PAIN AS

5 VITAL SIGN
TH

TRAINING MODULE FOR HOSPITAL SERDANG

TBK ROSS AZILA BINTI ZAHIT
ACUTE PAIN SERVICE
DEPT OF ANAESTHESIA AND INTENSIVE CARE
 Currently
• One of the requirement
for PAIN FREE
2008 HOSPITAL/CLINIC
• Implemented as a policy
nationwide

P5VS: Primary Care training module

 INTRODUCTION
AND
RATIONALE

P5VS: Primary Care training module

 PRIOR TO 2008- 4 VITAL SIGNS
Prior to 2008 (Pain as 5th Vital Sign implementation)
4 vital signs were routinely monitored:

Temperature (T) Pulse rate (PR)

Respiratory rate Blood pressure

(RR) (BP)

P5VS: Primary Care training module

 A BASIC APPROACH TO PAIN
R-A-T model (approach)

R ECOGNIZE

A SSESS

T REAT

P5VS: Primary Care training module

 APPROACH TO PAIN

Recognise

Does the patient have Do other people know

pain? patient has pain?

P5VS: Primary Care training module

 APPROACH TO PAIN

Assess

How severe is What type of Are there other

the pain pain is it? factors?

P5VS: Primary Care training module

 APPROACH TO PAIN

Treat

What non drug What drug treatment

treatment can I use? can I use?

P5VS: Primary Care training module

 PAIN ASSESSMENT

P5VS: Primary Care training module

 WHY ASSESS / MEASURE PAIN?
Produce a baseline to assess therapeutic interventions e.g.
administration of analgesic drugs

To ensure patients in pain receive adequate pain relief with

minimal side effects
Facilitate communication between staff looking after the
patient

For documentation

P5VS: Primary Care training module

Selection of Assessment Tool

Recommendation by Ministry of Health

(MOH), Malaysia
Age Scale
Adult MOH pain scale
Paediatrics
1 month-3 years FLACC scale
3 -7 years Faces scale
> 7 years MOH pain scale

P5VS: Primary Care training module

 CLINICAL TECHNIQUES FOR
MANAGEMENT OF PAIN

• Self reporting by the patient

• Gold standard
• Best method

• Observer assessment
• Observation of behaviour and
vital signs
• Functional assessment

P5VS: Primary Care training module

 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 POINT at the number on the scale to

show the severity of his/her pain, which is recorded as a
number (zero to 10)
 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?”
 “Selamat pagi Puan/Encik. Saya Jururawat
A yang menjaga Puan/Encik hari ini”.
 Ini adalah pembaris untuk menilai tahap
kesakitan Puan/Encik. (Tunjuk MOH scale)
 Di sini ada nombor dari skala 0 hingga 10.
 0 adalah tidak sakit dan 10 adalah paling
sakit.
 Boleh Puan/Encik beritahu tahap kesakitan
sekarang?
 FACES SCALE

• 3years - 7years

• This is a self report tool consisting of 6 faces

• Ask the child to choose a face which best describes

his/her pain
FACES SCALE
3-7years
 FLACC Score
(By Observation)
– For Paediatric : (1 month – 3 yrs)
– elderly old patient
– cognitively impaired patient
– Observe for 2-5 minutes
I. Observe patient’s behaviour
II. Select score according to behaviour
III. Add the scores to get the total
 FLACC Scale : 1 month - 3 years

Observational tool - looks at behavioural changes

- obser ve for 2-5 min
 WHEN SHOULD PAIN BE
ASSESSED?
As the 5th vital signs during routine observation of BP,
HR, RR, and temperature

• ½ to 1 hour after • During and after any • Whenever the patient

administration of painful procedures in complains of pain
analgesics and nursing the ward e.g. wound
intervention for pain dressing
relief

P5VS: Primary Care training module

WHOSE PAIN SHOULD BE ASSESSED?

INPATIENTS OUTPATIENTS AMBULATORY BEDRIDDEN

PATIENTS PATIENTS

ALL PATIENTS!

P5VS: Primary Care training module

WHERE IS PAIN ASSESSMENT DONE?

