1. Pain Assessment & Reassessment
AND
Medication Reconciliation

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
Differentiate between the different pain scales
Identify where to appropriately document pain assessment
Identify when an RN must use the Pasero Opioid Sedation Scale
Identify when and where to document pain reassessment

3. 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.

4. 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

5. 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)

6. 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.

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. Don’t Forget
Any nursing intervention must have a reassessment documented
If you are performing an intervention for pain don’t forget to go back and reassess the patient within 30 minutes.
If you are performing an intervention for any other reason perform a reassessment and document in the appropriate time frame.
Examples of items which need reassessment:
Intervention for nausea/vomiting (administration of Zofran)
Intervention for increase in temperature (administration of an anti-pyretic)
Intervention for decrease in temperature (administration of warming blanket)
Intervention for low O2 saturation (administration of oxygen)
Intervention for wheezing (breathing treatment)
These examples are just a few, but don’t forget any intervention needs a reassessment to see if the intervention was successful

16. Medication Reconciliation
Patients admitted to the floor from ED or DIRECT ADMIT
Responsibilities:
ED Nurse
Verifies if electronic “Home Medication Reconciliation” has previously been completed in chart
If not yet completed, ED nurse fills Home Med list with patient; If already completed, ED nurse reviews med with patient
When reviewing meds with patient, click “review” or “discontinue” only; click “continue” only if an order has been obtained from the MD to continue the specific home med
When available, reconciles med with MD
Admitting Nurse
Verifies if electronic “Home Medication Reconciliation” is completed in the chart, then the admitting nurse to follow the same process above
If Home Med Rec has not been completed, contacts the physician to complete the process
Physician
Completes the Home Med Rec electronically or by telephone order

17. Medication Reconciliation
Discharging Patients to Home
Responsibilities:
Physician
Places discharge order
Completes Discharge Home Med Rec
Provides written prescription for new medications
Nurse
Verifies that physician placed discharge order and Discharge Home Med Rec is completed
If not, nurse contacts physician and obtains a telephone order
Completes discharge instruction and process with patient

18. Medication Reconciliation
Discharging Patients to a Facility
Physician
Places Transfer order
Completes printed out/paper “Medication Reconciliation Discharge SNF” and returns to nurse
Provides written prescription for new medications
Nurse
Verifies that physician placed transfer order
Prints out “Medication Reconciliation Discharge SNF” and hands over the print out to the physician
After physician completes form, copies the Med Rec Form and places copy in patient chart (original goes to the facility)
If physician did not complete the Med Rec Discharge SNF, nurse obtains a telephone order and completes the process

19. Medication Reconciliation
Inter-Departmental Process
Endorsing Nurse
Verifies that physician placed transfer order
If available, reconciles medication with physician
Physician
Selects transfer button to either continue or stop current orders in the Transfer Med Rec
Physician places transfer order
Receiving Nurse
Verifies that physician placed transfer order and “Acknowledges” the order
Reviews all orders to ensure current medications were properly reconciled
If not, contacts physician to complete transfer order