1. Pain Management and Documentation
What
When
Where
Procedure changes and a refocus on quality patient pain management
Not control or even complete relief but addressed in a compassionate manner

2. Pain
Pain is a symptom that signals distress in diverse populations of all ages
Pain – “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” International Association for the Study of Pain
Patients have the right to have their pain needs assessed and addressed. Nurses and physicians should be aware of these needs and work to relieve pain if possible.
Look at the Patient Bill of rights

3. Self Report of Pain
Patients who are alert and have the ability to communicate appropriately
Adults of all ages
Children about 5 years or more

4. Self Report of Pain Scale of 0-10 Faces
0 = no pain 10 = worst possible pain
Google
Faces
Smiling = no pain Crying = worst possible pain
Page C15
Most common easy to use

5. Unable to Self Report
Pain is difficult to measure when the patient is not able to tell you about their pain:
Unconscious
Advanced Dementia
Limited cognitive ability
Infants under the age of 5 years
Use PAINAD scale for dementia, unconscious patients
Use FLACC scale for children ages 0-5 years of age or children who cannot self-report

6. Unable to Self Report: FLACC
Use on neonates, infants, and children to age 5
Observe and recognize associated behavioral and physiologic responses
Difficult to recognize
Limit or avoid unnecessary noxious stimuli – acoustic, visual, tactile
Page C15b

7. FLACC Scale Face Legs Activity Cry 1 2 Consol- ability Smiling or
Smiling or
relaxed
Relaxed
Lying quietly
Not crying
Content, 1
Occasional
grimace
Squirming
Squirming and shifting back & forth
Moans &
whimpers
Reassured by occ. touching, hugging, distractable 2
Clenched jaw & quivering chin
Kicking
Arched, rigid, or jerking
Crying steadily, screams or sobs
Difficult to console or comfort

8. Treatment Measures: Infants
Comfort Measures
Swaddling, pacifier, positioning
Oral administration of sucrose “sweetie”
Analgesia
Skilled personnel – venipuncture less painful than heel stick

9. Unable to Self Report: PAINAD
Lack of ability to self report
Cognitive disorder – cerebral palsy, head trauma, dementia, unconscious
Requires special consideration during assessment of pain
Multiple tools exist, but many have not been validated for reliability in a clinical setting

10. PAINAD Scale
This tool, while developed primarily for use in patients with advanced dementia can be used in other patients who lack the ability to report their pain
Assesses five areas
Breathing independent of vocalization
Negative vocalization
Facial expression
Body language
Consolablity
Scale:
Page C15b

11. Smiling or inexpressive
PAINAD Scale 1 2
Score
Breathing independent of vocalization
Normal
Occ. labored breathing. Short period of hyperventilation
Noisy labored breathing. Long periods of hyper-
ventilation. Cheyne-Stokes respirations.
Negative
vocalization
None
Occ. moan or groan. Low level speech with a neg. or disapproving quality
Repeated trouble calling out. Loud moaning or groaning. Crying.
Facial expression
Smiling or inexpressive
Sad. Frightened. Frown.
Facial grimacing
Body Language
Relaxed
Tense. Distressed pacing. Fidgeting.
Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.
Consolability
No need to console
Distracted or reassured by voice or touch
Unable to console, distract, or reassure.
Total

12. Surrogate Reporting of Pain
Don’t forget the help that can come from a caregiver who really knows and understands patient’s behavior

13. When to Assess
All patients regardless of where they enter the healthcare setting should have their pain level assessed on admission
Triage
Admission
Inpatient
Outpatient

14. The NEXT Assessment
Timing of the next assessment varies based on location of care and needs of the patient
Inpatients (ICU, 2 East, 3 East)
At least q 12 hours
60 minutes post any intervention – medication, repositioning, etc
At discharge

15. ODA ED PACU On return from surgery 60 minutes post any intervention
At discharge from ODA ED
Determined by category and patient condition
PACU
2 – 20 minutes post any intervention
Determined by patient condition

16. Special Circumstances
ODA and OR - Prior to surgery the nurse will check with anesthesia regarding need for pain relief due to the medication that will be given as sedation or anesthesia during actual procedure
MBU – many obstetric patients receive an epidural catheter for pain relief during labor and delivery
The catheter is placed by anesthesia and medication is delivered by anesthesia initially and placed placed on a pump for continued pain relief
Nurses continue to assess patient’s pain needs at least q 1 hour

17. Patient Controlled Analgesia
PCA
Ordered by physician
Consult Anesthesia
Document initial pain relief
Assess and document pain level at least q 2 hours
NOTE – PATIENT CONTROLLED ONLY

18. Barriers to Pain Management
Attitudes, biases
Misinformation about addiction
Fear of legal problems
Worries about side effects

19. Addiction
Fewer than 2 in 10,000 patients with pain will become addicted to an opioid.

20. Patient Attitudes Afraid of addiction Misinformed “Strong”
Remember to consider your patient’s cultural, religious, and social backgrounds

21. Education Discuss with patients and document their role in pain relief
Pain should be reported
If no relief, physician to be notified
Expected pain
Intractable pain

22. If the patient says he/she is in pain…they are in pain.
Remember….
If the patient says he/she is in pain…they are in pain.

23. Pain Management must be a
Team Effort!