PAIN AS THE

5TH VITAL SIGN

POORNIMA GOPAL
• 2008:
• Implemented as a policy nationwide

• Currently:
• one of the requirements
for PAIN FREE HOSPITAL

P5VS: Doctors’ training module

OBJECTIVES OF THIS TRAINING MODULE:

• Better awareness of pain

• Better pain management
• Train doctors, nurses and all health care personnel
in
• pain assessment
• approach to pain management

•  Implement pain as 5th vital signs

•  Working towards pain free hospital

P5VS: Doctors’ 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 (RR)
• Blood pressure (BP)

P5VS: Doctors’ training module

 ARE 4 VITAL SIGNS ADEQUATE?

He is quiet and comfortable.

BP, PR, RR are normal
He has no fever

I expect them to
know that I am in
severe pain

4 VITAL SIGN- ZERO COMMUNICATION

P5VS: Doctors’ training module
ISSUE WITH NOT ASSESSING PAIN:

“Those who do not feel pain

seldom think that it is felt”
Dr. Samuel Johnson
(1709-1784)

P5VS: Doctors’ training module

 BARRIERS TO PAIN MANAGEMENT

• Inadequate pain assessment

• identified as the greatest barrier to pain management
(Von Roenn JH, Cleeland CS, Gonin R, et al. Ann Intern Med, 1993)

• Lack of awareness
• If you don’t ask, you won’t know

P5VS: Doctors’ training module

 JCAHO / JCI STANDARDS:
PAIN AS THE 5TH VITAL SIGN

2006
2008
2002 Hospital MALAYSIA
2001 2003 2004
Australi Selayang Ministry of
USA Europe S’pore pilot
a Health
project
POLICY

P5VS: Doctors’ training module

 BENEFITS OF PAIN AS 5TH VITAL SIGN

• Promote doctor- patient & nurse- patient interaction

• Better communication
• Better patient satisfaction

• Provide better patient care

• Priority to pain assessment
• Individualized care

• Better awareness of pain

• Better management of pain
• Faster recovery
• Reduced length of stay

P5VS: Doctors’ training module

 APPROACH TO PAIN

• R-A-T model (approach)

• Recognise
• Assess
• Treat

P5VS: Doctors’ training module

 APPROACH TO PAIN

Recognise
• Does the patient have pain?
• Do other people know patient has pain?

P5VS: Doctors’ training module

 APPROACH TO PAIN

Assess:
• How severe is the pain
• What type of pain is it?
• Are there other factors?

P5VS: Doctors’ training module

 APPROACH TO PAIN

Treat

• What non drug treatment can I use?

• What drug treatment can I use?

P5VS: Doctors’ training module

 WHAT IS PAIN?

• Definition:
• Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage
(Bogduk & Merskey 1996 IASP)

P5VS: Doctors’ training module

 WHAT DOES THAT MEAN?

What we (health care provider) understand ….

•Unpleasant
•Emotions are important
•The cause is not always visible

For the patient…..

PAIN is what the patient says……
HURTS

P5VS: Doctors’ training module

 What are the
consequences of not
treating acute pain?

P5VS: Doctors’ training module

CLASSIFICATION OF PAIN

P5VS: Doctors’ training module

 CLASSIFICATION OF PAIN

Basis Types of pain

Duration Acute

Chronic

Acute on chronic

Cause Cancer

Non cancer

Mechanism Nociceptive (physiological)

Neuropathic (pathological)

P5VS: Doctors’ training module

 ACUTE vs CHRONIC PAIN

• Acute pain:
• Pain of recent onset and probably of limited duration

• Chronic pain:
• Pain persisting beyond healing of injury
• Often no identifiable cause
• Pain lasting for > 3 months

P5VS: Doctors’ training module

 CANCER vs NON CANCER PAIN

Cancer pain
•Progressive
•May be mixture of acute and chronic

Non Cancer pain

•Many different causes
•Acute or chronic

P5VS: Doctors’ training module

NOCICEPTIVE vs NEUROPATHIC PAIN
NOCICEPTIVE PAIN NEUROPATHIC PAIN
Well localized Not well localized
Burning
Sharp Shooting
Worse with movement Numbness
Pins and needles
Obvious tissue injury or
Tissue injury may not be obvious
illness
Nerve injury
Changes in wiring
Inflammation
Abnormal firing
Loss modulation
Physiological pain * Pathological pain
*needs to be treated differently
P5VS: Doctors’ training module
 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
P5VS: Doctors’ training module
 SPECTRUM OF PAIN
Healing
ACUTE
NO PAIN
PAIN

