PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
TITLE
PAIN MANAGEMENT GUIDELINE
REFERENCE
NUMBER
TO BE CONFIRMED AFTER RATIFICATION
MANAGER
RESPONSIBLE
Rosy Barnes - Acute Pain Clinical Nurse Specialist
DATE ISSUED
14 June 2012
REVIEW DATE
June 2014
Equality Impact
Assessment has been
applied to this policy
Rosy Barnes - Acute Pain Clinical Nurse Specialist
AUTHOR
RATIFIED BY
Rosy Barnes - Acute Pain Clinical Nurse Specialist
Nursing and Midwifery Committee
AMENDMENTS RECORD
DATE
PAGE(S)
COMMENTS
CONTENTS LIST:
1.
2.
3.
4.
5.
6.
7.
8.
Introduction
Status
Purpose
Scope/Audience
Definitions
Clinical Process
Supporting Evidence
Training
APPENDICES:
APPENDIX 1: Use of the Abbey Pain Scale
APPENDIX 2: Paediatric Pain Tools FLACC and Wong and Baker
APPENDIX 3: Inpatient referrals to the Chronic Pain Service
APPENDIX 4: Palliative Care referral tool
APPENDIX 5: Basic analgesia competency
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
APPROVED BY
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
1. Introduction/Background
Most patients experience pain or discomfort. The presence of pain causes distress and anxiety for patients. Managing
patient’s pain is vitally important and Portsmouth Hospital NHS Trust considers that pain should be monitored and
managed as the 5th vital sign. PHT believes that it is the right of all patients to receive adequate and appropriate pain
relief.
2. Status
This is a corporate clinical guideline
3. Purpose
The relief of pain and discomfort should be a fundamental objective of any health service. Accurate assessment of
patient’s pain and appropriate intervention reduces the risk of pain limiting an individual’s daily function. Good
management reduces post-op complications and facilitates early or timely discharge.
This guideline describes the standards of care to be provided to Portsmouth Hospitals NHS Trust patients
experiencing pain or discomfort.
4. Scope / Audience
This guideline applies to all staff involved in the direct care of patients. It is intended to be used in conjunction with
specialized guidelines provided by The Acute, Chronic Pain and End of Life and Palliative care services. It is used for
guidance only and is not ‘set in stone’.
5. Definitions
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 (IASP)
Acute pain
Pain associated with acute injury or disease
Chronic Pain
Pain that has persisted for longer then 3 months or past the expected time of healing following injury or
disease.
Palliative Care
Palliative care is the active total care of patients and their families, usually when their disease is no longer
responsive to potentially curative treatment, although it may be applicable earlier in the illness.
Pain Management
Pain management is a multidisciplinary approach to the assessment and treatment of patients with pain.
(Pain Management Services: The Royal College of Anaesthetists and the Pain Society)
Health Care Professionals
Registered Practitioners Band 5 – 9
Non-registered Practitioners
Practitioners Band 2 - 4
Wessex Pain Score
0 = no pain at rest or on movement
1 = no pain at rest, mild pain on movement
2 = moderate pain at rest or on movement
3 = severe pain at rest
6. Clinical Process
The provision of pain management for patients in PHT is underpinned by the following principles:
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Pain management is the responsibility of all members of the multidisciplinary team.
Pain will be anticipated wherever possible and appropriate prophylactic interventions applied e.g. for procedures.
All patients will receive an initial and ongoing pain assessment as part of their treatment and care.
All patients with pain will have evidence of pain management and a plan recorded in their notes.
Pain presence will be recorded as the 5th vital sign.
Pain intensity will be measured using the Wessex Pain Score (Verbal rating Score) and recorded on Vital Pac or the
patients observation chart/record of care. (However some departments may use the verbal rating 1-10 score).This
pain scale may not be appropriate for all patients, such as those with learning disabilities and/or dementia. In these
cases the Abbey Pain Scale may be found to be more appropriate. (Appendix1). The FLACC and Wong and Baker
Pain Scale are used for paediatrics. (Appendix 2)
Patient with a pain intensity of 2 or 3 will trigger pain relief intervention.
Pain will be reassessed and documented as part of each set of vital signs and:
Within an appropriate time after pain relief intervention (i.e. when pain relief action is anticipated)
After any procedure or activity anticipated being painful
At intervals determined by ongoing chronic pain issues
With each new report of pain
Pain assessment, intervention and effectiveness will be documented. Ineffective pain relief will be documented and
acted upon.
Staff should be appropriately trained in the effective management of pain. (See training section 9)
6.1 Clinical Practice Guideline
All health care professionals are responsible for:
 Assessment
 Planning
 Implementation of action plans
 Evaluation
 Clear documentation
 Liaison with all members of the multi-professional team
All non-registered Practitioners
 Assess the patient using the Wessex or other appropriate pain score
