1. Education Update Module 3
Pain Assessment & Reassessment
Restraint
Moderate Sedation

2. Objectives
After reviewing this module, the staff member will be able to:
Define pain and verbalize staff responsibility in the assessment and reassessment of pain.
Identify where to appropriately document pain assessment and reassessment.
Verbalize the change in obtaining an order for emergency restraint application.
Differentiate sedation levels.
Verbalize on how to document sedation level using POSS.

3. Topic I :
Pain Assessment & Reassessment

4. Definition
Pain may be defined as an unpleasant sensory and emotional experience. Because pain is always subjective, the clinician must accept the patient’s report of pain.

5. Staff Responsibility
Upon admission, all patients will be assessed for pain:
Previous and ongoing instances of pain and its effects on the patient
Previously used methods for pain control that the patient either found helpful or unhelpful
The patient’s/family’s beliefs regarding the use of pain medications
Any history of substance abuse
The patient’s typical coping response for stress or pain
Patient/Family expectations and beliefs concerning pain and identifying a pain goal
Ways the patient describes or shows pain
Complete inventory of patient’s medications including over-the-counter medications and herbal remedies

6. Staff Responsibility
The patient and nurse will establish an acceptable pain level using one of the following pain scales:
I Numeric Pain Intensity Scale
Wong-Baker Faces Pain Scale
FLACC (Faces, Legs, Activity, Cries, Consolability)
CRIES (Crying, Requires oxygen, Increased Vital Signs, Expression, Sleeplessness)
V CPOT (Critical Care Pain Observation Tool)

7. Pain Assessment : Pain Scales
I. Numeric Pain Intensity Scale
The 0 to 10 pain scale is commonly and successfully used with hospitalized and nursing home patients, even those with mild and moderate dementia
This scale asks the person in pain to assign a number, from zero to ten, to the severity of their pain, zero being no pain and ten being the worst possible pain they can imagine.

8. Pain Assessment : Scales – cont’d
Wong-Baker FACES Pain Scale
developed by Donna Wong and Connie Baker
generally recommended for children ages 3 or older
the scale shows a series of faces ranging from a happy face at 0, “No hurt” to a crying face at 10 “Hurts worst”.
the patient chooses the face that best describes his or her own pain

9. Pain Assessment : Scales – cont’d
FLACC (Faces, Legs, Activity, Cries, Consolability)
Recommended for children between 2 months to 7 years of age (not valid for children with developmental delay)
Each category is scored from 0-2: (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability. The score will be 0-10.
CATEGORY
SCORING 1 2
Face
No particular expression or smile
Occasional grimace or frown, withdrawn, disinterested
Frequent to constant quivering chin, clenched jaw
Legs
Normal position or relaxed
Uneasy, restless, tense
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; occasional complaint
Crying steadily, screams or sobs, frequent complaints
Consolability
Content, relaxed
Reassured by occasional touching, hugging or being talked to, distractible
Difficult to console or comfort

10. Pain Assessemt : Scales – cont’d
IV. CRIES (Crying, Requires Oxygen, Increased Vital signs, Expression, Sleeplessness)
Recommended for infants less than 6 months of age
Each of the five categories is scored from 0-2: (C) Crying; (R) Requires oxygen; (I) Increased vital signs; (E) Expression; (S) Sleeplessness . The total score will be 0-10.
CRIES SCALE
CATEGORY
SCORING 1 2
Crying –
Characteristic of pain is high pitched
No cry or cry that is not high pitched
Cry high pitched but baby is easily consolable
Cry high pitched but baby is inconsolable
Requires O2 for SaO2 <95% –
babies experiencing pain manifest decreased oxygenation. Consider other causes of hypoxemia, e.g. over sedation, atelectasis, pneumothorax
No oxygen required
<30% oxygen required
>30% oxygen required
Increased vital signs (BP* and HR*) – take BP last as this may awaken child making other assessments difficult
Both HR and BO unchanged or less than baseline
HR or BP increased <20% of baseline
HR or BP increased >20% over baseline
Expression – the expression most often associated with pain is a grimace characterized by brow lowering, eyes squeezed shit, deepening naso-labial furrow, or open lips and mouth
No grimace present
Grimace is alone and present
Grimace and non-cry vocalization grunt is present
Sleeplessness – scored based upon the infant’s state during the hour preceding this recorded score
Child has been continuously asleep
Child has awakened at frequent intervals
Child has been awake constantly

11. Pain Assessment : Scales – cont’d
V. CPOT (Critical Care Pain Observation Tool
Recommended for non-verbal patients or critically ill patients
Each of the four categories is scored from 0-2: Facial expressions; Body movements; Compliance with the ventilator; muscle tension. The total score will be 0-8.
Indicator
Score
Description
Facial Expression
Relaxed, neutral
No muscle tension observed
Tense
Presence of frowning, brow lowering, orbit tightening and levator contraction or any other change (e.g. opening eyes or tearing during nociceptive procedures)
Grimacing
All previous facial movements plus eyelid tightly closed (the patient may present with mouth open or biting the endotracheal tube)
Body movements
Absence of movements
Does not move at all (doesn’t necessarily mean absence of pain) or normal position (movements not aimed toward the pain site or not made for the purpose of protection)
Protection
Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements
Restlessness/Agitation
Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed
Compliance with the ventilator (intubated patients) OR
Vocalization (extubated patients)
Tolerating ventilator or movement
Alarms not activated, easy ventilation
Coughing but tolerating
Coughing, alarms may be activated but stop spontaneously
Fighting ventilator
Asynchrony: blocking ventilation, alarms frequently activated
Talking in normal tone or no sound
Talking in normal tone or no sound
Sighing, moaning
Sighing, moaning
Crying out, sobbing
Crying out, sobbing
Muscle tension
Evaluation by passive flexion and extension of upper limbs when patient is at rest or evaluation when patient is being turned
Relaxed
No resistance to passive movements
Tense, rigid
Resistance to passive movements
Very tense or rigid
Strong resistance to passive movements or incapacity to complete them
TOTAL
_____/8

