pain management protocol

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STANFORD HOSPITAL & CLINICSPATIENT CARE MANUAL

PAIN MANAGEMENT:PAIN MANAGEMENT PROTOCOL

I. PURPOSE/OUTCOME

Pain is a universal experience, frequently reported by hospitalized patients, whether thecause for admission to the hospital is of a medical or surgical nature. Healthcare providersat Stanford Hospital and Clinics (SHC) believe that patients have both rights andresponsibilities with regard to pain management, which form the basis for our painmanagement philosophy (Appendix A). Based on this philosophy, the followingstandards have been developed for all patients.

Who May Perform : Under the direction of the RN, the LVN, NA or MA may collectdata on the patient’s level of pain, and communicate this information to the RN.

II. IMPLEMENTAION

A. Initial Assessment

Upon admission and/or transfer to a nursing unit, assess the patient for pain(level, location, description and intervention). When appropriate, familyand/or significant others should be included in the pain assessment process.

1. Pain Level/Intensity a. In order to provide a standard method of assessing and

communicating pain intensity, several pain assessmentscales have been adopted. These scales are:

1) 0-10 Scale2) FACES Pain Rating Scale 3) Nonverbal Pain Scale 4) FLACC

b. Depending on the patient’s ability to communicate abouttheir pain, select the most appropriate scale with which toassess patient’s pain intensity. All scales are designed torate pain using the 0- 10 concept with “0” represen ting no

pain and “10” representing worst pain experience. 1) 0-10 SCALE

0 1 2 3 4 5 6 7 8 9 10 No Pain Mild Moderate Severe Worst

PossibleThe 0-10 scale can be used for most patients. The patient is instructed to ratethei r pain level or intensity with “0” representing no pain and “10” representingthe worst pain that the patient can imagine. This is usually done verballyalthough a patient can also point to appropriate number on a 0-10 scale diagram.



Pain Management: Pain Management Protocol

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2) FACES PAIN RATING SCALE

Wong- Baker FACES Pain Rating Scale from Wong et. al. Whaley and Wong’s Nursing Careof Infants and Children, ed 6 ST. Louis, p. 2040.Copyrighted by Mosby, Inc. Reprinted by

permission.

The FACES pain rating scale is useful in assessing patients whose developmentalage is approximately from 3-7 years. This scale is useful in patients of any agewho can understand instructions about the scale and can communicate but whomay have difficulty understanding abstract numbers like what is used in the

verbal 0-10 scale. Non-English speaking patients may also find the FACES scaleto be easier to communicate their pain level. When using the FACES scale it isimportant to instruct the patient that the face expression represents how muchthey hurt not how their mood is in general.

3) NON-VERBAL PAIN SCALE Use for adults who are unresponsive, intubated, unconscious and/or unable toarticulate pain level.

CATEGORY SCORINGFace 0

Face muscles relaxed1

Facial muscle tension,frown,

Grimace

2Frequent to constantfrown, clenched jaw

Face Score:

Restlessness 0Quiet, relaxed,

normal movement

1Occasional restlessmovement, shifting

positions

2Frequent restlessness,

may include extremities

Restlessness Score:

MuscleTone*

0 Normal muscle tone,

relaxed

1Increased tone, flexion

of fingers and toes

2Rigid tone

Muscle Tone Score:

Vocalization 0 No abnormal sounds

1Occasional moans,

cries, whimpers, grunt

2Frequent or continuous

moans, cries, grunts

Vocalization Score:

Consolability 0Content, relaxed

1Reassureable by touch

or talk, distractible

2Difficult to comfort by

touch or talk

ConsolabilityScore:

Non-Verbal Pain Assessment Scale Total (0-10) /10

From The Detroit Medical Center (DMC) Pain Assessment Behavioral Scale, 9-00. Based on the FLACC: Abehavioral scale for scoring postoperative pain in young children, by S. Merkel and others.

* Assess muscle tone in patients with spinal cord lesion or injury at a level above the lesion or injury. Assesspatients with hemiplegia on the unaffected side.

The Non-Verbal Pain Assessment Scale is designed for use in the patient that isunable to communicate. This may be related to intubation and sedation as in theICU patient or to the patient who is comatose. This tool requires the nurse toassess the five categories and rate the patient’s behaviors.




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Scoring The Non-Verbal Pain Scale Observe behaviors and assess which description best describes patient behaviors for each column.

Rate the patient for each of the five items. Total the score for the Non-Verbal Pain Assessment

Scale (0-10).