 Report and document
 Liaise with all members of the multi-professional team
Doctors, Dentists and Non medical Prescribers are responsible for:
 The prescribing of appropriate medication and regular review
 Provision of clear unambiguous prescription sheets (refer to Medicines Management Policy for completing
prescription sheet)
All Health Care Professionals have a role in the
 Initial and ongoing assessment of pain
 Provision of non-pharmacological pain relief intervention
 Administration of prescribed medication in a timely and non-judgemental fashion (HCSWs who have
successfully completed the competency assessment for administration of medicines)
 Monitoring effect of medication
 Ensuring non registered practitioner given delegated tasks are competent to undertake said task
 Provisions of therapies and aids to support pain relief
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Pharmacists are responsible for ensuring correct prescribing practice is adhered to and drugs prescribed are
available within The District Formulary.
For specialized areas of pain management, Portsmouth Hospitals NHS Trust provides an Acute Pain service, a
Chronic Pain Service, End of Life and Palliative Care Service.
The Acute Pain Team provides an inpatient service to the following areas:
Surgical Unit, (including Head and Neck), Orthopaedic Unit, Renal/Urology and Gynaecology Unit Paediatrics and
Maternity. Referrals may be made by phone on extension 5890 or via bleep 1645/1643 or 1838.
The Department of Pain Medicine, serves patients with chronic pain on an outpatient basis only (Referral documentSee Appendix 3).
The Hospital Specialist Palliative Care Team is a specialist service, working within the hospital. They work with those
patients who have a life limiting illness and are experiencing difficulties (such as pain management) at any stage.
(See referral form – Appendix 4) Guidance can also be obtained from the green ‘Palliative Care Handbook’, which
should be available in all clinical areas. Contact details are extension 6132 0900-1700 Monday – Friday and out of
hours The Rowans Hospice inpatient unit on 023 92 250001.
The End of Life Team can be contacted on Bleep 1384 or mob - 07818078876
Pain should be assessed, documented and responded to regularly, and a record made of the patient’s response to
treatment.
6.2 Process
Pain can be managed by a variety of methods comprising pharmacological and non-pharmacological.
Non-Pharmacological Interventions
Non-pharmacological can be classified as cognitive behavioural approaches (education, relaxation, distraction) and
physical agents (heat/cold, positioning, transcutaneous electrical nerve stimulation – TENS)
Non-pharmacological methods must be considered to be an important element of pain relief. These include simple
repositioning or ambulating when possible, application of hot or cold packs, distraction or relaxation techniques
including deep breathing. Consideration should be given to referring to Physiotherapy.
Approach
Cognitive Behavioural
Approach
Effective in reducing mild
to moderate pain and as
an adjunct to analgesic
drugs for severe pain.
Intervention
Jaw and Progressive
muscle relaxation
Use when patients express an interest in relaxation. Requires
2-3 minutes of staff time for instruction.
Education/Instruction
Provision of patient information leaflets, thorough, clear and
concise explanations
Simple imagery/Music
Cutaneous
Ice/Heat pads
Effective in treating mild to
TENS and acupuncture
Should be applied with caution following assessment of the
patient to ensure that there are no contradictions. Heat
stimulates the thermoreceptors in the skin and deeper
tissues that can reduce pain by closing the gating system in
the spinal cord (Gate –Control theory).
Cold will cause vasoconstriction and reduce swelling and
should be applied (not directly to the skin) using ice packs or
compresses.
Needs specialized equipment and personnel to initiate
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
moderate pain and as an
adjunct to analgesic drugs.
Positioning
treatment
Elevation of limb
Pharmacological Intervention
Pharmacological methods range from simple oral medication to complex interventions including epidural infusions
and patient controlled analgesia.
The WHO analgesic ladder is a recognised systematic approach to the majority of pain problems. It is a statement of
principles that can be used with a varying degree of interpretation, rather than a rigid framework.
Regular analgesia should be given in timed intervals and on demand (PRN) analgesia should be given promptly when
requested.
Paediatrics: same principles, but drug doses depend on weight. (Refer to specific paediatric guidelines that can be
found on the hospital intranet)
The following examples refer to patients who have acute pain or are experiencing an acute episode of their chronic
pain. In certain palliative care situations the green ‘Palliative Care Handbook’ should be used for guidance on
developing a treatment plan.
Below is a modified analgesic ladder for adults used in Portsmouth Hospitals NHS Trust for acute or an acute
exacerbation of chronic pain.
Chronic Pain, Non-Malignant Pain, Cancer Pain
Step 1
Step 2
(Non-opioid
(Weak opioids)
analgesics/NSAIDS)
Mild Pain (1)

