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P IG V I D
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Before we begin lets see what the experts says

OBJECTIVE
The purpose of pain as 5th
vital sign is to train doctors,
medical assistants and nurses
on pain assessment and pain
management in order to
implement pain as a 5th vital
sign effectively in OUR
hospital

FACTS : PAIN IS UNDER TREATED

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?

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.

DEFINITION OF PAIN
Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage
International Association for the Study of Pain (IASP)
Pain a common symptom, very individualized and very
subjective

PAIN is what the patient says SAKIT

Sakit..t !
Valikithe.
.

Kasihan

SPECTRUM OF PAIN
ACUTE
PAIN

Healing

NO PAIN

Insidious onset

CHRONIC
PAIN

ACUTE
PAIN

post-surgical, post-trauma syndromes

cancer

CHRONIC
PAIN

5th Vital Sign: Doctors training module: Pain Physiology

Different patients experience different

pain levels & pain tolerance varies

from patient to patient depending on
heredity, energy level, coping skills
and previous experiences with pain.

(Principles of Pain Assessment & Management)

Types of Pain
Acute pain pain associated with tissue
injury e.g. pain after surgery, fracture,
burns, inflammation, etc.
Chronic pain pain >3 months, or pain
that persists after the injury has healed
Neuropathic pain when there is injury
to the central or peripheral nervous
system

CHARACTER OF THE PAIN

Tajam (sharp)
Tumpul ( dull)
Menderita ( aching)
Mencucuk ( throbbing)
Memulas (colicky)
Terbakar (burning )
Meledak,Menikam @ Menusuk
(shooting,stabbing )
Nyilu (tingling )
Kebas (numbness )

Usually indicates
neuropathic pain

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

5th Vital Sign: Doctors training module: Pain Physiology

PAIN PATHWAY

PAIN PATHWAY

Sensory cortex
PAG / RAS
Descending
inhibitory
fibres

Thalamus

Ascending ST
tracts

Free nerve endings

Spinal cord
Dorsal horn
Afferent nerve ( A / c)

Why ?
th
Pain as 5 vital sign

Promote doctor-patient and nursepatient 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

RESULT OF APS NATIONAL

AUDIT 2007
Laparotomy patients post op pain
Maximum pain >4 (moderate to severe) in
first 24 hours:
64% APS patients and 76% non-APS patients

Pain on 1st POD:

12% of APS patients and 23% of non-APS patients
had moderate to severe pain (Pain score >4)

DEFICIENCY IN PAIN
MANAGEMENT
WHAT IS THE REASON FOR POOR MANAGEMENT OF POSTOPERATIVE
PAIN?
WHAT ABOUT OTHER PATIENTS IN MEDICAL WARD, ORTHO WARD
(POST TRAUMA) ETC?

INADEQUATE EDUCATION
Pain assessment not a routine practice.
Pain level not monitored.
Patient tolerate the pain in silence.
Some patients dare not disturb busy nurse;
Nurses may be ignorant; inexperienced;
Nurses overworked; fear of side effects of analgesic
medication.

Current Nursing Observation:

Only 4 vital signs are monitored
Temperature (T)
Pulse
(P)
Respiration (R)
Blood pressure (B/P)

The 4 vital signs : Is it adequate ?

Benefits of Pain as 5th Vital sign

i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.

Provide holistic patient care

To evaluate pain level
To give effective treatment
To promote early ambulation
Reduce post-operative complications
Reduce length of stay
Reduce health care costs
Promote nurse-patient interaction
Promote client satisfaction reduce
complaints
Improve quality of life

Patients Self Report :

-Is the gold standard in pain
assessment
JCAHO

Pain standard Sept 2001

(Joint Commission For Accreditation of
Health Care Organisations)

FINDINGS ....
STAFF SURVE
Y

PAIN ASSESSMENT IS NECESSARY TO KNOW IF

PATIENTS RECEIVE ADEQUATE PAIN RELIEF

Knowledge level increased 11% post pilot study

Good

PAIN ASSESSMENT PROMOTES NURSE-PATIENT

COMMUNICATION

Good !

