PAIN AS THE 5 TH

VITAL SIGN
 INTRODUCTION
“Pain as the 5th Vital Sign” was launched by the
Ministry of Health (MOH) in 2008 as one of the
strategies to enhance the pain services in the country
and subsequently implemented in all healthcare
facilities since 2015.
It is now known as Pain
Free Programme.
- Pain is a common symptom experienced by many
patients.
- Patients often have to tolerate severe pain due to
poor pain management.
-Implementation of Pain as the 5th Vital Sign allows
better assessment of pain leading to better and
effective pain management in both primary care and
hospital settings.
-This will result in reducing unnecessary referrals and
hospitalization, early ambulation and faster recovery
 DEFINITION OF PAIN
Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage.
(International Association for the Study of Pain
(IASP) 1994.)
CLASSIFICATION OF PAIN
Differences between acute and chronic
pain
NEUROPATHIC PAIN
Definition: Pain that is caused by a lesion or disease of the
somatosensory system (PNS or CNS)(IASP 2011)
Peripheral nerves:
▪ Traumatic brachial plexus injury ▪ Diabetes Mellitus ▪
Carpel tunnel syndrome ▪ Post herpetic neuralgia
Central nervous system:
▪ Central post stroke pain ▪ Neuropathic associated with
spinal cord injury
COMMON CAUSES
 Differences between Nociceptive pain
and Neuropathic pain
• resulting from activity in
neural pathways cause by
Nociceptive Pain actual tissue damage or
potentially tissue
damaging stimuli

• caused by a lesion or
disease of the
somatosensory system
• could be peripheral
Neuropathic Pain neuropathic pain due to
damaged nerve/central
neuropathic pain due to
injury to spinal cord or
brain
 Periphery (1st step)

PHYSIOLOGY OF - Nociceptors (free nerve endings that respond exclusively to intense stimuli) are
present at the skin, muscles, joints and viscera.

PAIN
- When triggered, the stimulus is carried through A-delta and C nerve fibers to the
next level (spinal cord)

Spinal cord ( 2nd step)

- A delta and C fibers (first order neurons) synapse with second order neurons in
the dorsal horn (substantia gelatinosa) of the spinal cord.
- The pathway continues through the contralateral spinothalamic/spinoreticular
tract to the next level (Supraspinal)

Brain (3rd Step)

- The brainstem and thalamus relay stimuli to the sensory cortex where pain is
perceived

Modulation (4th step)

-Inhibition or excitation of perception and response to pain occurs
through descending pathways from the reticular activating system (RAS) and
periaqueductal grey (PAG).
 PAIN ASSESSMENT TOOL
Recommendation by Ministry of Health, Malaysia

• MOH pain scale

-Show patient the pain assessment tool and teach how to
use, show the pain scale, if 0 = no pain and 10 = worst pain
you can imagine, what is your pain score now?

-The patient is asked to indicate his/ her level of pain

intensity by pointing along a scale.
• FLACC scale
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

• 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
When should pain be assessed?
1.As the 5th vital signs during routine observation of BP,
HR, RR, and temperature

2.½ to 1 hour after administration of analgesics and

nursing intervention for pain relief

3.During and after any painful procedures e.g. wound

dressing

4.Whenever the patient complains of pain 

HOW TO ASSESS PAIN?

Pain assessment requires taking a detailed pain

history. Other questions to ask about pain:
-Pattern of pain: constant / intermittent /
episodic
-Associated symptoms
-Impact of pain on mood and function: affect
sleep/appetite/daily
activities/relationship/work
-Past medical/surgical history, past and current
medications
 MANAGEMENT OF ACUTE
PAIN
Acute pain management is classified into:
1. Non-pharmacological
2. Pharmacological
Non-pharmacological approaches:
Pharmacological approach

• Analgesic medications can be broadly classified into non-opioids

and opioids.
- Non-opioids include e.g. Paracetamol, NSAIDs, COX-2 inhibitors.
- Opioids can be further classified into weak opioids (e.g.
Tramadol, Codeine, Dihydrocodeine) and strong opioids (e.g.
Morphine, Oxycodone, Pethidine, Fentanyl).

•Other adjuvant medications, used mainly in the management of

neuropathic pain, include antidepressants (e.g. amitriptyline,
duloxetine) and anticonvulsants (e.g. carbamazepine, gabapentin
and pregabalin).
 Analgesic ladder for acute
pain
• The WHO analgesic ladder recommends using simple
analgesics (e.g. paracetamol,NSAIDs) for mild to moderate
pain.
• For moderate pain, additional weak opioids (e.g.
tramadol, dihydrocodeine) should be considered.
• In patients with moderate to severe
pain, strong opioids like morphine must be offered.
• In addition, adjuvants are used for
neuropathic pain at all steps of the analgesic ladder
PAIN MANAGEMENT
 Key points
For Pain as the 5th Vital Sign to have an impact in • When to use (according to Analgesic
improving pain management in our clinics we ladder)
need:
When using analgesic medications, we must
•Proper pain assessment, using the appropriate
monitor : Pain score and side effects
tool
•Aim: to achieve reasonable pain relief without
•Proper pain diagnosis 
unacceptable side effects
• Acute or chronic? cancer or non-cancer?
•When managing patients with chronic pain, we
nociceptive or neuropathic?
also  need to focus on functional improvement
•Use of both non-drug and drug treatments  and achievement of goals, not just on pain
reduction 
•Good understanding of analgesic medications 
• What to use (what drug, what dose)