EFFECTIVE

IMPLEMENTATION
PAIN 5TH VITAL SIGN
Implementation Strategies :

1. Supervision
2. Training
3. Resources
4. Working committee at hospital level
5. Change agents
6. Positive Attitude
7. Nursing Audits
8. Internal / external peer review
9. Set & monitor KPIs
10. Competitions & awards
Implementation Strategies :

1. Supervision : WARD SISTERS to supervise and

frequent monitoring for effective implementation.

Monitor for :
• Nurses knows how to pain assessment tool
• Nurses follow flow chart in implementation
• Reassessment for high pain scores.
• Nurses document all nursing actions and
medications served in pain assessment chart.
2. Training : Pain the 5th vital sign
• Must be in included in all orientation programs
for doctors and paramedics. 100% training
* All nurses, sisters and matrons
* All attendants – PPK
* All assistant medical officers – AMO / PPP

* Include clinical nurses

and students in training
sessions.

* To include pain
assessment in the
nursing curriculum
3. Resources available:
• Training Module
• Flow Chart
• Pain assessment tools available
• Observation forms

• Echo Training Workshop (training of trainers)

• Maintain a learning environment

4. Hospital Level :

Set up Pain 5 Vital Sign Team / Committee

• To provide on-going training

• To conduct training for new staff –
include in orientation program

• To monitor implementation

• To conduct surveys or qualitative comparative

studies

( DO NOT Rely on a “key” individual )

PAIN THE 5TH VITAL SIGN TEAM ( HOSPITAL LEVEL)
5. Change Agents : Matrons / Sisters

• Change may be difficult but can be done.

• Start on a smaller scale then expand further.
• Convince nurses to accept change
• Coaching at the initial stage may be nec.
• Supervise and monitor implementation
• Give maximum support
• Passion - Carry out 5th vital sign diligently
6. Be positive
All Matrons, sisters, nurses & paramedics
Pain assessment brings about benefits to the
patients.
With proper education, practice and
supervision, Change will happen.

Make it a Nursing Culture to implement pain as

5th Vital Sign.

7. Increased workload?
• Do not only think of increase in workload
• Practice smartly but no slip-shods / ‘chartology’
8. OTHER IMPORTANT SUGGESTIONS :

8.1 Conduct Nursing Audit

8.2 Internal / External Peer Review Program to

evaluate performance to improve pain mx.

8.3. To set and monitor KPI standards : E.g

% of patients with pain score > 4 with
intervention recorded ( effectiveness of mx)

% of patients with pain scores < 4, post

operatively 48 hrs.
9. Educated patients : Don’t need to explain
Gerak sedikit tambah sakit, gerak sedikit lagi sakit
pertengahan, gerak sedikit lagi tanbah sakit lagi,….

• For Uneducated patients / elderly patients :

Teach with help from relatives

• Don’t mention too many numbers to patients

• Teaching of pain assessment scale – do not leave

button at No.10

• Medical cases (DM, HPT) – seldom have pain,

patients get irritated. What is the Solution ?

- Explain clearly on admission

gohsk.2009 11
FUNCTIONS OF PAIN COMMITTEE

• Give orientation : to new / transfer in staff

• Do monitoring on implementation of pain 5VS
• Conduct inter-ward audit – 3 monthly
• keep record of all audits conducted
• take corrective action for poor implementation
• creative ideas

• conduct SEPT yearly audit

to submit to state / KKM

gohsk.2016 12
 STAFF NURSES ROLES
• Introduce pain assessment tool to patient on
1st pt encounter –
“From today onwards / or from now on …”

• Best On admission: If language problem,

relations, friends available

• Follow flow chart recommended

* Take prompt action for high pain scores

* Reassessment for high pain scores

( within 30 mins – 1 hr)
• Observe for side effects of analgesics
gohsk.2016 13
• Be Observant & alert : verbal and non verbal cues –
words, expressions, body posture, patient’s comfort
on eye contact,

• Do not insist for pain scores

• Do not ask pt : “ what is your pain score?”

– if patient is not educated.