Knowledge level - increased 6% Post pilot study

Patients who complain of pain may not be

in pain and do not need analgesics
Answer = Wrong /
NO

Not
good
Enough

Attitude Test : 42% do not believe patients complaint of pain

even after the implementation of Pain assessm

Pain Assessment
Pain assessment made the 5th vital sign
(JCAHO) since 1st Jan 2001
In United States.
- Now implemented in many countries
throughout the world,
Eg: In UK, Australia, Singapore
In Malaysia - 16 April 2007 : Hosp. Selayang

PAIN ASSESSMENT
Why Pain Assessment?
When should pain be assessed?
Where shoud pain be assessed?
Who should do pain assessment?
What / Which tool to use?
How to use tool?

WHY Pain Assessment ?

To ensure patients in pain receive
adequate pain relief with minimal side
effects

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

WHEN SHOULD PAIN BE

ASSESSED ?
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

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

Who does Pain Assessment?

- All nurses

- All Doctors
- All Student nurses
- All medical students
.. Everyone!

WHICH PAIN ASSESSMENT TOOL

And
HOW TO USE

AVAILABLE PAIN ASSESSMENT TOOLS :

Numerical Rating Score (NRS)
Visual Analogue Score (VAS)
Combination Rating scale
(NRS &VAS)
Categorical Score
Functional Score
FLACC Observational Pain Score
Wong Baker Faces Scale

i. Numerical Rating Scale (NRS)

If 0 = no pain, and 10= the worst
pain you can imagine, what number is
your pain now?

ii. Visual Analogue Score

Patient is asked to slide a small bead
along a scale to indicate the severity
of pain
Total length of scale is 100 mm (10
cm)

iii. Combination Rating Scale (NRS &

VAS)

On a scale of 0 I0 (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
Nurse records the number on the scale (zero to 10)

iv. Categorical Scale

Patient rates pain using words : mild, moderate,
severe pain
0 = No pain
1 = Slight / mild pain
2 = Moderate pain (tolerable)
3 = Severe pain
4 = Worst pain imaginable
(intolerable)
- Not a preferred method (not sensitive)

v. Functional Score
Functional limitation :
Ask patient :
Can you sit up?
Can you take deep breaths?
Can you walk this morning?
-Not a preferred method
-Nurse is not able to record the numeric score
for the level of pain, only able to know the
functional level

VI. FLACC SCORE

(By Observation)
For Paediatric < 4 yrs
elderly patient
cognitively impaired patient
I. Observe behaviour
II. Select score according to behaviour
III. Add the scores for the total

vi. FLACC SCORE

Wong-Baker Faces

Pain Rating Scale

WHICH TOOL TO USE

Use the standard tool for pain assessment as
recommended by Ministry of Health, Malaysia
For adult patients, use the combined NRS / VAS scale
For paediatric patients 1 month to 3 years old, use the
FLACC
For paediatric patients > 3-7 years, use the Wong-Baker
FACES scale
For paediatric patients >7 years, use the combined
NRS/VAS scale (same as for adults)

*Always use the same tool for each patient

How to do Pain Assessment

i. Greet patient / salam
ii. Inform the purpose : to get the patients correct pain
score for proper treatment
iii. Show and teach patient pain assessment tool
If

0( smiling face ) no pain

10( crying face ) worst pain imaginable,
What is your level of pain now?

