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PAIN AS 5 TH VITAL SIGN

                          DR LEE OI WAH
                         PENGARAH HCM




        Powerpoint Templates
                                     Page 1
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
• 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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                               5 Vital Sign: Doctors’ training module: Intruduction
                                th                                         Page 3
• 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 Vital Sign: Doctors’ training module: Intruduction
                                  th                                         Page 4
• 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.
                                 Powerpoint Templates
                                         5 Vital Sign: Doctors’ training module: Intruduction
                                            th                                       Page 5
• 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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                              5 Vital Sign: Doctors’ training module: Intruduction
                              th                                          Page 6
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)




                Powerpoint Templates
                       5 Vital Sign: Doctors’ training module: Pain Physiology
                        th                                          Page 7
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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
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
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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PSYCHOLOGICAL EFFECTS OF
PAIN

    Anxiety
     Agitation

     poor sleep
     uncooperative patient
     depression



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                        5 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



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                      5 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



                   Powerpoint Templates
                          5 Vital Sign: Doctors’ training module: Pain Physiology
                           th                                          Page 18
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

              Powerpoint Templates
                                           Page 20
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

                 Powerpoint Templates
                                              Page 21
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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Pain as 5 th vs

  • 1. PAIN AS 5 TH VITAL SIGN DR LEE OI WAH PENGARAH HCM Powerpoint Templates Page 1
  • 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 Powerpoint Templates Page 2 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? Powerpoint Templates 5 Vital Sign: Doctors’ training module: Intruduction th Page 3
  • 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. Powerpoint Templates 5 Vital Sign: Doctors’ training module: Intruduction th Page 4
  • 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. Powerpoint Templates 5 Vital Sign: Doctors’ training module: Intruduction th Page 5
  • 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 Powerpoint Templates 5 Vital Sign: Doctors’ training module: Intruduction th Page 6
  • 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) Powerpoint Templates 5 Vital Sign: Doctors’ training module: Pain Physiology th Page 7
  • 9. Spectrum of Pain Healing ACUTE NO PAIN PAIN Insidious onset CHRONIC PAIN post-surgical syndromes / cancer ACUTE CHRONIC PAIN PAIN Powerpoint Templates Page 9 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) Powerpoint Templates Page 10 5th Vital Sign: Doctors’ training module: Pain Physiology Courtesy of Prof Ramani Vijayan, MASP
  • 11. TYPES OF PAIN Physiological Pathological or clinical Powerpoint Templates Page 11
  • 12. EFFECTS OF SEVERE UNRELIEVED PAIN  Physiological  Psychological  Economic Powerpoint Templates Page 14
  • 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 Powerpoint Templates Page 15
  • 14. PSYCHOLOGICAL EFFECTS OF PAIN Anxiety Agitation  poor sleep  uncooperative patient  depression Powerpoint Templates 5 Vital Sign: Doctors’ training module: Pain Physiology th Page 16
  • 15. ECONOMIC EFFECTS OF PAIN Delayed ambulation and feeding Increased postoperative complications Delayed recovery Prolonged hospital stay Increased cost Powerpoint Templates 5 Vital Sign: Doctors’ training module: Pain Physiology th Page 17
  • 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 Powerpoint Templates 5 Vital Sign: Doctors’ training module: Pain Physiology th Page 18
  • 17. FACTORS AFFECTING PAIN • Perception of Pain • Socio Cultural Factors • Age • Gender • Meaning of Pain • Anxiety • Past experience with Pain Powerpoint Templates Page 19
  • 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 Powerpoint Templates Page 20
  • 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 Powerpoint Templates Page 21
  • 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 Powerpoint Templates Page 22