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PAIN AS 5TH VITAL SIGNT R A I N I N G M O D U L E F O R
P A R A M E D I C S
Pain as 5th vital signs- Paramedics
PEKELILING KPK BIL 9/2008
• Mandatory to carry out Pain as 5th Vital sign
• To provide routine assessment, treatment and
documentation of pain score
Pain as 5th vital signs- Paramedics
CRITERIA
CRITERIA FOR PAIN FREE HOSPITALS: Does your hospital…
1. Have a written policy on pain assessment and management?
2. Implement Pain as the 5th Vital Sign?
3. Have standardized treatment protocols for management of acute pain?
4. Train all healthcare staff on knowledge and skills in pain assessment and
management?
5. Educate patients and get them actively involved in their own pain
management?
6. Carry out regular audit of pain assessment and management practices
and outcomes?
7. Have a policy and guidelines on Minimally invasive surgery?
8. Have a policy and guidelines on Day Care Surgery?
9. Use a multidisciplinary team approach in pain management?
10. Incorporate non-pharmacological including T/CM into pain
management practices?Pain as 5th vital signs- Paramedics
TRAINING OBJECTIVES:
• To improve understanding of pain
• To teach simple framework of pain assessment and
pain management
• To reduce barriers to pain management
• To meet objectives of Pain Free Hospital (PFH)
concept
Pain as 5th vital signs- Paramedics
DEFINITION OF PAIN
• Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such.(International Association for the Study of Pain, 1996)
• Sensory component
• Physical aspect of pain
• Emotional component
• Tolerance to pain
• Depression
• Anxiety
Pain as 5th vital signs- Paramedics
DEFINITION OF PAIN
To the patient
• Pain is what the patient says
Pain as 5th vital signs- Paramedics
Pain can affect…
ANYONE
Rich and poor
Young and old
Educated and illiterate
Doctors and nurses
Lay person
Pain as 5th vital signs- Paramedics
DIFFERENT TYPES OF PAINDIFFERENT LOCATION
Injection Neck pain Cancer Trauma
Low back pain
Post op pain
Arthritis LabourPain as 5th vital signs- Paramedics
CLASSIFICATION OF PAIN
Type Descriptions
Acute Pain of recent onset/sudden onset
Chronic Last for more than 3 months, cannot identify cause
Pain persist even after wound is healed
CancerProgressive; many different cause
May be a mixture of acute and chronic pain
Non cancer Acute or chronic
Nociceptive
/physiological pain
Obvious tissue injury or illness
Somatic = bones and tissues = well localized
Visceral pain: abdomen, thoracic cavity
Nature of pain: sharp or dull
Neuropathic/
pathological pain
Nervous system damaged or abnormality;
May not see tissue injury
Nature of pain: shooting + numbness, pins and needles, not
well localized
Pain as 5th vital signs- Paramedics
DIFFERENCES BETWEEN ACUTE AND CHRONIC PAIN
Acute pain Chronic pain
Onset & timing
Sudden, short duration
Resolves /disappears when
tissue heals
Insidious onset
Pain persists despite tissue
healing
SignalWarning sign of actual or
potential tissue damage
Not a warning signal of damage
False alarm
SeverityCorrelates with amount of
damage
Severity not correlated with
damage
CNS
involvement
CNS intact- acute pain is a
symptoms
CNS may be dysfunctional-
chronic pain is a disease
Psychological
effects
Less, but unrelieved pain
anxiety and sleeplessness
(improves when pain is
relieved)
Often associated with
depression, anger, fear, social
withdrawal etc.
Pain as 5th vital signs- Paramedics
ACUTE PAIN CHRONIC PAIN
Trauma/fracture/Surgery
Burns
Arthritis
Abscess
Myocardial infarction
Labour pain & child birth
Chronic headache
Chronic low back pain
Chronic abdominal pain
Chronic pelvic pain
Cancer pain
NEUROPATHIC PAIN
Acute shingles
Post spinal cord injury-
(immediate)
Brachial plexus injury-
(immediate)
Post herpetic neuralgia
Spinal cord injury (SCI)
Brachial plexus injury
Diabetic peripheral neuropathy
Post stroke pain
COMMON CAUSES
Pain as 5th vital signs- Paramedics
WHY PAIN AS 5TH VITAL SIGN?
Pain as 5th vital signs- Paramedics
Respiratoryrate
Temperature
Pulse rate Blood pressure
4
Pain as 5th vital signs- Paramedics
4 VITAL SIGNS- ARE THEY ADEQUATE?
In the past: zero communication
He is quiet and
comfortable. BP, PR, RR
are normal. He has no
fever.
