Clinical Protocol: PAIN MANAGEMENT

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PAIN MANAGEMENT

Clinical Protocol

Approved: April 2015 Next Review: Under revision

Clinical Area: All clinical areas

Population Covered: all adult and pediatric patients, excluding neonates

Campus: Ballard, Cherry Hill, Edmonds, First Hill, Issaquah,

Mill Creek, Redmond Implementation Date: September 1998

Related Procedures, Protocols, and Job Aids: Ketamine: Intravenous Infusion Management

Medication Range Orders Pain Assessment: Pediatric

Pain Management: Acute Pain in PACU

Pain Management: Epidural/Intrathecal Analgesia PCA Set-Up Instructions Therapeutic Duplication of PRN Medications (Adult)

Go directly to: Patient Assessment

Clinical Management

Reportable Conditions

Patient and Family Education

Documentation

Definitions

Addenda: Comparison of Nociceptive and Neuropathic Pain

Critical-Care Pain Observation Tool (CPOT)

Differences Between Acute and Persistent (Chronic) Pain

Equianalgesic Charts

FACES-R Tool in Multiple Languages (National Association for the Study of Pain)

FLACC Tool

Guidelines for the Use of Heating Pads/Packs

Opioid Reference Table

PABS Tool

Pain intensity tool sheet with 0-10 NRS/FACES/VERBAL Descriptors (NOTE: Handouts available in five

languages linked to education activity point “Pain.”)

PCA Pain Management Guidelines

Purpose

To provide pain assessment and management guidelines

Policy Statement

Clinical Protocol: PAIN MANAGEMENT

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None.

LIP Order Requirement

Elements of this protocol require a licensed independent practitioner’s (LIP) order.

Responsible Persons

Initial pain assessment: Registered nurse.

Reassessment of pain in response to therapeutic intervention: Registered nurse, licensed practical nurse (under

the supervision of the RN), nurse tech (under the supervision of the RN).

Assessment of pain related to therapy: Physical and occupational therapists.

All other staff members are accountable for reporting the patient’s pain reports, or staff/family observations that

indicate the patient may have pain, to the registered nurse, physical therapist, or occupational therapist.

Prerequisite Information

None.

PROCEDURE ► Requires an LIP order…

Responsible Person

Steps Supplemental Guidance

RN

ADMISSION ASSESSMENT

1. Screen all patients for the presence of pain

during the admission process or first contact; [16]

if pain is present perform a more

comprehensive assessment, the minimum

documentation elements are:

Pain location

Pain intensity

2. Address pain management in the plan of care if

pain is of primary concern to the patient or

patient’s family and/or affects hospital course

or discharge disposition upon admission or at

any time during the hospitalization.

Suggestions for a more comprehensive

assessment include [16]:

Pain quality (i.e., what words the

patients uses to describe pain; for

example, throbbing, aching, sharp,

dull stabbing, burning, shooting)

Duration

Pattern i.e., constant, intermittent, or

constant with periods of increased

pain.

Factors that relieve or aggravate pain

Current pain management regimen,

both prescribed and over the counter

(including effectiveness)

Impact of pain on daily life (e.g.,

sleep, mood, work)

Precipitating event, if known (e.g.,

procedure, infection, medical

condition)

Functional goals

RN

ONGOING ASSESSSMENT

NOTE: Prescribing opioid doses based solely on pain

intensity scores alone can be dangerous and is

discouraged17. The RN uses clinical judgment,

considering other assessment factors to determine

the appropriateness/safety of intervention and

addresses with provider as needed.

The hierarchy below (modified from the

Hierarchy of Pain Assessment

Techniques [12][16]) starts with patient’s self-

report. Use the hierarchy below as the basis

for assessing pain.

1) Attempt to elicit a self-report of pain.