(Nurses must be patient and allow patient to think and give

the pain score)

IS IT POSSIBLE TO GET A
PAIN SCORE IN ALL
PATIENTS??
Some groups where pain score may be difficult to elicit may be
Adult cognitively impaired patients
Use FLACC score where possible
Patients with severe head injury
Patients with language barriers

Use the visual analogue scale if possible

UNABLE TO ASSESS PAIN

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

Observation Chart
Patients Name :
Age :
Ward :
DATE TIME

BP

RN :

PULSE

RESP TEMP
RATE

DOA :

PAIN
SCORE

ACTION
TAKEN

COMME
NTS

Pain Assessment Chart

Record the following:
All 5 Vital Signs
(BP, Pulse, Respiration Rate,
Temperature and Pain Score )
Nursing actions taken to relieve pain
Analgesics administered to relieve pain
Comments if any

TAKING PAIN HISTORY

i. Ask the patient
Health professionals are advised to listen and believe the patient
who complains of pain. Pain history is taken using the acronym:

P : Place or site of pain

A : Aggravating factors (What makes the pain worse?)
I : Intensity
N : Nature and neutralizing factors (What makes the pain better?)

ii. In the first assessment you should :

- Mark the pain site (s), pain score and nature of pain on the
body chart.
- Subsequent observations, only pain scores are taken and
recorded in the pain assessment chart.

BODY CHART TO SHOW PAIN SITES

FRONT VIEW

BACK VIEW

29/6/08,
PS- 6 Throbbing
pain

29/6/08,
PS - 6
Pricking pain

30/6/08
PS 7
Tingling pain

FLOW CHART:
Greet
Greet
Patient
Patient
Teach
Teach Pt
Pt Pain
Pain
Assessment
Assessment Tool
Tool

Pain
Pain Score
Score >
> 4
4

Pain
Pain score
score 4-6
4-6

Pain
Pain score
score 7-I0
7-I0

Check
Check Pts
Pts
Notes
Notes

Nursing
Nursing
Action/PCM
Action/PCM*

Yes

Action
Action
required?
required?

Analgesics
Analgesics ordered
ordered

Analgesic
Analgesic not
not
ordered
ordered
Inform
Inform Dr
Dr

Pain
Pain Score
Score <
< 4
4

Assess
Assess
Pts
Pts Pain
Pain
Score
Score

No
Last
Last dose
dose >>

No

II hr
hr

Yes

No
No Nursing
Nursing Action
Action

Serve
Serve medication
medication

Reassess
Reassess
after
after
hr
hr

Pain
Pain Score
Score
<
< 4
4

Record
Record

Pain
Pain Score
Score >
> 4
4

#Only for opioids

* Maximum dose of paracetamol = 4 grams / day (4X1g)

EXPLANATION OF FLOW CHART

Pain the 5th Vital Sign
i.
.
.
.

If Pain Score 0 - 3:
ask whether patient requires action
Take nursing action if necessary
Reassess pain after nursing action taken

EXAMPLES OF
NURSING ACTIONS
Check possible causes of pain
Blocked urinary catheter
Swollen intravenous site
Uncomfortable position of patient
Encourage Relaxation
Deep Breathing
Meditation
Topical application
Heat therapy
Ice / cold pack
Touch therapy
Massage
Distraction techniques
Reading
Listening to music / radio
Watching TV

INFORM
DOCTOR IF
NURSING
ACTION IS
NOT
EFFECTIVE

ii. If Pain Score >4:

Tell patient that you are going to give him/her
some pain medication
Check patients notes any analgesics
prescribed?
If analgesics not prescribed, inform the doctor to
prescribe
If analgesics prescribed, check time last
analgesic served
* Only for opioids:
-- If analgesics last served more than one hour ago,
serve another dose of analgesic medication
-- If analgesics last served less than one hour ago,
inform doctor

iii. Record medications given

iv. Reassess level of pain after hr to 1
v. Inform doctor if pain still not relieved

ROLES & RESPONSIBILITY OF NURSES

FOR EFFECTIVE PAIN MANAGEMENT
Know how to use the pain assessment tool
Carry out pain assessment
Give Prompt nursing action
Provide Prompt pain relief
Observe for side effects of analgesics
Reassess after 30 mins to 1 hour
Record pain score in the Observation Chart
Monitor patients pain regularly
Educate patient & family on pain assessment and
treatment
Record all observations and actions

