PAIN
Management
San Diego Service Area
San Diego
The PAIN Problem
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Most common reason for medical appointments in the U.S.
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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
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how long it will last
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Have pain prevented & controlled
when it occurs
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Be asked acceptable level of pain
Rate pain using appropriate scales 
Develop a pain plan with the
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doctor & care delivery staff
Know the risks, benefits & side
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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
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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)
PAIN Management
Competency Post Test
GREAT!
San Diego
EXTRAORDINARY!
FEEL GOOD!
EXCELLENT!
NEVER BETTER!
San Diego
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. 0-10 Numeric
C. N-PASS
D. None of the above
San Diego
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.
A. True
B. False
5. Once a pain control measure is given, further assessment is not needed.
A. True
B. False
San Diego
Pain Management Competency Post Test
6. Which of the following are validated and approved pain scales? Select all
that apply.
A. 0-10 Numeric
B. Wong-Baker Faces
C. FLACC
D. 0-5 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
San Diego
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
San Diego
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.
A. True
B. False
San Diego
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
San Diego
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
San Diego
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
San Diego
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.”