This document outlines a training module for doctors and nurses on implementing pain as the 5th vital sign. The objectives are to train them on pain assessment and management. It discusses how pain is inadequately treated worldwide and provides standards from 2001 to record pain as the 5th vital sign. It also covers pain physiology, types of pain, effects of unmanaged pain, factors affecting pain perception, and barriers to effective pain management.

1. PAIN AS 5 TH VITAL SIGN
DR LEE OI WAH
PENGARAH HCM
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2. OBJECTIVE:
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
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5th 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
1st 24 hours
• What about patients in the medical wards or patients who
have not had surgery?
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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):6–8.
Sklar DP. Ann Emerg Med. 1996;27:412–413.
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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;1847–1880.
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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
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7. Definition of pain
“An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.”
Merskey,1964
International Association for
the Study of Pain (IASP)
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9. Spectrum of Pain
Healing
ACUTE
NO PAIN
PAIN
Insidious onset
CHRONIC
PAIN
post-surgical syndromes /
cancer
ACUTE CHRONIC
PAIN PAIN
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5th Vital Sign: Doctors’ training module: Pain Physiology Courtesy of Prof Ramani Vijayan, MASP

10. Pain Pathway PAIN
Sensory cortex
(Anatomy)
PAG / RAS Thalamus
Descending
inhibitory Ascending ST
fibres tracts
Free nerve endings
Spinal cord
Dorsal horn
Afferent nerve – ( A / c)
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5th Vital Sign: Doctors’ training module: Pain Physiology Courtesy of Prof Ramani Vijayan, MASP

11. TYPES OF PAIN
Physiological
Pathological or clinical
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12. EFFECTS OF SEVERE
UNRELIEVED PAIN
 Physiological
 Psychological
 Economic
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13. PHYSIOLOGICAL EFFECTS OF PAIN
No System Effects
1. CNS ↑ sympathetic activity,
hyperalgesia,chronic pain
2. Endocrine ↑ stress hormone, catabolic
state,hyperglycaemia,
immunesupression
3. CVS ↑HR,↑BP, myocardial ischaemia
4. Respiratory Inability of cough and deep breath, lung
collapse and lung infection
5. GIT ↓parasympathetic activity, ileus, nausea
and vomitting
6. Genitourinary Urinary retention
7. Muskuloskeletal Delayed ambulation, DVT
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14. PSYCHOLOGICAL EFFECTS OF
PAIN
Anxiety
Agitation
 poor sleep
 uncooperative patient
 depression
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15. ECONOMIC EFFECTS OF
PAIN
Delayed ambulation and feeding
Increased postoperative
complications
Delayed recovery
Prolonged hospital stay
Increased cost
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16. Conclusion
• Acute pain should be aggressively treated
for the following reasons:
– Patient comfort
– Prevent adverse physiological and
psychological consequences of unrelieved
pain
– Reduce risk of developing chronic pain
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17. FACTORS AFFECTING PAIN
• Perception of Pain
• Socio Cultural Factors
• Age
• Gender
• Meaning of Pain
• Anxiety
• Past experience with Pain
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18. Physician Barriers to Mgmt
• Inadequate knowledge of pain
management
• Poor assessment of pain
• Concern about regulation of controlled
substances
• Fear of patient addiction or misuse
• Concern about side effects, tolerance
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19. Patient Barriers to Mgmt.
– Older adults often expect pain with age
– Use other words than “pain’ (aching, hurting,
throbbing, “a misery”)
– Fear need for diagnostic tests or medications
that have side effects
– For some, pain is a metaphor for serious
disease or death
– For others, pain and suffering represent
atonement for past actions
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20. Barriers in LTC setting
• Different response (may not show typical sx)
• Cognitive and communication barriers
• Cultural and social barriers
• Co-existing illnesses and multiple meds
• Staff training and access to appropriate tools
• Practitioner limitations
• System barriers
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