12. Pain assessment shall be completed at a minimum of every 4 hours with vital signs

13. Pain Assessment & Reassessment
POSS - (Pasero Opioid-induced Sedation Scale)
POSS must be used when assessing and documenting sedation level on the following:
Prior to giving opioid medication or initiating PCA treatment
Reassessing sedation level after opioid administration
30 minutes after IV admin
1 hour after P.O. admin
30 minutes after the initiation or titration of dosage on PCA

14. Pain Assessment & Reassessment
In addition to POSS, the following will be included in the pain assessment:
Location
- accurately verbalize or pinpoint pain site location (a diagram may be helpful for some patients)
pain may also be described as diffused, localized or radiating
Intensity
- translate the patient’s subjective report of pain into an objective description by using the appropriate pain scale : Numeric, Wong-Baker, FLACC, CRIES or CPOT
Quality
- quality may include, but is not limited to: stabbing, throbbing, cramping, vise-like, searing or burning, superficial, deep.
Radiation
- determine if the pain radiates anywhere from the location of its greatest intensity
Duration
- the length of time the patient has been experiencing this pain

15. Documentation
Document the pain assessment, including POSS and interventions, as appropriate, on the Pain Assessment Intervention screen in the medical record.
Reassessment of pain to be completed 30 minutes after each intervention
The same pain scale initially used for assessment should be used for the reassessment
A plan of care on pain management must be included and updated as necessary

16. Topic II :
Restraint Updates

17. Definition
Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely. If the patient can easily remove the device, material or equipment, it is not considered a restraint.

18. Types of Restraints Types of Restraint
Non-Violent/Non-Self Destructive (Non-Behavioral) Restraint
- used to limit mobility or temporarily immobilize an acute care patient for a reason specifically related to a medical or post-surgical procedure
- examples include preventing a patient from removing an essential line or tube or performing an unsafe activity such as climbing out of bed
Violent/Self-Destructive (Behavioral Health) Restraint
- used only in an emergency or in a crisis situation if a patient’s behavior becomes violent or self-destructive presenting an immediate, serious risk to his/her safety or that of others and non-physical interventions are not effective

19. Physician Orders
In an emergency situation, the least restrictive, yet effective restraint may be initiated by a RN based on an appropriate assessment of the patient. In these emergency application situations, the order must be obtained either during the emergency application of the restraint or immediately after the restraint has been applied.
- this will apply to both Violent and Non-Violent restraint application

20. Physician Order Form Non-Violent/Non-Self Destructive Restraint
If a telephone order was obtained for the initiation of the restraint, the space for the telephone order must be completed by the RN
The attending physician will perform an in-person assessment of the restrained patient within 24 hours of the initiation of restraint and at least once every calendar day, at which time the restraint will either be re-ordered or discontinued as indicated

21. Physician Order Form Violent/Self Destructive Restraint
If a telephone order was obtained for the initiation of the restraint, the space for the telephone order must be completed by the RN
One-hour face-to-face assessment will be done by a physician or a RN who has successfully completed the competency for performing a face-to-face assessment. This assessment of the patient’s physical or psychological status will be done within one hour of the initiation of restraint.

22. Debriefing
As soon as possible, but no longer than 24 hours after the conclusion of each restraint episode , the patient and, if appropriate, the patient’s family may participate in a debriefing with staff members who were involved in the episode.

23. Leadership Notification
Leadership notification (Clinical Manager/Director/House Supervisor) will be immediately notified of any instance in which a patient:
Is placed in violent/self-destructive restraints and/or seclusion and when this restraints and/or seclusion are discontinued
Remains in restraint or seclusion for more than 12 hours
Experiences two or more separate episodes of restraint and/or seclusion of any duration within 12 hours
Thereafter, the Nurse Manager will be notified every 24 hours if either of the above condition continues.

24. Topic III :
Moderate Sedation

25. Definition
Moderate Sedation is defined as administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function.
- intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently.

26. Sedation Levels Minimal Sedation :
Response to verbal stimulation is normal
Cognitive function and coordination may be impaired
Ventilatory and cardiovascular functions are unaffected
Moderate Sedation (formerly called Conscious Sedation) :
Depression of consciousness is drug-induced
Patient responds purposefully to verbal commands
Airway is patent and spontaneous ventilation is adequate
Cardiovascular function is usually unaffected

27. Sedation Levels
Deep Sedation :
Depression of consciousness is drug-induced
Patient is not easily aroused but responds purposefully following repeated painful stimulation
Independent maintenance of ventilatory function may be impaired
Spontaneous ventilation may be inadequate
Cardiovascular function is usually maintained
Currently, we DO NOT DO deep sedation for our procedures (except anesthesiologists)

28. Table of Drugs Used for Moderate Sedation

29. Table of Drugs Used for Moderate Sedation

30. Table of Drugs Used for Moderate Sedation