2Our GOAL is to manage the patient’s PAIN effectively! The PAIN ProblemMost common reason for medical appointments in the U.S.50 million people affected by pain1 out of 3 people affected by pain140 million visits annually$120 billion in annual health costsPain affects quality of lifePatient’s fear addiction to treatment medsHealthcare provider’s fear treating malingering patients.PAIN is the most common reason for medical appointments in the United States, with 50 million patients with chronic pain and 21.6 million on routine pain medications. According to a recent survey by the Partners for Understanding Pain, 1 out of 3 are affected by it!Pain accounts for over 140 million visits annually - costing the American population upwards of $120 billion each year!Not ONLY in Medical Treatment, but also in its impact on society, in missed days, decreased work productivity, total quality of life: immune function, sleeping, eating, …The PAIN PROBLEM includes both patient and healthcare provider’s fears of patient addiction with opioid analgesics. Healthcare provider’s fear treating malingering patients.Pain assessment must rely on the patient's reported level of pain intensity.Our GOAL is to Mange the Patient’s PAIN effectively!Our GOAL is to manage the patient’s PAIN effectively!
3Patient’s Rights Be believed when pain is reported Have pain relief Ask for changes in treatments if pain persistsReceive pain medication in a timely mannerInclude family & others in decision making about pain managementConsiderate, respectful care, & made to be comfortableGiven respect for personal values & beliefsReceive information about the pain causes & preventionRefuse, accept, or suggest pharmacological or non-pharmacological interventionsBe believed when pain is reportedHave pain reliefBe told how much pain to expect & how long it will lastHave pain prevented & controlled when it occursBe asked acceptable level of painRate pain using appropriate scalesDevelop a pain plan with the doctor & care delivery staffKnow the risks, benefits & side effects of treatmentsKnow what alternative pain treatments may be available
4Pain, the Fifth Vital Sign Once the patient has been assessed and a pain management plan has been designed, pain should be monitored and recorded routinely at least as often as other vital signsPain assessment should include:Use of an appropriate, approved pain scaleAsk about location, quality, intensity, duration, aggravating, andalleviating factors, acceptable level of pain or pain score goal.Reassessment should occur after treatment for pain
5Barriers to Pain Management Multiple barriers to pain management have been identified, such asinadequate knowledge of pain management, poor assessment of pain,patients' reluctance to report pain, and the low priority given to painmanagement.Research shows that when nurses do not obtain pain ratings frompatients, they are likely to underestimate pain, especially moderate to severe pain.Education needs to address the relevance of the nurse's personal opinionof the patient's pain versus the need to record and act on what the patientsays about their painWe need to be aware of the need for cultural sensitivity and understandthat patients may be in severe pain but not “look like” they are.(Mc Caffrey, 2000)A teenage patient who has just been laughing with visitors may rate the pain as seven. Because the nurse observed the patient laughing may interpret this as the pain is not really a seven and record it as a three and not treat the pain with medication appropriate to seven. The teenage patient may indeed have significant pain but is being stoic in front of his friends.
