SACRED HEART HEALTHCARE SYSTEM
SACRED HEART HOSPITAL
421 CHEW STREET
ALLENTOWN, PA 18102-3490
GENERAL POLICY & PROCEDURE MANUAL
Subject: Pain Management Policy Number: 596
Approved: ______Initial Effective Date: 10/00
Most Recent Revision: 10/14
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Appendixes 5
I. PURPOSE:
The medical and hospital staff at Sacred Heart Healthcare System recognizes that the relief of pain and suffering for those we treat is integral to the mission of Sacred Heart Healthcare System. Compassionate caring includes the recognition and on-going assessment of pain by health professionals and the patient and its appropriate management; or prevention of pain prior to its beginning, if predictable. It is the purpose of this policy to establish a formal process by which the patient’s/resident’s/ client’s dignity and comfort is optimized by appropriate pain management.
II. SCOPE:
This policy applies to all Sacred Heart Healthcare System employees and services.
III. RESPONSIBILITY:
1. It is the responsibility of departmental managers to monitor staff orientation/education, annual competence assessment, and staff adherence to policy and procedure.
IV. REFERENCES:
Evans-Smith, P. (2007) Taylor’s Clinical Nursing Skills, Lippincott, Williams, &
Wilkins, Hagerstown, MD
Odhner, M, Wegman D, Freeland N, Steinmetz A, Ingersoll G. Assessing Pain
Control in Nonverbal Critically Ill Adults. Dimensions of Critical Care Nursing. 2003; 22:260-267
Payen JF, Bru O,Bosson JL, et al. Assessing Pain in Critically Ill Sedated Patients
by Using a Behavioral Pain Scale, Quality Assurance Standards, American Pain
Society Pain Management
The Joint Commission Standards (July 2012) MS.03.01.03, PC.01.02.01,
PC.01.02.07, PC.02.03.01, RI.01.01.01
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V. POLICY STATEMENTS:
A. All patients will be assessed for pain.
1. All departments providing treatment /services to patients/residents will
a. perform appropriate screening assessment for pain. Pain intensity and pain relief will be assessed:
b. on admission.
c. after any known pain-producing event
Pain Management General Manual # 596
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d. with each new report of pain, and
e. routinely at regular intervals (at least every shift) as appropriate to clinical service
2. When possible, the patient’s self-report of pain will be the primary
indicator of pain.
3. Pain Scales
a. The 0-10 numeric intensity pain rating scale will be the preferred pain rating measure (see appendix I)
b. Wong- Baker facial scales (see appendix II) will be used for
patients/residents who may have difficulty communicating their pain
and require particular attention with close assessment. This includes
patients who are any of the following:
i. elderly
ii. emotionally disturbed
iii. children
iv. those who do not speak English
c. The Cognitively Impaired Non-verbal Scale will be used for patient’s
who are not able to communicate due to mental or physical impairment for which behaviors will be assessed to give clues about pain levels. (see appendix III)
d. FLACC Infant and Child Pain Scale will be used for preverbal infants
and children ( see appendix IV)
e. Adult non-verbal pain scale will be used for intubated patients (see
Appendix V)
f. NIPS (see Appendix VI Neonatal Infant Pain Scale) will be used for
preterm and full-term neonates. This can be used to monitor before,
during, and after a painful procedure.
4. Reassessment of pain
a. Patients will be reassessed after each pain management intervention once a sufficient time has elapsed for the treatment to reach effect.
b. Patients not attaining a reduction in pain will have an in depth focused assessment of pain and appropriate action will be taken to reduce the patient’s pain
5. Documentation of pain assessment, interventions, and response to pain
a. When possible the patient should be screened for pain and a focused assessment performed when the patient complaints of
pain using the intervention will be documented at least every
shift using the appropriate pain scale.
Intervention for the pain will be provided, followed by timely
re-assessment of pain and documentation of the episode of pain
in succession.
Re-assesment of pain is documented in MAK. (Medication Administration Check). Click the medication and document under edit.
b. Documentation of the process may occur at the end of the shift and contain general terms such as “Patient medicated times 2 for pain. Resting comfortably.”
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c. When pain management is not attained, more in depth assessment and documentation should occur.
B. Staff caring for patients/residents will receive education about pain including
but not limited to physiological and psychological effects of pain, use of pain scales, pharmacologic and non-pharmacologic interventions for pain control.
