment
WHEN SHOULD PAIN BE ASSESSED ?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 patient4. 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?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 Assessment
UNABLE TO ASSESS PAINUNABLE 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
Patient’s Name : RN : DOA :Age :Ward :
DATE TIME BP PULSE RESP RATE
TEMP PAIN SCORE
ACTION TAKEN
COMMENTS
5th Vital Sign: Doctors’ training module: Pain Assessment
ANALGESIC LADDER: ANALGESIC LADDER: ACUTE PAIN MANAGEMENTACUTE PAIN MANAGEMENT
5th Vital Sign: Doctors’ training module: Pharmacology