6At Risk Populations for Under Treatment of Pain Patients with history of addiction or alcohol abuseNonverbal (intubated, unconscious)Cognitively impairedElderlyNeonates, infants, childrenEthnic, racial minorities
7Numeric Pain ScaleFor use in adults, adolescents & cognitively-appropriate pediatric patientsNo PainDistressing PainWORST PainReadiness for Discharge shall include Pain Assessment and Emetic - Although these 2 items must be assessed prior to the sedation/procedure as well!What are the Approved Pain Scales?REMEMBER: Patients have a right to appropriate pain assessment.All patients should be assessed for pain on admission and per hospital protocol (at least every 8 hours) - And must be DOCUMNETED!Patient’s pain is managed according to their comfort zone.Age appropriate assessment of pain will be based on a numeric or visual pain rating scale.ADULT PAIN SCALE - numerical 0-10 scaleAsk, “On a scale of 0 to 10, with 0 equaling no pain and 10 meaning the worst possible pain, what number would you give your pain right now?”Explain the purpose of the scale to the patient.When teaching the pain rating scale, discuss the definition of pain, using examples of ways pain can be described. For example, rather than the word pain, most people use adjectives such as aching, hurting, tight, burning, or pricking sensation.Mild Pain[1,2,3]Moderate Pain[4,5,6]Severe Pain[7,8,9,10]No PainUnbearable PainMay use FACES Scale if patient has difficulty with use of numeric scale
8Numeric Pain Scale - Spanish For use in adults, adolescents & cognitively-appropriate pediatric patientsNo me DueleEl Dolor meMortificaNo Aguantoel DolorReadiness for Discharge shall include Pain Assessment and Emetic - Although these 2 items must be assessed prior to the sedation/procedure as well!What are the Approved Pain Scales?REMEMBER: Patients have a right to appropriate pain assessment.All patients should be assessed for pain on admission and per hospital protocol (at least every 8 hours) - And must be DOCUMNETED!Patient’s pain is managed according to their comfort zone.Age appropriate assessment of pain will be based on a numeric or visual pain rating scale.ADULT PAIN SCALE - numerical 0-10 scaleAsk, “On a scale of 0 to 10, with 0 equaling no pain and 10 meaning the worst possible pain, what number would you give your pain right now?”Explain the purpose of the scale to the patient.When teaching the pain rating scale, discuss the definition of pain, using examples of ways pain can be described. For example, rather than the word pain, most people use adjectives such as aching, hurting, tight, burning, or pricking sensation.Dolor Leve[1,2,3]Dolor Moderado[4,5,6]Dolor Furte[7,8,9,10]May use FACES Scale if patient has difficulty with use of numeric scale
9Pain Rating Scale Wong-Baker FACES English Spanish The Wong-Baker FACES scale may be used with children as young as 3 years, and adults like it, as well. Elderly patients and those who have difficulty with 0-10 scale may be able to use this scale.Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain.Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don’t have to be crying to feel this bad. Ask the person to choose the face that best describes how he or she is feeling.
10Pharmacological Pain Management Non-opioid Analgesics (1-3 or mild pain)Examples include: Acetaminophen and nonsteroidal antinflammatory drugs such as Ibuprofen.Weak Opiod analgesics (4-6 or moderate pain) Example: CodeineStrong Opiod analgesics (7 or above, severe pain)Examples: Morphine, DilaudidAdjuvant Medications: Drugs with indications other than pain which may be analgesic in specific circumstances. Examples include: Decadron, antidepressants, anticonvulsants, Alpha-2-Adrenergic Agonists (Clonidine), muscle relaxants (Baclofen)
11FLACC Pain Rating Scale For infants to 7 years of ageCategory ScoringFace No particular expression Occasional grimace or frown Frequent-constant quiver or smile withdrawn, disinterested chin, clenched jawLegs Normal position, relaxed Uneasy, restless, tense Kicking or legs drawn upActivity Lying quietly, normal Squirming, shifting back & Arched, rigid or jerkingposition, moves easily forth, tenseFLACC is a behavioral scale that has been validated for assessment of postoperative pain in children between the ages of 2months and 7 years old. We use the scale for infants up to 7years of age.The acronym FLACC represents: Face, Legs, Activity, Cry, and Consolability. Responses in each category are scored between 0 and 2, for a maximum total score of 10.Cry No cry (awake or asleep) Moans or whimpers; Crying steadily, screams,occasional complaint sobs; frequent complaintConsolabilty Content, relaxed Reassured by occasional Difficult to console ortouching, hugging, or being comforttalked to, distractible