“0” indicates “no pain” and “10” indicates “verysevere uncontrolled pain ”.

4) FLACCCATEGORY SCORINGFace 0

No particular expressionor smile

1Occasional grimace or

frown, withdrawn,disinterested

2Frequent to constant

quivering chin, clenched jaw

Face Score:

Legs 0 Normal position or

relaxed

1Uneasy, restless, tense.

2Kicking or legs drawn

up

Legs Score:

Activity 0Lying quietly, normal position moves easily

1Squirming, shifting back

and forth, tense

2Arched, rigid or jerking

ActivityScore:

Cry 0 No cry (awake or

asleep)

1Moans or whimpers;occasional complaint

2Crying steadily, screams

or sobs, frequentcomplaints

Cry Score:

Consolability 0Content, relaxed

1Reassured by occasionaltouching, hugging, being

talked to, distractible

2Difficult to console or

comfort

ConsolabilityScore:

Pain Assessment Total (0-10) /10

FLACC: Merkel et al. (2009) The FLACC behavioral scale for scoring postoperative pain in young children.Pediatric Nursing.

The FLACC scale was designed for use with infants and children who could notcommunicate their pain using the FACES scale. As with the Non-Verbal PainScale, five categories of behavior are assessed. These include: Face, Legs,Activity, Cry And Consolability or “FLACC” scale. The typical age range for using this scale is the infant and the child up to developmental age of 2-3. At 2-3years of age, the FACES scale may be more appropriate.

The FLACC scale is used in the clinics that see infants and small children as wellas several hospital areas such as the ED.

Scoring the FLACC: Observe behaviors and assess which description best describes patient behaviors for each column.

Rate the patient for each of the five items. Total the score for the FLACC Scale (0-10). “0” indicates “no pain” and “10” indicates “very severe uncontrolled pain”.

2. Completing the pain assessment: In addition to the assessment of pain level/intensity, it may beimportant to include the following descriptors:a. Description/quality of pain (burning, throbbing, dull etc.)

The words a patient uses to describe their pain can be very




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useful in determining what the appropriate treatmentshould be. For example, a patient who describes burning

pain might best be treated with agents effective inneuropathic or nerve pain such as gabapentin.

b. Location/radiation. A patient may have more than one pain site and each site should be assessed separately. It is

also important to determine if the pain radiates in any particular pattern as this can be useful in diagnosis andtreatment. An example of radiating pain is that of chest

pain which radiates down the left arm or jaw.c. Aggravating and relieving factors (What makes it better

and what makes it worse?). Information on what makesthe pain improve or get worse can be useful in diagnosisas well as creating a plan on how to decrease painfulevents and enhance pain relief.

d. Duration of pain (how long has the patient experienced the pain). Pain may be of short duration or acute or of long

duration or chronic. Pain is considered chronic when it is present for six months or more.

e. Effectiveness of previous treatments for painmanagement. Information on what has been useful in the

past to managed pain can be very helpful in creating a plan for current pain management.

3. Additional Assessments to Consider a. Assess the effect pain has on other factors such as sleep,

appetite, mood, overall activity, functioning and ADLs. b. Determine patient’s perception of the pain experience by

asking “How would we know that you are in pain?” c. Assess the effectiveness of medication interventions by

asking the patient: 1) What medications and doses have been helpful in

the past? 2) Once medicated, how long does it take before the

medication works? 3) When the medication does work, how low does the

pain score go? 4) How long does the medication last? 5) Are there any side effects from the pain medication

(i.e., nausea, drowsiness, constipation, etc.)?

This information helps to select a medication regimentailored to the individual needs of the patient.

d. When appropriate, establish and use a target level. 1) The establishment of a target level may be useful in

assessing the chronic pain.




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2) The target level is a number from 0-10 that the patient states is a goal toward which painmanagement is directed.

3) As pain is decreased to this level, a new targetshould be developed to provide another mutuallyagreed upon goal for pain control.

4) The establishment of a target level is not requiredfor all patients. It is left to the discretion of the RNto determine if establishment of a target level willenhance the assessment and assist in themanagement of the patient’s pain.

B. Ambulatory Care

In the ambulatory (clinic) setting, patients are asked about pain related tothe current ambulatory (clinic) appointment. The assessment of pain levelis not applicable in the following ambulatory settings: 1. Psychiatry – Pain assessment is referred back to primary care physician.2. Sleep – Pain assessment is referred back to the primary care

physician.3. Pain Management – Pain is assessed using a comprehensive pain

and functional assessment approach.