Pain as 5th vital signs- Paramedics
BENEFITS OF OF PAIN AS 5TH VITAL SIGN
• To patient, family and organization
• To provide holistic patient care
• To evaluate pain level accurately
• To give effective treatment
• To promote early ambulation
• To reduce post operative complications
Pain as 5th vital signs- Paramedics
BENEFITS OF PAIN AS 5TH VITAL SIGN
• Enhance healing, reduce length of stay
• Reduce health care cost
• Promote staff- patient interaction
• Promote client satisfaction
• Improve QOL, sleep, appetite
• Reduce psychological distress
Pain as 5th vital signs- Paramedics
PAIN ASSESSMENT
• Patients are the experts to give their pain score
• Patient‟s self report is the most reliable indication of
the presence and intensity of pain
• The nurse is not a mind reader to read patient‟s
pain
Pain as 5th vital signs- Paramedics
WHY PAIN ASSESSMENT?
• To establish baseline of patient‟s pain
• To enhance patient‟s comfort and satisfaction
• Reduce complications
• Shorten stay in ward
• Enable titration of analgesia to achieve the best
analgesia with least side effects
• To reduce incidence and severity of pain
• For research and documentation
Pain as 5th vital signs- Paramedics
WHEN SHOULD PAIN ASSESSED?
• At regular interval- as the 5th vital sign • during routine observation of BP, HR, RR and temperature
• 4 hrly, 6 hrly or 8 hrly
• On admission of patient
• On transfer – in of patient
• At other times apart from scheduled observations:• 1/2 to 1 hr after administration of analgesics and nursing
• During and after any painful procedure in the ward e.g. wound
dressing
• Whenever the patient complains of pain
Pain as 5th vital signs- Paramedics
WHERE IS PAIN ASSESSMENT DONE?
WARDS
CLINICS
OPERATING ROOMS
CRITICAL CARE AREAS
EVERYWHERE
Pain as 5th vital signs- Paramedics
WHO DOES PAIN ASSESSMENT?
NURSES
DOCTORS
STUDENTS: MEDICAL & NURSING
MEDICAL ASSISTANTS
PHYSIOTHERAPISTS
OCCUPATIONAL THERAPISTS
EVERYONE!
Pain as 5th vital signs- Paramedics
Everywhere… everyone…
Pain as 5th vital signs- Paramedics
PAIN ASSESSMENT TOOL
WHICH TOOL TO USE? HOW TO USE?
Pain as 5th vital signs- Paramedics
WHICH TOOL TO USE
• Use the standard tool for pain assessment as
recommended by the Ministry of health, M‟sia
• For adult patients:
• use the MOH pain scale
• For paediatric patients:
• 1 month- 3yrs : FLACC scale
• 3-7 years old: WONG BAKER FACES scale
• >7 years: MOH pain scale
• Always use the same tool
Pain as 5th vital signs- Paramedics
MOH PAIN SCALE
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 (0 to 10)
Pain as 5th vital signs- Paramedics
FLACC SCORE
• Observational tool for pain assessment
• Indications:• For paediatric patients (1month-3 years)
• Elderly patient
• Cognitively impaired patient
• How to perform FLACC score?• Observe for 2-5 minutes
• Observe patient‟s behaviour
• Select score according to behaviour
• Add the scores to get the total score
Pain as 5th vital signs- Paramedics
Category
Score
0 1 2
F ace No particular expression or smile
Occasional grimace or frown, withdrawn, disinterested
Frequent to constant quivering chin, clenched jaw
L egsNormal position or relaxed
Uneasy, restless, tense Kicking or legs drawn up
A ctivityLying quietly, normal
position, moves easily
Squirming, shifting back
and forth, tense Arched, rigid or
jerking
C ryNo cry (awake or asleep)
Moans or whimpers; occasional complaint
Crying steadily, screams or sobs, frequent complaints
C onsolabilityContent, relaxed Reassured by occasional
touching, hugging or being talked to distractible
FLACC SCALE
Pain as 5th vital signs- Paramedics
FACES SCALES ( FOR 3-7 YEARS)
The Wong –Baker faces scale (adapted from Wong DL et al, eds. Whaley and Wong‟s essential of pediatric nursing. 5th ed. St Louis, MO: Mosby, 2001)
Pain as 5th vital signs- Paramedics
WONG BAKER FACES SCALE
• This is a self report tool consisting of 6 cartoon faces
• Ask the child to choose a face which best describe
his/her pain
• Multiply the score below the face by 2 to get a
maximum score of 10
• Be careful as some children might confuse the
faces as a measure of happiness
Pain as 5th vital signs- Paramedics
HOW TO ASSESS PAIN
• Important to:
listen and believe the
patient
• Take a pain history:
“Tell me about your
pain……
Pain as 5th vital signs- Paramedics
LANGUAGE / COMMUNICATION
Ooops…
Foreigner?!