12N-PASS Neonatal Pain, Agitation, & Sedation Scale N-PASS includes a “Sedation” Section!For purposes of “Procedural Sedation” -use ONLY the PAIN Section - ignore the Sedation section - use the actual procedural sedation documentation provided on the form.Pain assessment is the 5th vital sign!Pain should be included in every vital sign assessment.Pain is scored from for each behavioral and physiological criteria, then summed: Points are added to the premature infant’s pain score based on their gestational age to compensate for their limited ability to behaviorally or physiologically communicate painTotal pain score is documented as a positive number (0 - 10)Goal of pain treatment/intervention is a score<3.+ 3 if < 28 weeks gestation/corrected age+ 2 if weeks gestation/corrected age+ 1 if weeks gestation/corrected agePremature PainAssessment
13Non-verbal Pain ScaleNot validated but useful tool for pt’s who cannot communicateProcedureAssess pt. according to each 5 observation categoriesAssign points according to criteriaTotal the pointsApply point total to the 0-10 numeric scaleReassess frequently to compare scores & determine changes in pain levelNot validated, but useful as a tool for evaluation of pain in patients who cannot communicateProcedure:1. Assess the non-verbal patient according to each of the 5 observations or categories, using the criteria listed.2. Assign points according to the criteria selected. Circle the criteria displayed by the patient (e.g., restlessness, slow decreased movement).3. Total the points4. Apply the point total to the 0 to 10 numeric pain scale (value)5. Each re-assessment, compare the previous selected criteria in order to determine potential changes in the level of painRemember to include Special populations in your pain assessment such as:Age End of LifeGender Cognition & Communication abilitiesCulture Type of painSpiritual & Personal Beliefs Cause of pain
14Non-verbal Pain Scale Used in Health Connect for Documentation Movement0 = Positive response to interaction and touch1 = Startling, guarding, generalized tension2 = Thrashing, restless squirmingPosition0 = Restful position, joints relaxed, hands open1 = Finger curled, initial resistance to position change2 = Clenched fists, knees pulled up, strong resistance to positioningFacial Cues0 = Placid expression, smile, relaxed jaw1 = Frown, fearful expression, brow lowering2 = Scowling, clenched jaw, stern lookEmotion0 = Pleasant, serene, cooperative, sleeping1 = Uncooperative, anxious, confused2 = Irritable, combativeVerbal Cues0 = Agreeable responses, humming, singing to self, quiet1 = Moaning, groaning, monotone, muttering2 = Screeching, screaming, crying
15RASS Sedation ScaleRichmond Agitation Sedation Scale used in Health ConnectUse PASS Score of Procedural SedationScore Term Description+4 Combative Overly combative, violent, immediate dangerto staff+3 Very Agitated Pulls or removes tubes, catheters; aggressive+2 Agitated Frequent non-purposeful movement, fightsventilator+1 Restless Anxious, movements not aggressive0 Alert & Calm-1 Drowsy Not fully alert, has sustained awakening(eye-opening/contact) to voice >10secs-2 Light Sedation Briefly awakens w/eye contact to voice <10sec-3 Moderate Movement or eye opening to voiceSedation (no eye contact)-4 Deep Sedation No response to voice, movement or eyeopening to physical stimulation-5 Unarousable No response to voice or physical stimulationObserve Pt.Alert, restless, agitated (0 - +4)Not alert, state pt’s name, ask to “open eyes & look at me”Pt. awakens w/eyes open & contact (-1)Pt. awakens w/eyes open & contact unsustained (-2)Pt. has movement in response to voice but not eye contact (-3)No response to verbal, physically stimulate pt.Pt. has movement (-4)Pt. has no response (-5)The PASS is still in place in the procedural sedation documentation in HealthConnect. For procedural sedation, if you use the Procedural Sedation Navigator nurses and physicians have the ability to document the full process for procedural sedation that we are currently using and not skip any of the steps.A universal sedation scale was adopted for HealthConnect. This is the RASS scale. It is a sedation scale that is used in the Pain Management sections and can be used for patients getting PCA, continuous narcotics for pain, etc.
16PAIN Management Competency Post Test GREAT!EXTRAORDINARY!FEEL GOOD!EXCELLENT!NEVER BETTER!
17Pain Management Competency Post Test 1. Your patient reports that they are still experiencing moderate to severe pain even though they are taking the maximum dose/frequency prescribed by the physician. What is an appropriate nursing action?A. Encourage the patient to “wait and let the medicine take effect”B. Perform a thorough pain assessment and communicate and collaborate findings with the physicianC. Assume the patient is displaying drug seeking behaviors2. A 45-year-old man arrives in the Outpatient Treatment Center. He is unable toadequately verbalize information requested. You need to assess his pain. Whatpain assessment scale(s) would be best to use? Choose any that could be used.A. FacesB NumericC. N-PASSD. None of the above
18Pain Management Competency Post Test 3. Patient rights include: relief or control of pain, to be asked about acceptable levelof pain, to know the risks, benefits, and side effects of pain control measures, and to have respect for personal values and beliefs.A. TrueB. False4. When completing a pain assessment or reassessment, approved pain scalesappropriate for the patient must be used.5. Once a pain control measure is given, further assessment is not needed.