C. Non-English Speaking Patients

A thorough pain assessment should be done using an interpreter as soon as possible. In the meantime, five language tools are available to begin theassessment: Spanish, Russian, Tagalog, Chinese and German. Each card

has a Wong-Baker Faces Scale and a body diagram that may assist inevaluating pain.

The templates for these language cards may be accessed on the Share Drivefor Windows: NurseMgr Private Pain Tools Pain Assessment Tools.Select the appropriate language.

D. Reassessment

1. With routine vital signs, ask the patient if he or she has pain (level,location, description and intervention)

2. Frequency of reassessments will also be influenced by a variety of other factors. For example:a. Pain-producing procedures (e.g., bone marrow aspiration,

wound debridement, etc.) b. Functional activities (e.g., ambulation, coughing, deep

breathing, incentive spirometry)c. A change in patient status (e.g., chest pain, altered vital

signs, fever). Sudden, unexpected pain may indicate anacute change in patient's condition that requires immediateevaluation by a physician.




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3. If pain is present and requires intervention, reassess effectiveness of the intervention within 1-hour (level, location, description andintervention). Increase the frequency of assessment for changinginterventions or inadequate pain control. If the patient is sleepingafter an intervention, reassessment may be performed after the

patient wakes.

4. As the patient's pain level is reassessed, patterns of increased painintensity may become apparent. When possible, modify activities,

premedicate the patient, adjust medication doses or routes, and/or teach nonpharmacologic approaches to optimize pain management.

E. Intervention and Management

1. Based on the results of the assessment, collaborate with the healthcare team and the patient to develop and implement a plan of painmanagement (Appendices B and C).a. Pain Scale Ranges:

1) It may be helpful to have specific pain levelsindicated in the order. This indicates appropriatemedication or intervention based on a patient’s painlevel. One method of doing this is to establish arange for the 0-10 scale. For example:

0 = no pain

1-3 = mild pain

4-6 = moderate pain

7-10 = severe pain

2) The MD order might state: “Vicodin 2 tabs POevery 6 hours PRN moderate pain." The nursewould implement this order when the patient rateshis pain as a “4”, “5” or “6”.

b. Situations when pain is difficult to assess:1) When in doubt about a patient’s pain experience or

whether a particular behavior indicates pain, and if there are reasons to suspect pain, a trial of

analgesics can be both diagnostic for pain as well astherapeutic2) When a patient is unable to communicate about

pain and must undergo a procedure that would be painful for others, the patient should be treated presumptively for pain. (American Pain Society,Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 2008)




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2. Review orders for pain medication.a. If there are no orders for pain medication, review with the

physician the patient's possible pain medication needsand/or the intent to avoid pain medication administrationuntil the pain is fully evaluated by the physician.

b. For patients with PRN orders for pain medication,

consider scheduling and administering the medication onan around-the-clock basis. This is especially beneficialfor patients who have acute pain from surgery or trauma.

3. Communicate the plan for pain management to the patient.4. Educate the patient/family/significant other about pain management

including: assessment, planning, intervention and evaluation.5. The medication plan should include the use of pain medication in

advance of a painful event (such as chest tube insertion) or physicalactivity (such as ambulation or physical therapy). It is easier to

prevent pain than to bring it under control after an event has taken place.

6. Pharmacologic Managementa. Pharmacologic interventions continue to be a mainstay of

pain management. Drug options include non-steroidalanti-inflammatory drugs (NSAIDs), opiates (narcotics),anesthetics, antidepressants, and anxiolytics (antianxietymedication). Optimum pain management requires athorough investigation of the type, location, intensity andduration of pain. Every management plan must beindividualized and modified over time. The following areresources for pharmacologic management of pain (accessthe Analgesic Reference Card on the SHC Intranet under

“Stanford Hospitals and Clinics Intranet -> Departments -> Pharmacy -> P&T Approved Guidelines & ReferenceCards” . (Appendix E)1) Recommended pain management strategies

(Appendix C)2) Analgesic dosing guidelines (refer to Analgesic

Reference Card-Appendix E)3) Dosing guidelines for NSAIDs (refer to Analgesic

Reference Card-Appendix E) b. Prior to and following painful procedures and immediately

postoperatively, ensure that orders for adequate pain

medications are available.c. Side effects may occur and require intervention.Management of side effects may include: direct treatmentof the effect; alteration of the drug dose, route or interval;or a change of drug. The following are resources for management of analgesic side effects:1) Management of opiate side effects (refer to

Analgesic Reference Card).2) Possible side effects of analgesics and adjuvants.