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When, per orders or therapeutic duplication guidelines,

a numerical pain score needs to be generated,

verbal descriptors are interpreted as mild 1-3,

moderate 4-6 and severe 7-10. 1. Assess pain/comfort routinely during patient

care, at least once a shift and before and after

pain-relieving interventions. However, not

every assessment needs to be documented; see

documentation guidelines on page 8.

a. Determine the frequency and timing of

assessments based on factors including type

of intervention, medication

pharmacodynamics (e.g. onset, peak effect

and duration), concomitant medications,

pain history and patient condition.

Assessments include:

Pain location

Pain level

Sedation level (see scale below)

Respiratory status (see parameters

below)

2. To assess pain level use an appropriate pain

intensity rating option in the order listed below

(see table of scales below and supplemental

guidance to the right):

a. Attempt to obtain self-report as the primary

source of pain assessment when possible.[2]

b. If unable to self-report use behavioral pain

scales if appropriate.

c. If unable to use behavioral scale (e.g.

patient paralyzed) identify potential causes

of pain/discomfort and collaborate with LIP

to trial analgesia regimen.

SMC uses the following scales:

a) 0 to 10 Numeric Rating Scale

(NRS), where “0” = “no pain” and

“10” = “worst possible pain.”

b) Or corresponding descriptive

words, e.g., mild (1-3), moderate

(4-6), severe (7-10).

c) Or Wong-Baker FACES scale

d) Or document patient’s verbal self-

report if unable or unwilling to use

a scale

2) If patient unable to self-report ,

observe behavior using patient

appropriate scale/tool (see table below).

Behavioral pain scales are not

appropriate for pharmacologically

paralyzed infants, children, adults, or

those who are flaccid and cannot

respond behaviorally to pain.

Behavioral pain scales are also not

appropriate for patients who can self-

report by any means, as self-report is

gold standard for pain assessment.

Request surrogate report of pain from

family members and caregivers.

3) Identify potential causes of

pain/discomfort (existing medical

conditions, injuries, surgical/medical

procedures, invasive instrumentation,

painful routine care like suctioning,

turns, drain removal, wound care, etc.)

4) Analgesic trial can be initiated when

pain is suspected resulting from any of

assessment techniques listed above.

Patient Population SELF-REPORT SCALES: Able to Self-Report Unable to Self-Report

Neonates

N/A

Neonatal Pain, Agitation, & Sedation Scale (N-PASS) [1]

Children

FACES-R Pain Rating Scale 0-10 Numeric Rating Scale

Face, Legs, Activity, Cry, Consolability Revised (rFLACC)[1,12]

Adults, including adults with mild to severe cognitive impairment

0-10 Numeric Rating Scale Word Descriptor Pain Scale FACES-R Pain Rating Scale

Pain Assessment Behavioral Scale (PABS)[10]

Critical Care

0-10 Numeric Rating Scale Word Descriptor Pain Scale Wong-Baker FACES Pain Rating Scale

Critical-Care Pain Observation Tool (CPOT)[11]

Patients of any age who are comatose, flaccid, pharmacologically paralyzed or cannot

By definition, this population is unable to self-report.

By definition this population is unable to self-report or exhibit pain behaviors. Nurses will identify potential causes of pain and treat

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for any reason exhibit pain behaviors

appropriately. [12][16]

Goal-directed sedation (e.g., procedural sedation)

By definition, this population is unable to self-report.

Pain Assessment Behavioral Scale (PABS)[10]

NOTE: Behavioral pain scales are not appropriate for pharmacologically paralyzed infants, children, adults, or those who are flaccid and cannot respond behaviorally to pain.[12] Behavioral pain scales are also not appropriate for patients who can self-report by any means, as self-report is gold standard for pain assessment. Request surrogate report of pain from

family members and caregivers. [12] [16]

Responsible

Person Steps, continued Supplemental Guidance

RN

3. Assess sedation level.

Level of Sedation

Anticipated Response

3 Awake and responding

2 Sedated but responds to normal

voice or light touch

1 Sedated but responds to loud

voice or movement

0 Deeply sedated, unable to

respond

4. Assess respiratory status: rate, effort, depth,

noise, apneic spells etc. [7] Address and

document RR of:

10 or less per minute for patients 15 years

old and over (or over 40 kg)

14 or less for patients age 5 through 14

years old

20 or less for patients between age 1

through 4 years old

30 or less for patients age 1 month through

3 months

25 or less for patients age 4months through

11months

5. Assess side effects from medication (e.g.,

nausea, vomiting, myoclonus, itching).