HOSPITALS KLINIK PROCEDURE HOME (HOME

KESIHATAN ROOM VISIT)

EVERYWHERE!

P5VS: Primary Care training module

WHO DOES PAIN ASSESSMENT?

STUDENTS:
MEDICAL
NURSES DOCTORS MEDICAL &
ASSISTANTS
NURSING

PHYSIOTHERAPIS OCCUPATIONAL
PHARMACISTS
TS THERAPISTS

EVERYONE!

P5VS: Primary Care training module

SELECTION OF PAIN ASSESSMENT TOOL

P5VS: Primary Care training module

 UNABLE TO SCORE

Unconscious
Sedated patients
patients

Record “unable to
assess/score”

Ventilated but conscious is still able to give pain score!

Unable to score does not mean : Score : 0
 LAMPIRAN 2
FLOW CHART Greet
PAIN THE 5TH VITAL SIGN Patient

Teach Pt Pain
Assessment Tool

Pain Score ≥ 4
Assess pt’s Pain Score < 4
pain & pain
score
Yes
Check Pts
Notes
Action
required?
Analgesic not ordered Analgesics ordered Nursing Action/PCM *
No No
#Last
Inform Dr dose > 1Hr
Yes

Serve medication Record

Reassess Pain Score

after ½ hr <4

Pain Score > 4

#Only for opioids * Maximum dose of paracetamol = 4 grams / day (4X1g)

Appendix 2.2 FLOW CHART FOR PAIN MANAGEMENT IN ADULT PATIENT IN HOSPITALS
(DOCTORS)
 MANAGEMENT OF
ACUTE PAIN

P5VS: Primary Care training module

OVERVIEW OF PAIN MANAGEMENT

Non-
Pharmacological
pharmacological
(Drug)
(Non-drug)

P5VS: Primary Care training module

NON- DRUG TREATMENTS

• Physical :
• Rest, Ice, Compression, Elevation (RICE)
• Surgery
• Physiotherapy
• Acupuncture, massage

• Psychological
• Explanation;
Patient and
caregiver education
and support
• Reassurance
• Counselling
P5VS: Primary Care training module
• Deep breathing / relaxation
 Nonpharmacologic Strategies
Cortex-Focused

• Relaxation

• Distraction

• Music

• Guided
Imagery
NON PHARMACOLOGICAL METHODS
TO RELIEVE PAIN
MASSAGE ACUPUNCTURE

TENS
ANALGESIC LADDER FOR ACUTE PAIN
MANAGEMENT
SEVERE UNCONTROLLED

To refer to APS
7 - 10
for:
Regular PRN PCA or Epidural or
MODERATE IV/SC other forms of
IV/SC
Morphine Morphine analgesia
4-6 5-10mg 4H 5-10mg or
or
Regular PRN
MILD Aqueous
Opioid Additional Aqueous Morphine
Tramadol Tramadol
1-3 50- 50-100mg
Morphine 5-10mg or
5-10mg 4H
Regular No PRN 100mg (max total
or IR
medication PCM tds-qid dose:
Oxycodone
Or &/or 400mg/day)
IR 5-10mg
PCM 1g NSAID/ +PCM 1g
Oxycodone
QID COX2 QID
5-10mg
Inhibitor +NSAID/
4-6 H
COX2
Inhibitor + PCM 1g
QID
+NSAID/
COX2
Inhibitor

!
SEDATION SCORE

Sedation score

0 Awake, alert

1 mild., awake instantly to

call
2 Drowsy, arouse with
shaking
3 Very drowsy, difficult to
arouse
S Sleeping

P5VS: Primary Care training module

 MANAGEMENT OF OPIOD
SIDE EFFECTS

P5VS: Primary Care training module

P5VS: Primary Care training module
P5VS: Primary Care training module
P5VS: Primary Care training module
 HOW TO
DOCUMENTATION ?
INFORMATION ABOUT
PAIN FREE HOSPITAL

1) PUBLIC FOLDER  PAIN FREE HOSPITAL

2) PAIN FREE CORNER
3) PAIN FREE KIT
 TAKE HOME MESSAGE

Pain as the 5th vital sign is necessary to ensure patient’s pleasant

and comfortable hospital stay

We must be very positive and implement pain assessment

diligently

Pain as the 5th vital sign must be made a practice culture just as
the other 4.

