Our GOAL is to manage the patient’s PAIN effectively! The PAIN Problem Most common reason for medical appointments in the U.S. 50 million people affected by pain 1 out of 3 people affected by pain 140 million visits annually $120 billion in annual health costs Pain affects quality of life Patient’s fear addiction to treatment meds Healthcare 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!

Patient’s Rights Be believed when pain is reported Have pain relief Ask for changes in treatments if pain persists Receive pain medication in a timely manner Include family & others in decision making about pain management Considerate, respectful care, & made to be comfortable Given respect for personal values & beliefs Receive information about the pain causes & prevention Refuse, accept, or suggest pharmacological or non-pharmacological interventions Be believed when pain is reported Have pain relief Be told how much pain to expect & how long it will last Have pain prevented & controlled when it occurs Be asked acceptable level of pain Rate pain using appropriate scales Develop a pain plan with the doctor & care delivery staff Know the risks, benefits & side effects of treatments Know what alternative pain treatments may be available

Pain, 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 signs Pain assessment should include: Use of an appropriate, approved pain scale Ask about location, quality, intensity, duration, aggravating, and alleviating factors, acceptable level of pain or pain score goal. Reassessment should occur after treatment for pain

Barriers to Pain Management Multiple barriers to pain management have been identified, such as inadequate knowledge of pain management, poor assessment of pain, patients' reluctance to report pain, and the low priority given to pain management. Research shows that when nurses do not obtain pain ratings from patients, they are likely to underestimate pain, especially moderate to severe pain. Education needs to address the relevance of the nurse's personal opinion of the patient's pain versus the need to record and act on what the patient says about their pain We need to be aware of the need for cultural sensitivity and understand that 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.

At Risk Populations for Under Treatment of Pain Patients with history of addiction or alcohol abuse Nonverbal (intubated, unconscious) Cognitively impaired Elderly Neonates, infants, children Ethnic, racial minorities

Numeric Pain Scale For use in adults, adolescents & cognitively-appropriate pediatric patients No Pain Distressing Pain WORST Pain 0 1 2 3 4 5 6 7 8 9 10 Readiness 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 scale Ask, “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 Pain Unbearable Pain May use FACES Scale if patient has difficulty with use of numeric scale

Numeric Pain Scale - Spanish For use in adults, adolescents & cognitively-appropriate pediatric patients No me Duele El Dolor me Mortifica No Aguanto el Dolor 0 1 2 3 4 5 6 7 8 9 10 Readiness 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 scale Ask, “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

Pain 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.

Pharmacological 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: Codeine Strong Opiod analgesics (7 or above, severe pain) Examples: Morphine, Dilaudid Adjuvant 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)

FLACC Pain Rating Scale For infants to 7 years of age Category Scoring 0 1 2 Face No particular expression Occasional grimace or frown Frequent-constant quiver or smile withdrawn, disinterested chin, clenched jaw Legs Normal position, relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal Squirming, shifting back & Arched, rigid or jerking position, moves easily forth, tense FLACC 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 complaint Consolabilty Content, relaxed Reassured by occasional Difficult to console or touching, hugging, or being comfort talked to, distractible

N-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 0 - 2 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 pain Total 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 28-31 weeks gestation/corrected age + 1 if 32-35 weeks gestation/corrected age Premature Pain Assessment

Non-verbal Pain Scale Not validated but useful tool for pt’s who cannot communicate Procedure Assess pt. according to each 5 observation categories Assign points according to criteria Total the points Apply point total to the 0-10 numeric scale Reassess frequently to compare scores & determine changes in pain level Not validated, but useful as a tool for evaluation of pain in patients who cannot communicate Procedure: 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 points 4. 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 pain Remember to include Special populations in your pain assessment such as: Age End of Life Gender Cognition & Communication abilities Culture Type of pain Spiritual & Personal Beliefs Cause of pain

Non-verbal Pain Scale Used in Health Connect for Documentation Movement 0 = Positive response to interaction and touch 1 = Startling, guarding, generalized tension 2 = Thrashing, restless squirming Position 0 = Restful position, joints relaxed, hands open 1 = Finger curled, initial resistance to position change 2 = Clenched fists, knees pulled up, strong resistance to positioning Facial Cues 0 = Placid expression, smile, relaxed jaw 1 = Frown, fearful expression, brow lowering 2 = Scowling, clenched jaw, stern look Emotion 0 = Pleasant, serene, cooperative, sleeping 1 = Uncooperative, anxious, confused 2 = Irritable, combative Verbal Cues 0 = Agreeable responses, humming, singing to self, quiet 1 = Moaning, groaning, monotone, muttering 2 = Screeching, screaming, crying