Insidious onset
CHRONIC
PAIN

post-surgical, post-trauma syndromes

cancer
ACUTE CHRONIC
PAIN PAIN

P5VS: Doctors’ training

5th Vital module
Sign: Doctors’ training module: Pain Physiology
 DIFFERENCES BETWEEN ACUTE AND CHRONIC PAIN

Acute pain Chronic pain

Sudden, short duration Insidious onset

Onset & timing Resolves /disappears when Pain persists despite tissue
tissue heals healing

Warning sign of actual or Not a warning signal of damage

Signal
potential tissue damage False alarm

Correlates with amount of Severity not correlated with

Severity
damage damage

CNS CNS intact- acute pain is a CNS may be dysfunctional-

involvement symptoms chronic pain is a disease

Less, but unrelieved pain 

Often associate with depression,
Psychological anxiety and sleeplessness
anger, fear, social withdrawal
effects (improves when pain is
etc.
relieved)

P5VS: Doctors’ training module

 COMMON CAUSES

ACUTE PAIN CHRONIC PAIN

Trauma/fracture/Surgery Chronic headache

Burns Chronic low back pain
Arthritis Chronic abdominal pain
Abscess Chronic pelvic pain
Myocardial infarction Cancer pain
Labour pain & child birth

NEUROPATHIC PAIN

Acute shingles Post herpetic neuralgia

Post spinal cord injury Diabetic peripheral neuropathy
Brachial plexus injury Post stroke pain

P5VS: Doctors’ training module

 PAIN
PATHWAY

5.6 P5VS: Doctors’ training module

PAIN PHYSIOLOGY

• 4 steps:
• Periphery
• Spinal cord
• Brain
• Modulation

Let’s look at each

step

P5VS: Doctors’ training module

PERIPHERY (1ST STEP)

Tissue injury

Release of chemicals

Stimulation of pain
receptors ( nociceptors)

Signal travels in Aδ or C
nerve fibres to spinal
cord

P5VS: Doctors’ training module

SPINAL CORD ( 2ND STEP)

Dorsal horn:
2nd 1st relay station
nerve Aδ or C nerve fibres
synapse (connect) with
second nerve

Second nerve travels up
opposite side of spinal
cord
Aδ or C
nerve fibres

P5VS: Doctors’ training module

BRAIN (3RD STEP)

• Thalamus is the 2nd relay

station

• Connections to many
parts of brain
• Cortex
• Limbic system
• Brainstem

2nd relay
station
• Pain perception occurs at
the cortex

P5VS: Doctors’ training module

MODULATION (4TH STEP)

• Descending pathway
from brain to dorsal
horn

• Usually decreases pain

signal

P5VS: Doctors’ training module

PAIN ASSESSMENT

P5VS: Doctors’ training module

 WHY ASSESS / MEASURE PAIN?

• Produce a baseline to assess therapeutic

interventions e.g. administration of analgesic drugs

• Facilitate communications between staff looking

after the patient

• For documentation

P5VS: Doctors’ training module

 HOW TO ASSESS PAIN:

• Important to
• Listen and believe the patient

• Take a pain history

• “Tell me about your pain…….”

P5VS: Doctors’ training module

 HOW TO ASSESS PAIN

P: Place or site of pain

“where does it hurt?”
Record on a body chart

A: Aggravating factors
“what makes your pain worse?”

I: Intensity
“How bad is the pain?”

N: Nature and neutralising factors

“what does it feel like’
“What makes the pain better?”

P5VS: Doctors’ training module

 CLINICAL TECHNIQUES FOR
MEASUREMENT OF PAIN

• Self reporting by the patient

• Gold standard
• Best method

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

P5VS: Doctors’ training module

 MOH PAIN SCALE

On a scale of ‘0’ to ’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 pain, which is recorded as a number ( 0 to 10)
P5VS: Doctors’ training module
 PAIN MEASUREMENT

• Scale used in children/infants and in cognitively

impaired patients

• Wong Baker Faces scale (self report scale)

• FLACC scale (behavioural pain scale)

