2. 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!

3. 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

4. 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

5. 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.

6. 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

7. Numeric Pain Scale
For use in adults, adolescents & cognitively-appropriate pediatric patients
No Pain
Distressing Pain
WORST Pain
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

8. Numeric Pain Scale - Spanish
For use in adults, adolescents & cognitively-appropriate pediatric patients
No me Duele
El Dolor me
Mortifica
No Aguanto
el Dolor
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

9. 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.

10. 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)

11. FLACC Pain Rating Scale
For infants to 7 years of age
Category Scoring
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

12. 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 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 weeks gestation/corrected age
+ 1 if weeks gestation/corrected age
Premature Pain
Assessment

13. 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

14. 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

15. 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.

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

17. 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 Numeric
C. N-PASS
D. None of the above

18. 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.

19. Pain Management Competency Post Test
6. Which of the following are validated and approved pain scales? Select all that apply.
A Numeric
B. Wong-Baker Faces
C. FLACC
D 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

20. 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

21. 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.

22. 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

23. 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

24. 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

25. 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.”