1. Malaysian 5 th Vital Sign Implementation: 2008-2010 5 th Vital Sign: Doctors training module: Intruduction DR LEE OI WAH PENGARAH HOSPITAL CHANGKAT MELINTANG

2. 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: 5 th Vital Sign: Doctors training module: Intruduction

3.

• 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 1 st 24 hours

• What about patients in the medical wards or patients who have not had surgery?

5 th Vital Sign: Doctors training module: Intruduction

4.

• New standards in 2001

• Record pain as the 5th vital sign

Joint Commission on Accreditation of Healthcare Organizations. Jt Comm Perspect . 1999;19(5):68. Sklar DP. Ann Emerg Med . 1996;27:412413. 5 th Vital Sign: Doctors training module: Intruduction

5.

• 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;18471880. 5 th Vital Sign: Doctors training module: Intruduction

6.

• 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

5 th Vital Sign: Doctors training module: Intruduction

7. Spectrum of Pain ACUTE PAIN CHRONIC PAIN ACUTE PAIN Healing NO PAIN CHRONIC PAIN Insidious onset post-surgical, post-trauma syndromes cancer 5 th Vital Sign: Doctors training module: Pain Physiology

8. Pain 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, MASP 5 th Vital Sign: Doctors training module: Pain Physiology

9. Main effects of severe unrelieved pain

• Physiological

• • Increased stress hormones

• • Negative effects on CVS, RS leading to increased risk of hypoxemia and myocardial ischaemia

• • Increased risk of developing chronic pain conditions

• Psychological

• • Anxiety and sleeplessness

• Economic

• • Increased hospital complications, prolonged length of stay and increased costs

5 th Vital Sign: Doctors training module: Pain Physiology

10. Malaysian 5 th Vital Sign Implementation: 2008-2010 PAIN ASSESSMENT METHODS (ADULT AND PAED)

11. 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

5 th Vital Sign: Doctors training module: Pain Assessment

12. Clinical techniques for measurement 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

5 th Vital Sign: Doctors training module: Pain Assessment

13. 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)

5 th Vital Sign: Doctors training module: Pain Assessment

14. Wong-Baker Faces Pain Rating Scale 5 th Vital Sign: Doctors training module: Pain Assessment

15. FLACC SCORE 5 th Vital Sign: Doctors training module: Pain Assessment

16. 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 patient

• 4. 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

5 th Vital Sign: Doctors training module: Pain Assessment

17. 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

5 th Vital Sign: Doctors training module: Pain Assessment

18. UNABLE TO ASSESS PAIN

• Record Unable to Score for adult cognitively impaired patients and unconscious patients

5 th Vital Sign: Doctors training module: Pain Assessment

19. Observation Chart 5 th Vital Sign: Doctors training module: Pain Assessment Patients Name: RN: DOA: Age: Ward : DATE TIME BP PULSE RESP RATE TEMP PAIN SCORE ACTION TAKEN COMMENTS

20. 5 th Vital Sign: Doctors training module: Pain Assessment FLOWCHART FOR NURSES

21. FLOWCHART FOR DOCTORS

22. ANALGESIC LADDER: ACUTE PAIN MANAGEMENT 5 th Vital Sign: Doctors training module: Pharmacology

23. THANK YOU