6. Skin anesthesia level: If patient receiving

intraspinal anesthetic agents, assess level of

skin anesthesia if present with reassessments.[4]

7. Pulse oximetry checks: Check oxygen

saturation with reassessments on all patients

receiving epidural or intrathecal opioids and for

24 hours after last dose.[7]

For pain reassessment with neuraxial (epidural

or intrathecal) analgesia see Pain

NOTE: Populations at risk for opioid-

induced respiratory depression (multiple

factors increase risk): [7]

Infants less than 30 months old

Opioid-naïve patients

Frail elders

Patients with chronic pulmonary

disease, CHF, and other major organ

failure

Patients receiving other CNS

depressants such as anesthetics,

benzodiazepines

Patients who have recently ingested

alcohol

Patients with history of sleep apnea

Obese patients

When pain is finally controlled after a

period of poor control

NOTE: Opioid naïve patients receiving the

equivalent of 10 mg IV morphine (≈1.5 mg

hydromorphone) in a short period of time

(e.g., in PACU or during painful treatment/

intervention) have been shown to be at

higher risk for respiratory depression from

peak effect of last dose given for the

duration of opioid effect (3-4 hours)[2].

For a comprehensive list, see Addendum

“Patients at risk for opioid induced

respiratory depression”

If patient sleeping, attempt to assess

patient’s oxygen saturation level while they

are sleeping/dozing; if low and patient is

awakened to deep-breathe until saturation

level is acceptable, saturation level may

continue to be inadequate when patient falls

back to sleep.

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Management: Epidural/Intrathecal Analgesia,

Adult.[4]

8. Sleeping patient: If the patient is sleeping,

assess respiratory status and sedation

level/arousability as follows:

a. If pain previously well managed and:

Sedation level of 2 (patient responds to

light touch, voice or gentle movement),

Respiratory rate (per minute) is:

RR more than 10 for patients

15 years old and older or weighing

over 40 kg

RR more than 15 for patients age

6 through 14 years old

RR more than 20 for patients age

1 through 5 years old

RR more than 25 for patients age

4 to 11 months

Respirations are quiet, regular, deep

Document “NS” (normal sleep) in pain

level row.

b. If criteria above are not met, awaken

patient fully, assess and address over-

sedation or respiratory issues as appropriate

and document.

PT, OT, Speech

Therapist

ASSESSMENT AND DOCUMENTATION OF PAIN DURING PHYSICAL, OCCUPATIONAL AND SPEECH LANGUAGE THERAPY TREATMENTS

1. Therapists assess and document pain level in

their progress note with each treatment.

2. Therapists document on the pain flow sheet

when pain interferes with treatment (i.e., unable

to begin or complete entire treatment), in

addition to communicating to nursing.

RN

CLINICAL MANAGEMENT

1. Collaborate with LIP and patient to develop an

individualized pain management plan

considering multimodal treatment strategies.

2. Provide realistic expectations regarding pain

management including functional goals for the

patient. (see scripting on right)

3. Administer/titrate medications/treatments as

ordered based on patient pain assessment.

1. Multimodal Pain Treatment Strategy [16]:

Involves the use of two or more

classes of analgesics to target

different pain mechanisms

Combines analgesics to maximize

pain relief and prevent analgesic

gaps that may lead to pain that is

worse or uncontrolled

May reduce doses of each drug in

the pain plan, potentially reducing

adverse effects

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a. Initiate interventions if pain exceeds the

patient’s acceptable level. Use both

medication prescribed for pain relief and

non-medication therapies.

b. For acute pain in the first 24-72 hours of

onset, anticipate that patient may need

routine analgesic medications in order to

establish and maintain a steady state blood

level to maximize pain relief; if pain

assessment warrants, offer medication

routinely when available.

c. Manage analgesic side effects using

pharmacological and non-drug approaches.