How to do
pain score? I
can’t speak
his language.
Pain as 5th vital signs- Paramedics
HOW TO DO PAIN ASSESSMENT
• Greet patient/ salam
• Inform the purpose: • To get the patient‟s correct pain score for proper treatment
• Show and teach patient pain assessment tool• If „0‟ ( smiling face) – no pain
• „10‟ ( crying face)- worst pain imaginable
• What is your pain score now?
Pain as 5th vital signs- Paramedics
TAKING PAIN HISTORY
1. Ask the patient
Listen and believe the patient who complains of pain. Pain history is taken using the acronym:
P: place or site of pain
A: aggravating factor (what makes the pain worse?)
I: intensity (pain score)
N: nature and neutralizing factors (what makes the pain less?)
2. In the first assessment you should:Mark the pain sites(s), pain score and nature of pain in the body
chart
Pain as 5th vital signs- Paramedics
UNABLE TO ASSESS
3. Subsequent observations
Only pain scores are taken and recorded in the pain
assessment chart
Record “Unable to score” for
• Unconscious patients
• Sedated patients
Pain as 5th vital signs- Paramedics
Greet patient
Assess pt’s pain &
obtain pain score
Teach patient
pain assessment tool
Pain Score > 4
Check pt’s notes Action required?
Inform doctor
Nursing action
Last dose > 1 hour (only for opioids)
Pain Score < 4
Analgesic not ordered Analgesic ordered
Serve medication
Reassess after ½ hour
Pain score >4
Pain score < 4
Record
YES
YES
NO
NO
Pain as 5th vital signs- Paramedics
Flow Chart
Pain the 5th Vital Sign
*Paracetamol :
Maximum dose of paracetamol
4gm/day or (4 x 1gm)
# only for opioids
#
*Paracetamol
NURSING OBSERVATION CHART (VITAL SIGNS CHART)
PS.KKM1/2014
Patient’s Name :
Age :
Ward :
DATE TIME BP PR RR T°C PS NURSING INTERVENTION
Pain Score
Pain as 5th vital signs- Paramedics
What Will Happen
When Pain Is Not Treated Properly ?
Pain as 5th vital signs- Paramedics
ADVERSE EFFECTS OF UNTREATED ACUTE PAIN
System Effects
Cardiovascular
system HR, BP, O2 demand, risk of MI
Respiratory system Alveolar ventilation, pneumonia
Gastrointestinal
system Motility
Musculoskeletal Immobility, DVT
Personal Poor sleep, appetite, self esteem, weight loss
depression, social deprivation, affects ADL/QOL
Economic burden – going for treatment, financial stress
Pain as 5th vital signs- Paramedics
APPROACH TO PAIN
Recognize
Assess
Treat
Pain as 5th vital signs- Paramedics
APPROACH TO PAIN MANAGEMENTR- RECOGNIZE
• Does the patient have pain?
• Do other people know the patient has pain?
• Do YOU know the patient has pain?
Pain as 5th vital signs- Paramedics
IN PATIENT WHO IS UNABLE TO REPORT PAIN
• Recognize pain in the cognitively impaired/non
verbal patient/patient who don‟t tell or cannot tell
• Assess behaviors that may indicate pain:
• Facial grimaces
• Guarding, hitting, motioning for assistance
• Sighing
• Restlessness, tension anxiety, rubbing
• Decreased appetite
• Negative or repetitive vocalizations
• Insomnia
• Sadness or drying
Pain as 5th vital signs- Paramedics
APPROACH TO MANAGEMENT:A- ASSESS
• How severe is the pain? (Pain score)
• What type of pain is it? (Acute/chronic)
• Aggravating factors?
• What relieves the pain?
Pain as 5th vital signs- Paramedics
APPROAC TO PAIN MANAGEMENTT-TREAT
• What non pharmacological (non drug) treatment
can I use?
• What pharmacological treatment can I use?
