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PAIN AS 5 TH VITAL SIGN
DR LEE OI WAH
PENGARAH HCM
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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:
5th Vital Sign: Doctors’ training module: Intruduction
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• 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?
5th Vital Sign: Doctors’ training module: Intruduction
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• 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.
5th Vital Sign: Doctors’ training module: Intruduction
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• 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. 5th Vital Sign: Doctors’ training module: Intruduction
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• 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
5th Vital Sign: Doctors’ training module: Intruduction
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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)
5th Vital Sign: Doctors’ training module: Pain Physiology
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Spectrum of Pain
ACUTE
PAIN
CHRONIC
PAIN
ACUTE
PAIN
Healing
NO PAIN
CHRONIC
PAIN
Insidious onset
post-surgical syndromes /
cancer
5th Vital Sign: Doctors’ training module: Pain Physiology Courtesy of Prof Ramani Vijayan, MASP
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Pain Pathway
(Anatomy)
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 5th Vital Sign: Doctors’ training module: Pain Physiology
PAIN
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TYPES OF PAIN
Physiological
Pathological or clinical
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EFFECTS OF SEVERE
UNRELIEVED PAIN
Physiological
Psychological
Economic
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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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Anxiety
Agitation
poor sleep
uncooperative patient
depression
PSYCHOLOGICAL EFFECTS OF
PAIN
5th Vital Sign: Doctors’ training module: Pain Physiology
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ECONOMIC EFFECTS OF
PAIN
Delayed ambulation and feeding
Increased postoperative complications
Delayed recovery
Prolonged hospital stay
Increased cost
5th Vital Sign: Doctors’ training module: Pain Physiology
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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
5th Vital Sign: Doctors’ training module: Pain Physiology
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FACTORS AFFECTING PAIN
• Perception of Pain
• Socio Cultural Factors
• Age
• Gender
• Meaning of Pain
• Anxiety
• Past experience with Pain
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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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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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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