May result in comparable or greater

pain relief than any single analgesic

2. Sample scripting to manage patient

expectations: “Most patients can expect to

have some pain when hospitalized for

surgery or a painful medical condition. We

will do everything we can to keep you

comfortable enough to perform your

activities necessary to heal –such as to

move, walk, sit, exercise, breathe deeply,

rest and sleep.”

CAUTION: Some antiemetics can increase sedation and decrease respiratory rate.

d. Continue to monitor response to pain

treatments and side effects. If the current

regimen is ineffective despite titration or if

intolerable side effects cannot or managed

notify LIP.

CAUTION: The total dose of acetaminophen should not exceed 4000 milligrams per 24 hours for adults and children

over 12 years old, including acetaminophen in compound medications. For children, doses should not exceed:

Ages 0-90 days: 60 mg/kg per day

Ages 90 days to 12 years: 90 mg/kg per day

e. Anticipate the need for higher analgesic

doses for patients who have been on

opioids for ongoing or chronic pain or have

a history of opioid abuse.

NOTE: Patients admitted on

buprenorphine or methadone maintenance

may require individualized pain treatment

plans. Addiction medicine physician on

call via Addiction Recovery Unit 781-6209

if assistance is needed.

2. Encourage and offer use of non-drug therapies

as part of pain management plan. Non-drug

therapies include:

Position changes

Distraction (e.g., music, play therapy, TV)

Modification of room environment –

lighting, temperature, fan

Warm blankets, ice packs (generally used

for 20 minute periods)

Mechanical heated water-circulating pads

► TENS unit provided by physical therapy

(requires LIP order)

Specialty beds, bed cradles, and heel/elbow

protectors

Solicit suggestions from patient and family

Massage, if not contraindicated;

Relaxation therapies (videos available on

Opioid tolerant is defined as: Patient takes

more than 50 mg of oral morphine (or

equivalent) per day for five or more days.

Sample scripting for patient expectation

management: “Most patients can expect to

have some pain when hospitalized for

surgery or a painful medical condition. It is

our goal to keep you comfortable enough to

perform your necessary activities to heal –

such as to move, walk, sit, exercise, breathe

deeply, rest and sleep.”

Buprenorphine is a partial agonist at the

opiate receptor. It only partially activates

the receptor, thus it has a mild opiate effect.

However, buprenorphine also has a high

affinity for the opiate receptor and blocks

the effects of other opiates such as

morphine. Buprenorphine can be displaced

by other very high affinity opiates such as

hydromorphone (Dilaudid) or fentanyl if

given in adequate doses.

Hand massage is a practical and effective

option that can be performed by family or

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patient health channel)

Spiritual care support

3. Make referrals and seek consultation as

appropriate:

► Rehabilitation Services (requires LIP order)

Spiritual Care

► Pain Consultation Services (requires LIP

consult) through Swedish Pain and

Headache Center or at Edmonds campus

contact Swedish Edmonds Specialty Clinic

friends.

RN

PATIENT AND FAMILY EDUCATION

1. Teach patient and/or family importance of

reporting pain, treatment effectiveness, and side

effects. Encourage patient to notify staff early

when pain level is beginning to increase.

2. Educate patient and family, as appropriate to

the setting and situation, on the following:

Understanding pain and the importance of

effective pain management

Safe and effective use of medication,

medical equipment and other non-

pharmacological interventions

Reporting potential side effects

When and how to obtain further treatment,

if needed

Opioid side effects may include the

following:

Dry mouth

Nausea

Rash, skin irritation

Sedation

Confusion

Vomiting

Urinary retention

Headache

Itching

Constipation

CAUTION: Constipation is a side effect of opioids that does not resolve with time.

► 5. Patients on opioid therapy for a prolonged time

need a bowel care regimen generally with a

stimulant and softener (e.g., Colace and senna).

An LIP order is required.

Benyamin, R., et al. (2008). Opioid

complications and side effects. Pain

Physician, 11, S105–S120.