7. Nonpharmacologic Management




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a. Relaxation Techniques1) Imagery, distraction (music, TV, conversation)2) Relaxation tapes (available through the hospital

chaplains)3)4)

Music CDs (available through Guest Services)Aroma therapy (available in Comfort Cart)

b. Cutaneous Techniques1) Application of heat or cold (see See Nursing:

Patient Care Manual: “Compresses: Cold, Moist,”“Compresses, Warm, Moist” a nd “Heating Pad”)

2) Massage (call Guest Services to schedule )3) TENS (Transcutaneous Electrical Nerve

Stimulation) unit. (MD order needed; callRehabilitation Therapy Department to obtain TENSunit.) NOTE: TENS are only available as a “trial”for 1-2 hours. If effective, the patient must obtain

the TENS unit from an outside source after discharge.

c. Positioning/repositioning8. When an effective pain management plan has been established, the

health care team makes appropriate adjustments in medications or pain management techniques to allow for transition to dischargeand continuing care at home or other facility. This planincorporates the patient and/or family/significant other in themanagement of pain and of the side effects of the medications usedto treat pain.

F. Patient Education

1. Instruct patient in the use of the pain rating scale (0-10 or Facesrating scale)

2. Instruct patient/family and/or significant others:a. That untreated pain can be harmful and pain management

is important and possible. b. About pain, treatment and what to expect from treatment.c. About medications for pain, the drug, the dose, the

frequency and potential side effects.d. In the use of a target level when appropriate.

e. To report unrelieved pain or new onset pain.3. Provide education materials (for example: Patient Information onPain Management Brochure, Micromedex Care Notes on Paintopics).




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III. DOCUMENTATION

A. Document initial assessment on the Nursing Admission Assessment or theappropriate Docflowsheet (level, location, description and intervention) for eachsite pain site. If the patient does not have pain, document the pain level as a “0”.

B. Document reassessment, interventions and responses to interventions on the

appropriate Docflowsheet. (level, location, description and intervention) for each pain site. If the patient does not have pain, document the pain level as a “0”.

C. Document medications administered on the Medication Administration Record(MAR).

References:

1. Analgesic Reference Card, Stanford Hospital and Clinics, April 2010. 2. National Guideline Clearinghouse: Assessment and Management of Pain (2007).

http://www.guideline.gov/summary/summary.aspx?doc_id=115073. American Pain Society, http://www.ampainsoc.org/pub/cp_guidelines.htm. American

Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain 6th ed, 2008.

Appendices:

Appendix A: Pain Management PhilosophyAppendix B: Overview of Types of Pain and Management StrategiesAppendix C: Acute Pain Management: Pain Treatment Flow ChartAppendix D: Possible Side Effects of Analgesics and AdjuvantsAppendix E: Analgesic Reference Card

Revised by: Leitha Sangermano, PCS Clinical Practice Coordinator, Martha Berrier, PCM,D1 CCU/CSU and Tracey Mallick, RN, NP, Pain Management

Reviewed by: Dana Radman, Manager, Pharmacy Clinical Effectiveness, 9/12Approved by: Patient Care Procedure Committee, 9/12

Pharmacy and Therapeutics Committee, 10/12 Nancy Lee, Vice President of Patient Care Services, Chief Nursing Officer, 9/12

Original date: 5/97Reviewed date:Revised date: 3/00, 1/01, 10/03, 7/06, 12/09, 9/12W:\NurseMgr\Private\Sangermano, Leitha\P&P\PCM\Pain Management Protocol 9-12.doc

This document is intended for use by staff of Stanford Hospital & Clinics. No representations or warranties are made for outside use. Not for outside reproduction or publication without permission.