Pain as 5th vital sign is beneficial to patient, staff and organisation.

P5VS: Primary Care training module

 THING YOU NEED TO KNOW DURING AUDIT PAIN FREE

1) Do you know that “pain as 5th Vital Sign “ is implemented in Hospital Serdang
YES
 
2) Are you aware that PAIN FREE HOSPITAL (PFH) POLICY is incorporated into
Hospital Serdang policies? Where can you find the POLICIES?
YES.
1) Public Folder –> PAIN FREE HOSPITAL
2) Pain Free Corner
3) Pain Free Kit
 
3) Where can you find the client charter (PIAGAM PELANGGAN) on pain
management?
1) Public Folder  PAIN FREE HOSPITAL
2) Pain Free Corner
3) Pain Free Kit
 
4) What do you understand by PAIN AS 5TH VITAL SIGN?
It means that the patient should be asked about pain and the pain score should be charted
every time the other vital signs (BP/HR/RR/Temp) are taken.
Pain score should also be taken on admission, after transfer in from other wards, before
and after procedures such as wound debridement in the ward or at any times patient says
PAIN
5) Do you know where to find ACUTE PAIN PROTOCOL?
1) Public Folder PAIN FREE HOSPITAL
2) Pain Free Kit
3) Acute Pain Management Handbook.
 
6) What is the FLOWCHART FOR PARAMEDIC in term of pain management?
Where can you find it ? and explain it……
-PLS refer Pain Free Corner and Pain Management Kit
GUIDELINES FOR DOCTORS
GUIDELINE FOR PARAMEDIC

7) Can you list down the TOOLS to assess pain levels?

8) What is the ANALGESIC LADDER?
The modified analgesic ladder for acute pain management is a guide for what analgesic to
order for patient with acute pain ( eg: Post-operative Pain) according to the pain severity
(their pain score)

9) Where can you find the ANALGESIC LADDER for acute pain?
1) Public Folder  PAIN FREE HOSPITAL
2) Pain Free Corner
3) Pain Free Kit

10) What is IV MORPHINE PAIN PROTOCOL

• Pain score > 6
• How to dilute IV Morphine
• Monitoring (every 5 minutes)
 Pain score
 Sedation score
 Respiratory rate

11) How do you assess SEDATION SCORE?

Score Sedation level Clinical finding
0 None Patient awake and alert
1 Mild Occasionally drowsy, easy to rouse and can
stay awake once awaken
2 Moderate Constantly drowsy, still easy to rouse, unable
to stay awake once awaken
3 Severe Somnolence, difficult to rouse, severe
respiratory depression.
12) What are sign & symptom of OPIOIDS OVERDOSE?

- severe dizziness and giddiness

- pin point pupils
- severe nausea & vomiting
- respiratory depression RR < 8/min, shallow breathing
- decreased level of consciousness & sedation score (SS : 3)
- Late respiratory depression – cyanosis (very rare)
- Convulsion (pethidine due to accumulation of nor-pethidine)
 
13) Management of OPIOIDS OVERDOSE?

a) ABC - (airway, breathing, circulation)

- stop the drug and call for help
- administer oxygen
- stimulate the patient – tell him/her to breathe

b) D – drug
Antidote is NALAXONE
It can be found in the emergency trolley (1 st drawer)

 
 
 How to prepare Nalaxone

• 1 amp Nalaxone 0.4mg/ml

• Dilute 1 amp into 4cc of NS
• Concentration : 0.1mg/ml
• Give 0.1mg stat and titrate to effect
• Observe patient every 2-3min
 
14) Can you list down the NON-PHARMACOLOGICAL methods available?

 Explanation to patient / reassurance

 Rest, Ice, Compression, Elevation (RICE)
 Deep breathing / relaxation
 Hypnosis / music
 Acupuncture / massage
 Comfort the patient

15) Where do you chart the pain score?

 Electronic system
 Progress notes for doctor and nurses
 Hard copy paper – body chart / big chart
THANK YOU FOR
YOUR ATTENTION