RN

DOCUMENTATION

1. Document in EMR:

Pain assessments per table below

Medications given

Patient and family education

2. Add pain to care plan when it is an issue for the

patient and/or effects hospital course/discharge.

3. Document provider notification in the Vital

Signs Flowsheet or under the “interventions”

area for pain management.

4. Use following supplementary documentation /

communication methods as needed:

a. Use smart text “NSG Pain Note” when

needed for detailed pain notes.

b. Shift note: Briefly address whether current

pain regimen/plan is effective or not in

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your shift note (encouraged).

c. Nurse-to-nurse verbal communication of

pain with patient handoff/bedside report.

d. White board in patient’s room – time pain

medications are available/scheduled.

PAIN ASSESSMENT DOCUMENTATION GUIDELINES

Minimum standards for clinical areas (Exception: PACU per Pain Management: Acute Pain in PACU)

What to document:

Document: 1. Sedation level if 0 or 1 2. Respiratory Rate if :

10 or less per minute for patients 15 years old and over (or over 40 kg)

14 or less for patients between 5 to 14 years old

20 or less for patients between 1 and 5 years old

Or respirations are irregular, shallow, or noisy 3. Pain level

Patient can self-report: Document a pain level entry or “normal sleep.” *

Patient unable to self-report: Document a behavioral pain score and/or progress note. 4. Side effects if medication change is required due to side effects.

* Document NS (Normal Sleep) if patient meets following criteria:

1) Pain previously well managed 2) Sedation scale of 2 (patient responds to light touch, voice or gentle movement) 3) Respiratory Rate per minute (RR)

a. Above 10 for adults and adolescents age 15 or older or weighing more than 40 kg, b. Above 15 for age 6 -14 years c. Above 20 for patients 1-5 years d. Above 25 for patients 4-11 months e. Above 30 for patients 1-3 months

4) Respirations are quiet, regular and deep

If criteria not met, awaken patient fully, assess and address over-sedation or respiratory issues as appropriate and document.

Medication Administration When to Document Pain Assessment

All patients o Includes patients with regularly scheduled

pain meds

Minimum: Document pain assessment once Q shift. Document more frequently as appropriate (e.g. medication increased, new medication added; patient has new or worsening pain, pain level not acceptable to patient, etc.)

Nurse administered PRN dosing

One-time pain medication administration

Minimum: Document one set of pre/post medication assessments Q shift. Document more frequently as appropriate (e.g. medication being titrated, increased or new medication added; patient has new or worsening pain, pain level not acceptable to patient, etc.)

Patient-controlled analgesia (PCA)

Continuous opioid infusion – IV or SC

Ketamine Infusion (for further information see Ketamine: Intravenous Infusion Management.)

1) Document an assessment at initiation and

Within 30 minutes after initiation

Every 2 hours for 8 hours

Every 4 hours until discontinued 2) Document assessment with rate or dose increase

Within 30 minutes of increase

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Epidural/Intrathecal, see Pain Management: Epidural/Intrathecal Analgesia.

Document epidural, patient controlled epidural analgesia, intrathecal continuous and single intraspinal dosing: Q1hx12h, then Q2h, x 12H, then q4h. Continue to monitor (not document) Q4h x 24h after final dose.

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Definitions

Pain. “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or

described in terms of such damage.” Pain is subjective. (IASP, 1994).

Acute pain. Brief, physical cause usually known, pain subsides as healing takes place, intensity can range from

mild to severe.

Chronic or persistent pain (preferred descriptor is “persistent pain”). Prolonged, usually persists for three

months or longer, cause may or may not be known. Pain has not responded to medical-surgical treatment, does

not subside after injury heals, intensity may range from mild to severe.

Breakthrough pain. Intermittent exacerbation of pain that can occur spontaneously or in relation to specific

activity.

Incident pain. A type of breakthrough pain that is related to specific activity, such as eating, defecation,

socializing, or walking.

