pain 5th Vital Sign.ppt

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

Malaysian 5th Vital Sign Implementation: 2008-2010

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

FLACC SCORE

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

5th Vital Sign: Doctors’ training module: Pain Assessment

ANALGESIC LADDER: ANALGESIC LADDER: ACUTE PAIN MANAGEMENTACUTE PAIN MANAGEMENT

5th Vital Sign: Doctors’ training module: Pharmacology