FLOWCHART
FOR DOCTORS

ANALGESIC LADDER:
ACUTE PAIN MANAGEMENT

5th Vital Sign: Doctors training module: Pharmacology

SUGGESTEDMEDICATIONAVAILABLEATHOSPITALROMPIN, THEDOSAGESANDSIDEEFFECTS.
DrugClass

Drug

Prescribers Recommendeddosage
category
C
0.5- 1gm, 6- 8
hourly
Max: 4g/day

SideEffects

Simple
analgesic

Paracetamol

NonSelective
NSAIDs

Diclofenac
Sodium

Mefenamic
Acid
Ibuprofen

Meloxicam

Pepticulcer,
GI bleed,
Platelet
dysfunction,
Renal failure,
Hypertension,
Allergic
reactionin
susceptible
individuals,
Increasein
CVSevents

Indomethacin

50- 150mg
daily,
8- 12hourly
Max: 200
mg/day
250-500mg8
hourly
200-400mg, 8
hourly
Max: 2400
mg/day
7.5-15mgdaily
Max: 15mg/day
25-50mg/ dose2-3times/day

Rare

Cautionand
PRECAUTIONS
Hepaticimpairment

Gastroduodenal
Ulcer,
Asthma,
Bleedingdisorder,
Renal dysfunction,
Ischaemicheart
disease,
Cerebrovascular
Disease,
Inflammatory
bowel disease,

DrugClass

Drug

Selective
Cox-2
Inhibitors

Celecoxib

Prescribers Recommended dosage

category
A
400mgBDin
acute pain (48
hours only)
200-400mg
daily(for
longer term
use)
<18 years: not
recommended

Side Effects
Renal
impairment
Allergy
reaction in
susceptible
individuals
Increase in
CVSevents
Hypertension

Caution and
PRECAUTIONS
Ischaemic heart
disease
Cerebrovascular
disease
Hypersensitivityto
sulfonamides
Higher doses
associated with
higher incidence of
GIT, CVSside
effects
Patients with
indicationsfor
cardio protection
require aspirin
supplement
Uncontrolled
Hypertension

DrugClass

Drug

Weak opioids

Tramadol

Strong
opioids

Morphine

Prescribers Recommended dosage

category
A
50 - 100mg, 6
- 8hourly
Max: 400
mg/day

SC(Adults):
<65 yrs: 5mg-10m4 hrly
>65 yrs: 2.5 mg5mg4hrly
IV:
Follow
morphine pain
protocol

Strong
opioids

Pethidine

IV and Sc :
<65yrs : 50mg-100mg3-4hrly
>65yrs : 25mg-50mg3-4hrly

Side Effects
Dizziness
Nausea
Vomiting
Constipation
Drowsiness

Nausea,
Vomiting,
Pruritus,
Sedation
Constipation,
Respiratory
depression

Nausea,
Vomiting,
Pruritus,
Sedation
Constipation,
Respiratory
depression

Caution and
PRECAUTIONS
Risk of seizures in
patientswith
historyof seizures
and with high
doses
In elderly, start at
lowest dose (50
mg) and maximum
300 mgdaily
Acute bronchial asthma
Respiratory depression
Head injuries
Renal and
hepatic dysfunction:
needs dose adjustment

Reduce dose in renal

and hepatic impairment

THE 5TH VITAL SIGN BROCHURE FOR PATIENTS

Pain as the 5th Vital Sign
We aim to make your stay in Hospital Tg.
Ampuan Afzan as pleasant
and as comfortable as possible.

When you are admitted to Hospital Tg.

Ampuan Afzan, we will measure your pain
level frequently just as when we monitor
your vital signs. ( Your temperature, Pulse,
Respiration and Blood Pressure). That
means your pain level will be monitored
from the time of your admission and during
any other observations until you are
discharged.