C. Patients will be informed:
1. That pain relief is an important part of their treatment plan and they can
negotiate an acceptable pain level.
a. Patients will be educated about the pain that can be anticipated
as a normal process of their hospitalization and recovery.
b. Though complete pain relief is a preferred goal, patients will be
made aware if complete relief is a realistic goal. When
necessary patients should have a comfort function level
determined to establish an acceptable level of comfort which
still allows the patient to participate in their own care as much as
possible.
2. About options to control pain
a. Medicating prior to activity (physical therapy, etc.) to increase
participation
b. Scheduling doses on an “around-the-clock” dosing schedule to maintain the level of drug that will prevent recurrence of pain
c. Utilize the use of breakthrough medication, inform the patient of availability of PRN and the need to request when pain was present.
d. That they may discuss concerns and preferences with the health care team.
D. Family members and/or significant others shall be involved in the patient’s/resident’s pain management plan when appropriate.
E. For patients whose initial pain intensity rating is 4 or greater (on 0-10 scale), additional assessments will be obtained relating to location, quality, aggravating and alleviating factors, associated signs and symptoms, physical exam/observation, present pain management, effects of pain on daily function, and patient’s pain goal.
F. All patients whose self-report of pain is above the negotiated comfort function level or 4 or greater on a scale of 0-10, will have interventions implemented for the relief of pain, or be referred for treatment, as appropriate.
1. Healthcare staff will work together with the patient and other health
providers to establish a goal for pain relief and develop and implement a
plan to achieve that goal.
2. Health providers will respond to reports of pain in a timely manner.
3. Healthcare providers will review and collaboratively modify the plan of
care for patients who have unrelieved pain.
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4. Unexpected intense pain in hospitalized patients, particularly if sudden or
associated with altered vital signs, such as hypertension, tachycardia, or
fever, should be immediately evaluated and reported to the physician
G. Side Effect Management and Symptom Management
1. Assess sedation level after pain intervention. Identify status of arousal
a. awake & alert
b. dozing, easily aroused
c. dozing, aroused with difficulty
d. unarousable, unresponsive
e. use appropriate sedation scale for patient population
2. Establish a bowel program upon initiation of analgesic therapy
3. Assess and observe for known side effects of pharmacologic agents
a. unstable blood pressure
b. inadequate respiratory rate and depth
c. nausea & vomiting
d. pruritis
e. constipation
f. urinary retention
4 Collaborate with physician for appropriate measures to relieve side
effects
5 Assess patient safety risks and implement necessary safety measures. 6. Implement Fall Standards when appropriate
7. Identify a baseline sleep assessment prior to onset of assist pain
patient to develop a rest schedule and minimize interruptions (i.e.,
visitors, telephone, physical care, etc.)
8. Medication management of sleep disturbances
H. An AD Hoc Pain Management Committee will be established to update the
pain management process and monitor performance when quality indicators
indicate a need for action.
Disclaimer Statement
This policy and the implementing procedures are intended to provide a description of recommended courses of action to comply with statutory or regulatory requirements and/ or operational standards. It is recognized that there may be specific circumstances not contemplated by laws or regulatory requirements that make compliance inappropriate. For advice in these circumstances, please consult with Risk Management/Patient Safety and/or Legal Services.
Revised Date: 7/12; 10/14 Reviewed Date: 10/10 Typist: Donna Schiavone
596 gen pain management
Appendix I
Pain Scale
CHOOSE A NUMBER FROM 0 TO 10 THAT BEST DESCRIBES YOUR PAIN
No pain Distressing pain Unbearable pain
│_____│_____│_____│_____│____│____│____│____│____│____│
0 1 2 3 4 5 6 7 8 9 0
Appendix II
BAKER-WONG PAIN SCALE
CHOOSE THE FACE THAT BEST DESCRIBES HOW YOU FEEL
Spanish /Espanol
0 2 4 6 8 10
Appendix III
Pain Assessment for the Cognitively Impaired Patient
Write a “0” if the behavior was not observed, and a “1” if the behavior occurred even briefly during activity or rest.
Behavior / With Movement / Rest1. vocal complaints: non –verbal
(expressions of pain ,not in words, moans, groans, grunts, cries, gasps, sigh)
2. Facial grimaces/winces
(furrowed brow, narrowed eyes, tightened lips, jaw drop, clenched teeth, distorted expressions)
3. Bracing (clutching or holding onto side rails bed tray tables or affected area during movement)
4. Restlessness (constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still
5. Rubbing ( massaging affected area)
6. (In addition record verbal/vocal complaints)
Verbal/Vocal complaints: (words expressing discomfort or pain, “ouch”, “that hurts”, cursing during movement, or exclamations of protest ,e.g. stop!, that’s enough!