19Pain Management Competency Post Test 6. Which of the following are validated and approved pain scales? Select all that apply.A NumericB. Wong-Baker FacesC. FLACCD Pediatric FacesE. N-PASS7. A night shift RN notices that an infant is crying more than usual, and wants to assess the newborn’s pain. The RN would use the FLACC pain scale for assessment.A. TrueB. False
20Pain Management Competency Post Test 8. Populations at risk for under management of their pain:A. ElderlyB. History of drug/alcohol abuseC. NeonateD. Cognitively impairedE. NonverbalF. All of the above9. Patients and their caregivers must be provided education about the following:A. Pain scalesB. How to control painC. Consequences of uncontrolled painD. Various pain control measures and potential side effectsE. All of the above
21Pain Management Competency Post Test 10. Which of the following best describes the “5th Vital Sign” initiative?A. Pain should be assessed at least five times a dayB. Pain should be assessed after other vital signsC. Pain is the least important vital signD. Pain information should be recorded at least as frequently as other vital signs11. If a pain control measure is given and a re-assessment is completed but notdocumented, it really doesn’t matter.A. TrueB. False12. Failure to ask patients about their pain and accepting and acting on the patient’sreports of pain is probably the most common cause of unresolved treatable pain.
22Pain Management Competency Post Test 13. A 14-year-old male admitted for ambulatory surgery at one of our clinics doesnot need pain assessment.A. TrueB. False14. Assessment of pain must include location, quality, intensity, duration,aggravating and alleviating factors, and one other item. What is that item?Acceptable level of pain or pain goal15. Which of the following statements is true regarding opioid therapy?A. Pain at a level of five or above on a 10-point scale is treatable by opioid agentsB Intensive opioid therapy remains an end-of-live therapy for severe chronic painC. Intensive opioid therapy is limited largely to cancer painD. Opioid therapy for non-cancer pain exposes the clinician ti regulatory sanction
23Pain Management Competency Post Test 16. A 35-year-old male patient with testicular cancer is joking and playing cards withhis roommate. When assessed by the pain management nurse, the patient rateshis pain as a seven on a numeric pain rating scale of 0 to 10. The nurseconcludes that the patient's behavior:A. is an emotional reaction to the anticipated pain.B. is in anticipation of future pain.C. is more indicative of the need for pain medication than the pain rating.D. may be in conflict with the pain rating, and accepts the report of pain17. The pain management nurse notices a male patient grimacing as he moves fromthe bed to a chair. The patient tells the nurse that he is not experiencing anypain. The nurse's response is to:A. clarify the patient's report by reviewing the patient's nonverbal behaviorB. confronting the patient's denial of painC. obtaining an order for pain medicationD. supporting the patient's stoic behavior
24Pain Management Competency Post Test 18. When teaching a 65-year-old patient to use a pain scale, a painmanagement nurse anticipates that:A. additional time is needed for the patient to process the informationB. older adults are unable to use pain scales reliablyC. the Pain Assessment in Advanced Dementia Scale is appropriatefor the patientD. the patient's family is included in the education sessions19. Patients should be encouraged to establish an acceptable level ofpain score or pain relief score goal.A. TrueB. False
25Pain Management Competency Post Test 20. A 75-year-old female patient comes to the oncology clinic for management of chronic cancer pain. The patient has been prescribed morphine sulfate (MS Contin), 30 mg, every 12 hours. The patient states that she is taking the medicine only when the pain becomes severe because of her husband's concern about addiction. The pain management nurse responds:A. “It is okay to continue doing what you are doing.”B. “The risk of developing addiction when taking opioids for pain isvery low.”C. “We need to consider other alternatives for managing your pain.”D. “You must take the medication as prescribed, regardless of yourhusband‘s concerns.”