Why ? This is to ensure that you receive

adequate pain relief and experience minimal
pain throughout your stay here.

How ?
To monitor your pain level, you are expected
to rate your pain level using a scale of 0 to
10.
0 for no pain and 10 for maximum pain.

Rate your score according to how you feel

is your pain level.

Your pain score is important to us because

the score will determine whether we need to
give you pain relieve medication.

This is your Right. So help us to help you

make your stay here pleasant and
comfortable.
1
2
3
4
5
6
7
8
9
10

10

Kesakitan sebagai Tanda Vital Ke- 5

Kami di Hospital Tg. Ampuan Afzan berharap

kami dapat memberi keselesaan yang maxima
semasa anda masuk ke Hospital Tg. Ampuan
Afzan.

Bila anda masuk ke wad di Hospital ini, kami

akan menilai tahap kesakitan anda seperti
tanda vital yang lain ( suhu badan, nadi,
pernafasan and tekanan darah). Ini
bermakna tahap kesakitan anda akan
sentiasa dinilai dari masa kemasukkan,
semasa penilaian tanda vital yang lain
sehingga discaj.

Kenapa? Ini adalah untuk mempastikan anda

mendapat ubat tahan sakit yang mencukupi
dan mengalami kesakitan yang minima atau
tiada kesakitan, semasa di hospital.

Bagaimana ?
Untuk menilai tahap kesakitan, anda akan di
minta supaya menilai dengan sendiri tahap
kesakitan menggunakan scala 0 to 10.
0 menandakan tiada kesakitan and 10
untuk sakit yang maxima atau sakit kuat.
Berikan nilai dari 0 hingga 10 untuk
menunjukkan tahap kesakitan yang di rasai
anda.

Nilai tahap kesakitan ini amat penting kepada

kami untuk tindakan seterusnya dalam
mengurangkan tahap kesakitan anda.

Ini adalah hak anda. Harap dapat kerjasama

1 untuk
2
3kami membantu
4
5
6 anda
7 mencapai
8
9
10
anda
keselesaan semasa di Hospital Tg. Ampuan
Afzan

10
Tiada kesakitan

Kesakitan

FINDINGS ....
PATIENTS' SU
RVE

Adakah tuan / puan berpuas hati dengan

rawatan mengurangkan kesakitan semasa di
wad?

PRE

PRE

POST

POST

YA

TIDAK

YA

TIDAK

544
(69 %)

250
(31%)

268
(96.4%)

10
(3.6%)

(base on 278)
Good !

27.4% improvement significant increase in client satisfaction

- Support implementation of Pain as 5th vital Sign

Adakah ubat tahan sakit diberi dengan segera setelah

diberitahu kepada jururawat tahap kesakitan tuan
/puan ?

PRE

PRE

POST

POST

YA

TIDAK

YA

TIDAK

564
(71 %)

230
(29%)

261
(94%)

17
(6%)
NA-39(12%
tiada sakit)

Good !

Good 23% improvement seen post pilot study

analgesics given immediately

Adakah tuan / puan bersetuju bahawa jururawat

sentiasa menilai tahap kesakitan untuk
mempastikan pesakit dapat ubat tahan sakit
dengan mencukupi?

Good

POST

POST

YA

TIDAK

293
(92%)

1
(27%)
NA-23 (7.3%)

92% - Support implementation of Pain as 5th vital Sign

Effective Management of Pain

i.
Correct pain assesment
ii. Prompt response
iii. Teach patient
iv. Administer analgesics
v. Correct time
vi. Observe for side effects
vii. Regular monitoring
viii. Appropriate nursing action
ix. Documentation pain score & analgesics

Conclusion
Weighing the benefits of pain as 5th vital sign,
and the support from the nurses and patients in
the surveys conducted, it was therefore
recommended to MOH that Pain as 5th Vital
Sign be implemented throughout hospitals
under MOH.