Pain as 5th vital signs- Paramedics
PAIN MANAGEMENT BY PARAMEDICS
Pain as 5th vital signs- Paramedics
NON DRUG TREATMENTS:
• Physical:
• RICE
• Surgery
• Acupuncture, massage, physiotherapy
• Psychological
• Explanation
• Reassurance
• Counseling
• Patient and care giver education and support
Pain as 5th vital signs- Paramedics
PHYSIOTHERAPY:
Diaphragmatic breathing exercises
• Place both hands over the diaphragm region
• Ask patient to breathe through the nose and blow out through
the mouth
• At the same time, you can feel your hands follow the
breathing movements of the diaphragm but not the chest
Pain as 5th vital signs- Paramedics
NON PHARMACOLOGICAL STRATEGIESCORTEX FOCUSED
Relaxation Relaxation Distraction Distraction
Music Guided imagery Guided imagery
Pain as 5th vital signs- Paramedics
NON PHARMACOLOGICAL STRATEGIESCORTEX FOCUSED
Ice Massage Acupuncture
Physiotherapy Elevation Hydrotherapy
Pain as 5th vital signs- Paramedics
NON PHARMACOLOGICAL STRATEGIESPSYCHOLOGICAL APPROACHES
Explanation : Now I know what is happening to me
Counseling: I am taken notice of
Reassurance:
Everything is gonna be alright
Pain as 5th vital signs- Paramedics
OTHER NURSING ACTIONS:
• Check possible causes of pain
• Blocked urinary catheter/distended bladder
• Swollen intravenous site/tissued
• Uncomfortable lying position
• Inform doctor if nursing action is not effective
Pain as 5th vital signs- Paramedics
PHARMACOLOGICAL METHODS TO RELIEVE PAIN
Pain as 5th vital signs- Paramedics
ANALGESIC LADDER
Pain as 5th vital signs- Paramedics
Pain as 5th vital signs- Paramedics
ANALGESIC LADDER FOR
ACUTE PAIN MANAGEMENT
SEVERE UNCONTROLLED
7 - 10
To refer to APS
for:
PCA or Epidural or other forms of
analgesia
MODERATE
Regular
IV/SC Morphine
5-10mg 4H
or
Aqueous
Morphine
5-10mg 4H or
IR Oxycodone
5-10mg
4-6 H
+ PCM 1g
QID
+NSAID/ COX2
Inhibitor
PRN
IV/SC Morphine
5-10mg
or
Aqueous
Morphine
5-10mg or
IR Oxycodone
5-10mg
4 - 6
MILD Regular
Opioid Tramadol
50-
100mg tds-qid
+PCM 1g
QID +NSAID/
COX2 Inhibitor
PRN
Additional Tramadol
50-100mg
(max total dose:
400mg/day)
1 - 3
Regular
No
medication
Or PCM 1g
QID
PRN
PCM
&/or
NSAID/ COX2
Inhibitor
!
ABCD OF PAIN MANAGEMENT PAIN ASSESSMENT, JACOX ET AL 1992
ABCD of PAIN ASSESSMENT
AAsk patients pain level regularly
Assess pain systematically
BBelieve patient pain level
Believe patient family on pain relief methods
CChoose pain control options appropriate for the
patient
DDeliver intervention timely, logically and
coordinated
E Empower patient and family in pain management
Pain as 5th vital signs- Paramedics
RECOMMENDATION FOR EFFECTIVE IMPLEMENTATION:
1. PATIENT EDUCATION
• Importance of giving accurate pain score
• Correct use of the pain scale
• Inform the nurse or doctor when in pain
• Patient's right to adequate pain treatment
• Discharge plan
2. DOCTORS, NURSES AND ALL ALLIED HEALTH
PERSONNEL
• Be positive
• Make it a culture to implement pain as 5th vital sign
Pain as 5th vital signs- Paramedics
RECOMMENDATIONS FOR EFFECTIVE IMPLEMENTATION OF P5 VS
3. DO NOT THINK OF INCREASE WORKLOAD
• Think of patient‟s comfort and recovery
4. INVOLVE MATRONS & SISTERS
• Constantly monitoring and supervision of their staff in the
implementation
5. POSTING: involve clinical nurses and students in training
6. NURSING CURRICULUM: Training must start from nursing
college
7. Always follow the pain as 5th vital signs flow chart
Pain as 5th vital signs- Paramedics
Pain assessment & 10 ‘S’
Salam/greet
Senyum/smile
Sopan/well mannered
Sensitif/sensitive
Segera/immediately
Sentuh/touch
Segak/ professional
Selia/supervise
Semangat/motivated
Selidik/study and audit
Pain as 5th vital signs- Paramedics
ROLE OF TRAINERS
• Be a member of the PFH or P5VS committee at hospital
level, headed by hospital director (pengarah)
• Conduct training for all nursing and allied health staff weekly or fortnightly
• Conduct orientation talk on P5VS & PFH for all new staff
• Ward sisters carry out daily monitoring/spot checks on
implementation in your own wards
• Compile report for quality improvement for your hospital
Pain as 5th vital signs- Paramedics
CONCLUSIONS
• Pain as the 5th vital sign is necessary to ensure
patients a pleasant and comfortable stay in the
hospital
• We must be very positive and implement pain
assessment diligently
• Pain 5th Vital signs must be made a practice culture
just as for the other 4 vital signs
• Pain as 5th vital sign is beneficial to patient, staffs
and organizations
Pain as 5th vital signs- Paramedics
When pain is well managed….
Pain as 5th vital signs- Paramedics
Pain as 5th vital signs- Paramedics
Pain as 5th vital signs- Paramedics