Opioid withdrawal. Cessation or abrupt reduction in dosage of an opioid. Initial symptoms and signs may

develop up to 48 hours after cessation or reduction in dosage of the opioid, depending upon the half-life of the

drug concerned. These include restlessness, mydriasis (dilation of pupils), lacrimation, rhinorrhea, sneezing,

piloerection, yawning, perspiration, restless sleep, and aggressive behavior. Severe manifestations include muscle

spasms, back aches, abdominal cramps, hot and cold flashes, insomnia, nausea, vomiting, diarrhea, tachypnea,

hypertension, hypotension, tachycardia, bradycardia, and cardiac dysrhythmias.

Opioid-naïve. An individual who does not routinely use opioids for pain relief (e.g., daily or every-other-day

use).

Chronic opioid use. An individual who is routinely using opioids for pain relief (e.g., scheduled routine use

and/or PRN use of opioids daily) for greater than five days. Patient’s initial and/or loading doses may need to be

adjusted upward based on the amount of opioid medication used the previous five days.

Opioid tolerant. Patient takes more than 60 mg of oral morphine (or equivalent) per day for five or more days.

Pain Classifications:

Acute and chronic pain: Acute pain predominates in the inpatient setting but can be an exacerbation of chronic

pain or can exist in the context of chronic pain. See addendum, Differences Between Acute and Persistent

(Chronic) Pain.

Nociceptive and neuropathic pain: Pain can also be mixed nociceptive-neuropathic. See addendum, Comparison

of Nociceptive and Neuropathic Pain.

Forms

None.

Supplemental Information

For more information on pain:

American Pain Society: http://www.ampainsoc.org/

American Society for Pain Management Nursing: http://www.aspmn.org/

City of Hope Professional Resource Center web site: http://www.cityofhope.org/prc/

Partners Against Pain: http://www.partnersagainstpain.com/

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Regulatory Requirement

The Joint Commission (TJC). PC.01.02.07 – Provision of Care, Treatment, and Services.

Centers for Medicare & Medicaid Services (CMS). 482.13 – Patient Rights.

Det Norske Veritas (DNV). PR – Patient Rights.

Department of Health (DOH). WAC 246-320-226 – Patient Care Services.

References (see Johns Hopkins Evidence-Based Practice Evidence Rating Scales)

1. American Academy of Pediatrics and the American Pain Society. (2001). The assessment and management

of acute pain in infants, children, and adolescents: A position statement.

http://pediatrics.aappublications.org/content/108/3/793.full.pdf+html (accessed March 2, 2015).

2. American Pain Society (2003). Principles of analgesic use in the treatment of acute pain and cancer pain (5th

ed.). Glenview, IL: American Pain Society.

3. American Society of Anesthesiologists Task Force on Acute Pain Management. (2004). Practice guidelines

for acute pain management in the perioperative setting: An updated report by the American Society of

Anesthesiologists Task Force on Acute Pain Management. Anesthesiology, 100, 1573-81.

4. American Society of Anesthesiologists Task Force on Neuraxial Opioids. (2009). Practice guidelines for the

prevention, detection, and management of respiratory depression associated with neuraxial opioid

administration: An updated report by the American Society of Anesthesiologists Task Force on Neuraxial

Opioids. http://www.asahq.org/resources/standards-and-guidelines/search?q=neuraxial (accessed March 2,

2015).

5. American Society for Pain Management Nurses. (2002). Core curriculum for pain management nursing.

Philadelphia: W.B. Saunders Company.

6. American Society for Pain Management Nursing and the American Pain Society. (2004). The use of “as

needed” range orders for opioid analgesics in the management of acute pain.

http://americanpainsociety.org/uploads/about/position-statements/ps-opioid-dosage.pdf (accessed March 2,

2015).

http://americanpainsociety.org/uploads/about/position-statements/ps-opioid-dosage.pdf

7. American Society for Pain Management Nursing. (2011). Guidelines on monitoring for opioid-induced

sedation and respiratory depression: A position paper. http://www.aspmn.org/pages/positionpapers.aspx.