Direct inquiries to: PCS Clinical Practice Coordinator 650-723-8301Stanford Hospital & ClinicsStanford, California 94305

http://www.guideline.gov/summary/summary.aspx?doc_id=11507

http://www.ampainsoc.org/pub/cp_guidelines.htm

http://www.ampainsoc.org/pub/cp_guidelines.htm

http://www.guideline.gov/summary/summary.aspx?doc_id=11507




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Appendix A

PAIN MANAGEMENT PHILOSOPHY

(For Complete citation, see SHC Administrative Manual: Pain Management Philosophy)

A. Patient Rights

As a patient at this hospital, you can expect:

information about pain and pain relief measures a concerned staff committed to pain prevention and management health professionals who respond quickly to reports of pain that your reports of pain will be believed state of the art pain management

B. Patient Responsibilities

As a patient at this hospital, we expect that you will:

ask your doctor or nurse what to expect regarding pain and pain management discuss pain relief options with your doctors and nurses work with your doctor and nurse to develop a pain management plan ask for pain relief when pain first begins help your doctor and nurse assess your pain tell your doctor or nurse if your pain is not relieved tell your doctor or nurse about any worries you may have about taking pain

medication.

C . When appropriate, family and/or significant others will be included in the painmanagement plan.




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ASSESS

-- Initiate analgesia or adjust analgesic(dose, interval, route)-- Initiate adjuvants (pharmacologic andnonpharmacologic

Acute onset or acute increasedpain which is unexplained

Yes

No Yes

Reassess with vital signs after interventions for pain, painful

procedures and activities, and whenthe patient complains of pain

Further medicalevaluation and work-up

is indicated

-- Treat cause

-- Treat pain symptoms

REASSESS

Did interventions producesatisfactory pain relief?

-- Optimize dose, route,assessment interval-- Use/adjust adjuvants and non-pharmacologic measures

Yes If inadequate analgesia ,change drug, dosing interval,route, modality and/or addadjuvants (pharmacologic or non-pharmacologic)If unacceptable sideeffects , treat side effects

No

REASSESS

Did interventions producesatisfactory pain relief?

Discharge Planning

Yes -- Transition painmanagement interventions tohome care environment-- Work within patient'sresources and constraints

Appendix

ACUTE PAIN MANAGEMENT: PAIN TREATMENT FLOW CHART

-- Termination of operative anesthesia/analgesia-- Onset of pain-- Increase of baseline pain

If dose range, determine dose to beadministered based on factors such as:-- Patient's self-report of the magnitude of the pain-- Patient's account of what has worked inthe past to manage the pain-- How well this particular medication and dose has worked previously

-- Length of time since previous dose wasadministered -- Age-- Weight -- Current condition, such as the type and/or magnitude of surgery performed -- Plan of care (e.g., anticipation of a painful

planned treatment such as a dressing change or post-op ambulation)-- Concurrent medications

If the lower dose in the range is chosenand does not have the desired effect,the nurse may administer another doseto the maximum of the ordered rangewithin one hour for parenteral medications, and within 2 hours for oral medications.The administration interval (every 4hours, every 6 hours, etc.) is calculated from the time the second dose isadministered.




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Appendix D

POSSIBLE SIDE EFFECTS OF ANALGESICS AND ADJUVANTS

DRUG CATEGORY SIDE EFFECTS

1. Opiates (narcotics)

Route: PO, Rectal, IM, IV, IT (epidural).The more invasive the route, the stronger the possible side effect reaction.

Nausea/vomitingPruitusSedationConstipationRespiratory depressionConfusion

2. Anesthetics:(a) Epidural

Marcaine

(b) Intrathecal

- One time OR dosing v/s continuousIT infusion (local anesthetic, baclofen,clonidine, ziconitide, opiate – as describedabove)

(c) Systemic (IV)

Lidocaine

Ketamine (IV or PO)

Numbness/weaknessHypotensionInability to void

Same as with epidural. Also confusion,delirium.

Tinnitus (ringing in ears)Circumoral numbnessConfusionDiplopia (double vision)CNS excitation (tremors and seizures)Delirium

3. NSAIDs (non-steroidal anti-inflammatory drugs)

Route: PO, Rectal, IM, IV.

GI bleed/ulcer bleeding potentialrenal blood flow

4. Anti-anxiety Drugs (anxiolytics)

Examples: Ativan, Lorazapam, Diazepam,Midazolam

SedationSleep disturbancesParadoxical reactions

5. Antidepressants

Examples: TCA’s (des piramine,amitriptyline). SNRI’s (Cymbalta)

6. Other

Clondine (Oral, Transdermal, IT)

Muscle relaxants (baclofen given po or IT,flexeril, zanaflex)

Sedation/excitationDizzinessInsomnia

Urinary retentionDry mouth

Hypotension, rebound hypertension withabrupt cessation if IT infusion.

Sedation, severe systemic response if IT baclofen is abruptly discontinued.




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Appendix EFor reference only




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