Subtotal Score
Total Score
Appendix IV
The following scale can be used to assess pain behaviors. Observe the behavior in each category. Add up the five “scores” to obtain a number on a scale of 0-10. This scale is used when patients are unable to use other pain scales; they are unable to self-report their pain
OBSERVATION / VALUE= 0 / VALUE= 1 / VALUE= 2
FACE / Normal position or relaxed / Occasional grimace or frown , withdrawn, disinterested / Frequent to constant frown, clenched jaw, quivering .
LEGS / Normal position or relaxed / Uneasy, restless / Kicking or legs drawn up
ACTIVITY / Lying quietly, normal position, moves easily / Squirming, shifting back and forth, tense / Arched, rigid, or jerking
CRY / No cry (awake or asleep) / Moans or whimpers, occasionally / Crying steadily, screams or sobs, frequent complaints
CONSOLABILITY / Content, relaxed / Reassured by occasional
l touching, hugging, or “talking to”, distractible / Difficult to console or comfort
Appendix V
Tool for Pain Assessment of the Intubated Patient
i. Each of the five categories is scored from 0 – 2
ii. Score 0 – 2 = no pain
iii. Score 3 -6 = moderate pain
iv. Score 7 -10 = severe pain
Categories / 0 / 1 / 2Face / No particular expression or smile / Occasional grimace, tearing, frowning, wrinkled forehead / Frequent grimace, tearing, frowning, wrinkled forehead
Activity ( movement) / Lying quietly, normal position / Seeking attention through movement or slow cautious movement / Restless, excessive activity and/or withdrawal reflexes
Guarding / Lying quietly, no positioning of hands over areas of body / Splinting areas of body, tense / Rigid, stiff
Physiology (vital signs) / Stable vital signs / Change in any of the following:
· SBP>20 mm Hg
· Hr > 20/min / Change in any of the following:
· SBP > 30 mm Hg
· HR > 25/min
Respiratory / Baseline RR/ SpO2 compliant with ventilator / RR > 10 above baseline, or 5% ↓SpO2, mild asynchrony with ventilator / RR > 20 above baseline, or 10% ↓SpO2 severe asynchrony with ventilator
© Strong Memorial Hospital, University of Rochester Medical Center 2004
Appendix VI.
Neonatal Infant Pain Scale (NIPS)
Overview: The Neonatal Infant Pain Scale (NIPS) is a behavioral assessment tool for measurement of pain in preterm and full-term neonates. This can be used to monitor a neonate before during and after a painful procedure such as venipuncture. It was developed at the Children’s Hospital of Eastern Ontario.
Parameters: (1) facial expression (2) cry (3) breathing patterns (4) arms (5) legs (6) state of arousal
Parameter / Finding / Pointsfacial expression / relaxed / 0
grimace / 1
Cry / no cry / 0
whimper / 1
vigorous crying / 2
breathing patterns / relaxed / 0
change in breathing / 1
Arms / restrained / 0
relaxed / 0
flexed / 1
extended / 1
Legs / restrained / 0
relaxed / 0
flexed / 1
extended / 1
state of arousal / sleeping / 0
awake / 0
fussy / 1
Where:
· Relaxed muscles (facial expression): restful face neutral expression
· Grimace: tight facial muscles furrowed brow chin jaw (negative facial expression – nose mouth brow)
· No cry: quiet not crying
· Whimper: mild moaning intermittend
· Vigorous cry: loud scream rising shrill continuous (Note: silent cry may be scored if baby is intubated as evidence by obvious mouth facial movements).
· Relaxed; usual pattern for the baby
· Change in breathing: indrawing irregular faster than usual gagging breath holding
· Relaxed/restrained: no muscular rigidity occasional random movements of limb
· Flexed/extended: tense straight rigid and/or rapid extension flexion
· Sleeping/awake: quiet peaceful sleeping or alert and settled
· Fussy: alert restless and thrashing
Neonatal infant pain scale = SUM (points for the 6 parameters)
Interpretation:
· Minimum score: 0
· Maximum score: 7
Limitations:
· A falsely low score may be seen in an infant who is too ill to respond or who is receiving a paralyzing agent.
References:
Lawrence j Alcock D et al. The development of a tool to assess neonatal pain. Neonatal Network. 1993; 12 (6 September): 59:66.