P5VS: Doctors’ training module

WONG BAKER FACES PAIN RATING
SCALE

P5VS: Doctors’ training module

 FLACC SCALE

F
L
A
C
C

P5VS: Doctors’ training module

 WHEN SHOULD PAIN BE ASSESSED

1. At regular interval
• as the 5th vital signs during routine observation of BP, HR, RR,
and temperature
• This can be done 4hourly, 6houry, or 8 hourly
2. On admission of patient
3. On transfer in of patient

P5VS: Doctors’ training module

4. At other times apart from scheduled observations:
• ½ to 1 hour after administration of analgesics and nursing
intervention for pain relief
• During and after any painful procedures in the ward e.g.
wound dressing
• Whenever the patient complains of pain

P5VS: Doctors’ training module

 WHO SHOULD BE ASSESSED?

ALL patients
•Patient in labour room
•Operating theatre (recovery room)
•ICU/ HDU/CCU
•Ambulatory day care units
•Clinics

P5VS: Doctors’ training module

 WHO DOES PAIN ASSESSMENT?

EVERYONE
•All nurses/ paramedics
•All doctors
•All student nurses
•All medical students
•All health personnel

P5VS: Doctors’ training module

 SELECTION OF PAIN ASSESSMENT TOOL

• Use the standard tool for pain assessment

• Use appropriate scale
• Appropriate for age, learning, development

*Always use the same tool for the same patient

P5VS: Doctors’ training module

 SELECTION OF ASSESSMENT TOOL

• Recommendations by Ministry of Health, Malaysia

Age Scale

Adult MOH scale

Paediatrics

1 month-3 years FLACC scale

3 -7 years Wong Baker faces scale

> 7 years MOH pain scale

P5VS: Doctors’ training module

 UNABLE TO ASSESS

• Sedated patients
• Unconscious patient

• Record ‘unable to assess/score’

P5VS: Doctors’ training module

NURSING OBSERVATION CHART (VITAL
SIGNS CHART) PS.KKM1/2014

Patient’s Name :
Age : Pain Score
Ward :

DATE TIME BP PR RR T°C PS NURSING

INTERVENTION

P5VS: Doctors’ training module

ACUTE PAIN MANAGEMENT

P5VS: Doctors’ training module

 NON- DRUG TREATMENT:

• Physical :
• Rest, Ice, Compression, Elevation
• Surgery
• physiotherapy
• Acupuncture, massage,

• Psychological
• Explanation
• Reassurance
• Counselling

P5VS: Doctors’ training module

 MEDICATIONS: NON OPIOIDS

• Acetaminophen
• Paracetamol

• NSAIDS
• Non specific COX • Cox 2 inhibitors
inhibitor • Celecoxib
• Diclofenac • Etoricoxib
• Ibuprofen • Parecoxib
• Naproxyn
• Mefenamic acid

P5VS: Doctors’ training module

 MEDICATIONS: OPIOIDS

• Opioids • Opioids antagonist:

• Weak opioids: • Naloxone
• DF 118
• Tramadol

• Strong Opioids:
• Morphine
• Pethidine
• Oxycodone
• Fentanyl

P5VS: Doctors’ training module

 ANTINEUROPATHIC AGENTS

• Antidepressants: • Anticonvulsants
• Tricyclic antidepressants • Gabapentin
(TCA) • Pregabalin
• Amitryptyline • Carbamazepine
• Nortriptyline • Phenytoin

• SNRI • Others
• Duloxetine • Ketamine
• Venlafaxine • Clonidine
• Entonox ( O2/N2O)
• Local anaesthetics

P5VS: Doctors’ training module

TREATMENT - PERIPHERY

• Non drug treatment (RICE)

• Rest
• Immobilisation
• Cold compression
• Elevation

• Drug treatment:
• Anti-inflammatory drugs
• NSAIDS/ COX 2 inhibitors
• Local anaesthetic agents

P5VS: Doctors’ training module

Treatment – spinal cord

• Non drug treatment:

• Acupuncture
• Massage

• Medications:
• Local anaesthetics
• Opioids
• Ketamine

P5VS: Doctors’ training module

TREATMENT - BRAIN

• Non drug treatment

• Psychological

• Drug treatment:
• Paracetamol
• Opioids
• Amitriptyline
• Clonidine

P5VS: Doctors’ training module

ANALGESIC
STRATEGIES:

ENHANCING
• Inhibit BLOCKING
• ascending pain signal

• Enhance
• descending inhibition

P5VS: Doctors’ training module

 Analgesic Ladder for SEVERE UNCONTROLLED

Acute Pain Management 7 - 10

To refer to APS
for:
Regular PRN PCA or Epidural or
MODERATE IV/SC IV/SC other forms of
Morphine Morphine analgesia
4-6 5-10mg 4H 5-10mg
Regular PRN or or
MILD
Opioid Additional
Tramadol Tramadol Aqueous Aqueous
1-3 Morphine Morphine
50- 50-100mg
Regular PRN 100mg (max total 5-10mg 4H 5-10mg
No PCM tds-qid dose: or or
medication &/or 400mg/day)
Or NSAID/ +PCM 1g IR IR
PCM 1g COX2 QID Oxycodone Oxycodone
QID Inhibitor +NSAID/ 5-10mg 5-10mg
COX2 4-6 H
Inhibitor
+ PCM 1g
QID
+NSAID/
COX2
Inhibitor
!
P5VS: Doctors’ training module
 MORPHINE PAIN PROTOCOL

• Use for rapid control of severe acute pain

• Route: IV
• Morphine dilution: 10 mg/10 ml (1mg/ml)
• Monitoring (every 5 minutes)
• Pain score
• Sedation score
• Respiratory rate

P5VS: Doctors’ training module

P5VS: Doctors’ training module
 MANAGEMENT
OF OPIOID SIDE EFFECTS

5th Vital Sign: Doctors’ training module: Pharmacology

 NAUSEA & VOMITING

• A common side effect of opioids

• Treat nausea and vomiting and continue giving
opioids
Drug Route Dose interval
Metoclopramide IV 10-20 mg Stat & 6 hourly

Ondansetron IV 4-8 mg Stat & 8 hourly if necessary

Granisetron IV 2 mg Stat & 8hourly if necessary

Haloperidol IV 1 mg BD

Oral 1.5mg BD

Dexamethasone IV 4mg Stat

P5VS: Doctors’ training module
 RESPIRATORY DEPRESSION
• Very uncommon
• May occur with overdose of opioids, always associated with
sedation
• Risk of respiratory depression is minimal
• If strong opioids are titrated to effect
• Only used to relieve pain ( ie not to help patients to sleep or to
calm down agitated patients)
• Risk of respiratory depression also minimal in patients on
chronic opioids use (e.g. patients on morphine for cancer
pain)

P5VS: Doctors’ training module

 MANAGEMENT OF RESPIRATORY
DEPRESSION
• Confirm diagnosis
• Respiratory rate < 8/minute & sedation score=2 (difficult to
arouse)
• Or Sedation score = 3 (unarousable)
• Pin Point pupils

• Sedation score
• 0 = none (patient is alert)
• 1 = mild (patient is sometimes drowsy)
• 2 = moderate (patient is often drowsy but easily arousable)
• 3 = unarousable
• S = patient is sleeping, easily arousable
P5VS: Doctors’ training module
 MANAGEMENT OF RESPIRATORY
DEPRESSION:
1. Stop the drug and call for help
2. Administer oxygen – face mask or nasal prongs
3. Stimulate the patient- tell him/her to breathe
4. Dilute naloxone 0.4mg/mg in 4 mls
• Give 0.1 mg (1ml) every 1-2 minutes until the patient wakes up or
respiratory rate >10/min

5. Monitor RR, sedation score hourly for 4 hours

6. Give another dose of naloxone if respiratory depression
recurs
7. Refer to ICH/HDU for close monitoring (patient may
require naloxone infusion)

P5VS: Doctors’ training module

 KEY points…..in
MANAGEMENT OF ACUTE PAIN

P5VS: Doctors’ training module

 KEY POINTS

• For pain as the 5th vital signs to have an impact in

improving pain management in our hospitals:

• Good understanding of analgesic medications

• How to use
• When to use

P5VS: Doctors’ training module

 KEY POINTS

• Important points to note on the pharmacology of

drugs:

• Onset and duration of action

• (how often to prescribe the drug)

• Side effects
• (so one can anticipate and treat side effects)

P5VS: Doctors’ training module

 KEY POINTS

• During and after administrations of analgesic

medications, we must monitor:
• Pain score
• Sedation score
• Respiratory rate

Aim:
• Achieve reasonable pain relief without
unacceptable side effects

P5VS: Doctors’ training module

THANK YOU FOR YOUR
ATTENTION

P5VS: Doctors’ training module