PAIN Management San Diego Service Area San Diego 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. Our goal is to manage the patient’s pain effectively! Patient’s Rights San Diego for changes in treatments if pain Be believed when pain is reported Ask persists Have pain relief Receive pain medication in a timely Be told how much pain to expect & manner 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 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 nonpharmacological interventions Pain, the Fifth Vital Sign San Diego 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 Barriers to Pain Management San Diego 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) San Diego 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 San Diego Numeric Pain Scale For use in adults, adolescents & cognitively-appropriate pediatric patients No Pain 0 No Pain 1 Distressing Pain 2 3 4 5 6 WORST Pain 7 8 9 Mild Pain Moderate Pain Severe Pain [1,2,3] [4,5,6] [7,8,9,10] May use FACES Scale if patient has difficulty with use of numeric scale 10 Unbearable Pain San Diego Numeric Pain Scale - Spanish For use in adults, adolescents & cognitively-appropriate pediatric patients No me Duele 0 1 El Dolor me Mortifica 2 3 4 5 No Aguanto el Dolor 6 Dolor Leve Dolor Moderado [1,2,3] [4,5,6] 7 May use FACES Scale if patient has difficulty with use of numeric scale 8 9 Dolor Furte [7,8,9,10] 10 Wong-Baker FACES Pain Rating Scale San Diego English Spanish San Diego 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) FLACC Pain Rating Scale San Diego For infants to 7 years of age Category Scoring 0 1 2 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 Activity Lying quietly, normal Cry Kicking or legs drawn up Arched, rigid or jerking position, moves easily Squirming, shifting back & forth, tense No cry (awake or asleep) occasional complaint Moans or whimpers; sobs; frequent complaint Crying steadily, screams, Consolabilty Content, relaxed Reassured by occasional Difficult to console or touching, hugging, or being comfort talked to, distractible N-PASS Neonatal Pain, Agitation, & Sedation Scale Premature Pain Assessment + 3 if < 28 weeks gestation/corrected age + 2 if 28-31 weeks gestation/corrected age + 1 if 32-35 weeks gestation/corrected age San Diego Non-verbal Pain Scale San Diego Not validated but useful tool for pt’s who cannot communicate Procedure 1. Assess pt. according to each 5 observation categories 2. Assign points according to criteria 3. Total the points 4. Apply point total to the 0-10 numeric scale 5. Reassess frequently to compare scores & determine changes in pain level Non-verbal Pain Scale San Diego 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 RASS Sedation Scale San Diego Richmond Agitation Sedation Scale used in Health Connect Use PASS Score of Procedural Sedation Score Term +4 Combative +3 +2 +1 0 -1 Description Overly combative, violent, immediate danger to staff Very Agitated Pulls or removes tubes, catheters; aggressive Agitated Frequent non-purposeful movement, fights ventilator Restless Anxious, movements not aggressive Alert & Calm Drowsy Not fully alert, has sustained awakening -2 Light Sedation -3 Moderate Sedation -4 Deep Sedation -5 Unarousable (eye-opening/contact) to voice >10secs Briefly awakens w/eye contact to voice <10sec Movement or eye opening to voice (no eye contact) No response to voice, movement or eye opening to physical stimulation No response to voice or physical stimulation Observe Pt. 1. Alert, restless, agitated (0 - +4) 2. Not alert, state pt’s name, ask to “open eyes & look at me” a. Pt. awakens w/eyes open & contact (-1) b. Pt. awakens w/eyes open & contact unsustained (-2) c. Pt. has movement in response to voice but not eye contact (-3) 3. No response to verbal, physically stimulate pt. a. Pt. has movement (-4) b. Pt. has no response (-5) San Diego Pain Assessment GREAT! EXTRAORDINARY! FEEL GOOD! EXCELLENT! NEVER BETTER!