RASS Sedation Scale Richmond Agitation Sedation Scale used in Health Connect Use PASS Score of Procedural Sedation Score Term Description +4 Combative Overly combative, violent, immediate danger to staff +3 Very Agitated Pulls or removes tubes, catheters; aggressive +2 Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious, movements not aggressive 0 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 voice Sedation (no eye contact) -4 Deep Sedation No response to voice, movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation Observe 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.

PAIN Management Competency Post Test GREAT! EXTRAORDINARY! FEEL GOOD! EXCELLENT! NEVER BETTER!

Pain 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 physician C. Assume the patient is displaying drug seeking behaviors 2. A 45-year-old man arrives in the Outpatient Treatment Center. He is unable to adequately verbalize information requested. You need to assess his pain. What pain assessment scale(s) would be best to use? Choose any that could be used. A. Faces B. 0-10 Numeric C. N-PASS D. None of the above

Pain Management Competency Post Test 3. Patient rights include: relief or control of pain, to be asked about acceptable level of pain, to know the risks, benefits, and side effects of pain control measures, and to have respect for personal values and beliefs. A. True B. False 4. When completing a pain assessment or reassessment, approved pain scales appropriate for the patient must be used. 5. Once a pain control measure is given, further assessment is not needed.

Pain Management Competency Post Test 6. Which of the following are validated and approved pain scales? Select all that apply. A. 0-10 Numeric B. Wong-Baker Faces C. FLACC D. 0-5 Pediatric Faces E. N-PASS 7. 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. True B. False

Pain Management Competency Post Test 8. Populations at risk for under management of their pain: A. Elderly B. History of drug/alcohol abuse C. Neonate D. Cognitively impaired E. Nonverbal F. All of the above 9. Patients and their caregivers must be provided education about the following: A. Pain scales B. How to control pain C. Consequences of uncontrolled pain D. Various pain control measures and potential side effects E. All of the above

Pain 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 day B. Pain should be assessed after other vital signs C. Pain is the least important vital sign D. Pain information should be recorded at least as frequently as other vital signs 11. If a pain control measure is given and a re-assessment is completed but not documented, it really doesn’t matter. A. True B. False 12. Failure to ask patients about their pain and accepting and acting on the patient’s reports of pain is probably the most common cause of unresolved treatable pain.

Pain Management Competency Post Test 13. A 14-year-old male admitted for ambulatory surgery at one of our clinics does not need pain assessment. A. True B. False 14. 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 goal 15. 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 agents B Intensive opioid therapy remains an end-of-live therapy for severe chronic pain C. Intensive opioid therapy is limited largely to cancer pain D. Opioid therapy for non-cancer pain exposes the clinician ti regulatory sanction

Pain Management Competency Post Test 16. A 35-year-old male patient with testicular cancer is joking and playing cards with his roommate. When assessed by the pain management nurse, the patient rates his pain as a seven on a numeric pain rating scale of 0 to 10. The nurse concludes 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 pain 17. The pain management nurse notices a male patient grimacing as he moves from the bed to a chair. The patient tells the nurse that he is not experiencing any pain. The nurse's response is to: A. clarify the patient's report by reviewing the patient's nonverbal behavior B. confronting the patient's denial of pain C. obtaining an order for pain medication D. supporting the patient's stoic behavior

Pain Management Competency Post Test 18. When teaching a 65-year-old patient to use a pain scale, a pain management nurse anticipates that: A. additional time is needed for the patient to process the information B. older adults are unable to use pain scales reliably C. the Pain Assessment in Advanced Dementia Scale is appropriate for the patient D. the patient's family is included in the education sessions 19. Patients should be encouraged to establish an acceptable level of pain score or pain relief score goal. A. True B. False

Pain 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 is very low.” C. “We need to consider other alternatives for managing your pain.” D. “You must take the medication as prescribed, regardless of your husband‘s concerns.”