8. Ersek, M., & Irving, G.A. (2007). Nursing management of pain. In Lewis, S.M., Heitkemper, M.M.,

Dirksen, S.R., O’Brien, P., Giddens, J., & Bucher, L. (Eds.) Medical-surgical nursing: Assessment and

management of clinical problems (7th ed.), 125-150. Philadelphia: Elsevier.

9. Ersek, M. (2007). Overview of pain types and prevalence. In Dahl, J., Gordon, D.E., & Paice, J.A. (Eds.).

Pain resource nurse (PRN) curriculum. Madison, WI: University of Wisconsin.

10. Campbell, M.L., Renaud E., & Vanni, L. (2005). Psychometric testing of a new pain assessment behavior

scale (PABS). Paper presented at the 29th Annual MNRS Research Conference (April 1-4, 2005) Session

#1199 - Pain. Abstract retrieved March 2, 2015 from

http://www.nursinglibrary.org/vhl/handle/10755/161141

11. Gélinas, C., Fillion, L., Puntillo, K.A., Viens, C., & Fortier, M. (2006). Validation of the critical-care pain

observation tool in adult patients. American Journal of Critical Care, 15, 420-427.

12. Gomez, R., Barrownmann, N., Elia, S., Manians,E., Royle, J., Harrison, D. (2013). Establishing intra and

inter rater agreement of the Face, Legs, Activity, Cry, Consolability scale for evaluating pain in

toddlers during immunization. Pain Research & Management, 18(6), 124-128.

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13. Herr, K.A., Coyne, P.J., Key, T., Manworren, R., McCaffery, M., Merkel, S., Pelosi-Kelly, J., & Wild, L.

(2006). Pain assessment in the nonverbal patient: position statement with clinical practice

recommendations. http://www.aspmn.org/documents/PainAssessmentinthePatientUnabletoSelfReport.pdf

(accessed March 2, 2015).

14. Hospice and Palliative Nurses Association. (2013). The ethics of opioid use at end of life.

http://hpna.advancingexpertcare.org/wp-

content/uploads/2014/09/The_Ethics_of_Opioid_Use_at_End_of_Life_111513.pdf

15. International Association for the Study of Pain (IASP). (2005). Core curriculum for professional education

in pain (3rd ed.). http://www.iasp-pain.org/.

16. Puntillo, K., Morris, A., Thompson, C., Stanik-Hutt, J., White, C., & Wild, L. (2004). Pain behaviors

observed during six common procedures: Result form Thunder Project II. Crit Care Med, 32, 421-427.

17. Pasero, Chris et al. (2016). American Society for Pain Management Nursing Position Statement: Prescribing

and administering opioid doses based solely on pain intensity. Pain Management Nursing, 17(3):170-180.

18. Pasero, C., & McAffery, M. (2011). Pain assessment and pharmacologic management. St. Louis, MO:

Mosby.

Addenda

Comparison of Nociceptive and Neuropathic Pain

Critical-Care Pain Observation Tool (CPOT)

Differences Between Acute and Persistent (Chronic) Pain

Equianalgesic Charts

FACES-R Tool in Multiple Languages (National Association for the Study of Pain)

FLACC Tool

Guidelines for the Use of Heating Pads/Packs

Opioid Reference Table

PABS Tool

Pain Assessment Documentation Guidelines

Pain intensity tool sheet with 0-10 NRS/FACES/VERBAL Descriptors (NOTE: Handouts available in five

languages linked to education activity point “Pain.”)

PCA Pain Management Guidelines

Using PCA Pump

STAKEHOLDERS

Author/Contact

Jeanine Keefe, RN, MSN, Clinical Education and Practice

Co-Authors

Christy Novasio, RN, PNQL Chair

Expert Consultants

Clinical Education and Practice Department

Pain Management Committee

Anesthesia Pain Team

Pain and Headache Center

Pain Management Nurse Quality Leader Team

Sponsor

Jennifer Graves, Chief Executive and Nurse Executive, Swedish Ballard, & Interim Chief Executive, Swedish Edmonds

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09179801.doc(rev.06/17/20)