• Video clips in training package - not all that perfect

• Be tactful base on different encounters

gohsk.2009 14
Sample Nursing Observation Chart KKM.JR.PAIN5VS.1/2009

Patient’s Name :
Age : MRN:
Ward :
Diagnosis:
DATE TIME PAIN Nursing action Medication COMMENTS / SIGN
SCORE
29/6/09 8.00 8 Cap.TRAMODAL Throbbing pain /
am (SHOULDER) - 50 mg Gsk
29/6/09 8.30 4 - - Patient
am comfortable / Gsk
29/6/09 12.00 1 - - Pt comfortable /
pm sally
29/6/09 4.00 pm 2 - - Pt comfortable /
susana
29/6/09 8.00 pm 2 - - Pt comfortable /
susana
29/6/09 10.00 pm 6 Cap TRAMODAL 50 mg Pricking /
(SPINE) anna
29/6/09 10.30 pm 3 Positioning – supine, - Pt does not want
Elevate limb with pillow analgesics / Aleez
15
 Effective Monitoring of Implementation
The Observation form :

1. Look out for high pain scores – whether any action was taken and
Reassessment for high scores (within 30 mins – 1 hr)

2. High pain scores without action is unacceptable

Unless patients refuse analgesics or
Patient is comfortable without analgesics- Document!
Otherwise staff will be questioned why no action was taken

3. Empty row on observation form is unacceptable

Use ‘ unable to score’ if really not able to do so.

16
gohsk.2009
 Frequently Asked Questions

Q. "Why are you asking me about my pain?"

A. We take pain very seriously and consider it a vital
sign. We will frequently ask about your pain every
time we check your blood pressure and temperature.
Please tell us if you have pain anywhere.

Q. "Why do you keep asking me about my pain if you

never do anything about it?"
A. If you are not in pain, we just record. But if your pain
is not relieved, we will refer you to the doctor for
medication to reduce your pain.
17
cont ….

Q. My Pain is a 14.
A. You must be in a lot of pain to choose 14 on a 10
point scale.

“Let's look at the scale again

and think of the number from ‘0- 10’.
If ‘0’ is no pain and ’10’ the worst pain you can imagine
What is the number for your pain now.”

Lets, try the scale again or

Try alternative pain Rating Scale - categorical

gohsk.2009 18
9. Have Competitions and Awards for :

‘The Best Ward’

 TIPS FOR SUCCESSFUL
ASSESSMENT

( GETTING THE PAIN SCORES

& DOCUMENTATION)
 I. Tips for Successful Pain Assessment

· Allow sufficient time for patient to self-reported

pain score.

· Environment quiet and free of distractions.

· Have appropriate aids for hearing and vision

available, e.g., charts with enlarged words,
numerical scales, anatomical drawings.

· Use enlarged copies (8½” x 11”) of assessment

tool
cont ….
Cont ….

· Speak slowly, clearly, and as loudly as needed.

· Involve family members or caregivers.

· Teach the patient how to use the pain rating

scale.

· Always Use the same pain rating scale

 II. BASIC PAIN HISTORY / PAIN ASSESSMENT
SIMPLIFIED !!
“Ask, Listen and Believe the Patient”
i. Use the PAIN Acronym:
P : Place or site of pain

A : Aggravating factors
(What makes the pain worse?)

I : Intensity

N : Nature of pain & Neutralizing factors

(What makes the pain less?)
ii. In the first assessment you should :
Mark the pain site (s),
date, time, pain score & nature of pain
on the body chart.

Subsequent observations, no need to

mark pain site if similar pain sites.
 ABCD of pain management
Pain assessment, Jacox et al 1992

ABCD of PAIN ASSESSMENT

Ask patients pain level regularly
A
Assess pain systematically
Believe patient pain level
B
Believe patient family on pain relief methods
Choose pain control options appropriate for the patient
C

D Deliver intervention timely, logically and coordinated

E Empower patient and family in pain management

 NURSING KPI ON
PAIN ASSESSMENT AND DOCUMENTATION

OBJ: To Improve Pain Assessment and Documentation

KPI: Compliance to pain assessment and documentation
Standard : 95%
Performance :
Status: ? SIQ
Action Plan:
• Assure pain is assessed, promptly managed and documented as per policy
• Conduct monthly audits
• Conduct in-services training

gohsk.2009 26
 Conclusions
• Pain as the 5th vital sign is necessary to ensure
patients a pleasant and comfortable stay in the
hospital

• We must be very positive and implement pain

assessment diligently

• Pain 5th Vital signs must be made a practice culture

just as for the other 4 vital signs

• Pain as 5th vital sign is beneficial to patient, staffs and

organizations
Pain as 5th vital signs- Paramedics
 Take Home Message

“With The SMILE On The Face And

WARMTH From The Heart
Carry Out The 5th Vital Sign With PASSION
To Ensure Patients’ COMFORT And
DELIGHT”

GSK
1/6/2016
JURURAWAT-
BOLEH !!
gohsk.2009 29
 IX. Sharing Tips from Experience,
Video clips & Role Plays

• “ Patient rubbing abdomen indicating pain”

“ sangat sakit-lahhhh”
patient groaning in pain
Do not insist for a number or the pain score?

• Patients Uncooperative- WHY?

Don’t understand, irritated and language barrier,

* “ Wa tak sakit-lah” – patient irritated with frequent

assessment for pain score start to raise voice
Why ?
30
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