Paracetamol
+/NSAID

Non-pharmacological
interventions
Moderate Pain (2)

Co-codamol (30/500)
+/NSAID

If unresponsive add
Oral or Parenteral Opioids

Non-pharmacological
interventions
Step 3
(Strong opioids, oral administration, transdermal
patch, intravenous, subcutaneous, specialist
local anaesthetic interventions)
Severe Pain (3)

Morphine
10-15mgs IM regularly or
PCA or syringe driver if appropriate

+ NSAID
+Paracetamol
+ Adjuncts

Epidural, Neurolytic block therapy or spinal
stimulation
Acute Pain, Chronic Pain without control, acute crisis of Chronic Pain
Paracetamol
A maximum of 4 grams per day (8  500 mg tablets) Ensure patient is not already on a drug that contains
Paracetamol (intravenous Paracetamol is available only for those patients unable to tolerate oral medication)
Consider smaller doses if the patient weighs under 50kg for example 15mg/kg for under 50kg would be an
appropriate dose.
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Non Steroidal Anti-Inflammatory Drugs
Ibuprofen
(e.g. 400mg QDS)
Diclofenac
max 150mg per day (50mg TDS Oral/or PR)
Use with caution. May cause GI upset/ulceration, renal failure and impaired clotting. May exacerbate symptoms in
sensitive asthmatics (10%)
Opioids
Codydramol
(paracetamol/dihydrocodeine)
A maximum of 8 tablets per day
Do not administer with Paracetamol
Cocodamol
(Paracetamol/codeine)
A maximum of 8 tablets per day. Do not administer with Paracetamol. (2 strengths
30/500 and 8/500. The 8/500 is no more effective than Paracetamol but consider its
use in the elderly, frail patient)
Dihydrocodeine
30mg every 4-6 hours oral or IM
Morphine Sulphate
(Oral morphine solution)
The bioavailability via the oral route is greatly decreased and the dosage when
converting from IV/IM must be increased by a factor of 3
Morphine IV (rarely IM)
10-15 mg 2 hourly. Patient Controlled Analgesia (see PHNHST protocols http://pharmweb/publications/guidelines/Opioids%20IV%20in%20Postoperative%20Pain%20Management.pdf. IV bolus 2mg every 5 min. (10mg in 10ml
N/Saline).
Morphine SC
2.5 – 5 mg bolus (if opioid naive) Titrate to pain score and side effects
Pethidine
Morphine is preferred drug of choice
Fentanyl/Alfentanyl
May be appropriate in patients with poor renal function for PCA’s or syringe drivers
Diamorphine
IV or SC
Oxycodone
For use in patients with intolerable hallucinogenic side effects to morphine.
Oxycontin® 10mg bd. Oxynorm® – 5mg 4 hourly oral prn for breakthrough pain.
These are initial doses -that should be titrated to pain score and side effects
Tramadol
Produces analgesia by an opioid effect and an enhancement of serotonergic and
adrenergic pathways. It is contraindicated in patients on warfarin or with epilepsy
and should be used with caution in patients on SSRI’s, with poor renal function or
low blood sodium
Tapentadol
Tapentadol is a new molecular entity that is structurally similar to tramadol. It has
opioid and nonopioid activity in a single compound. Its general potency is
somewhere between tramadol and morphine in effectiveness
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
This is only a limited guide to some analgesics that are available. Other adjunct drugs (ie tricyclic antidepressants,
anticonvulsants) should also be considered.
Entonox should also be considered as a stand alone or adjunct analgesic. (See Entonox policy http://www.porthosp.nhs.uk/Clinical-Policies/Entonox%20management.doc.
Other supporting guidelines are:
Naloxone for the treatment of opioid overdose in adults –
http://pharmweb/publications/guidelines/Naloxone%20for%20the%20treatment%20of%20opioid%20overdose%20in%
20adults.pdf
Controlled drugs management –
http://www.porthosp.nhs.uk/Clinical-Policies/Controlled%20drugs%20management.doc
Specialist local anaesthetic interventions
These include continuous or single shot epidurals, regional blocks or other local anaesthetic interventions. They may
be performed by the anaesthetist as part of a patient’s anaesthetic and post-operative management or in an
outpatient clinic such as the Chronic Pain Clinic.
http://pharmweb/publications/guidelines/Local%20Anaesthetic%20Infusions%20-%20Excluding%20Epidurals.pdf
6.3 Patients with Special Needs.
Paediatrics/Neonates
There are several categories of patients with special needs in pain management.
Paediatrics and neonates, differ from adults in their response to drugs. Special care is needed in the neonatal period
due to immature metabolic and excretory pathways (first 30 days of life) . Doses in this patient group invariably
require calculations which should always be checked. Where possible, medicines for children should be prescribed
within the terms of the product licence. However, many analgesics are not specifically licensed for paediatric use (See
unlicensed medicines policy -.
http://www.porthosp.nhs.uk/Clinical-Policies/Unlicensed Medicines use.doc
Non-pharmacological interventions can be used with more success than perhaps in adults. Whenever possible,
painful intramuscular injections should be avoided in children. The management of acute pain in children has been
agreed at a multidisciplinary level (2005) under the umbrella of the Trust's Paediatric Clinical Governance Group
which aims to ensure the highest standards of care for children undergoing surgery in Portsmouth and the
recommendations and guidelines are available on the hospital intranet http://pharmweb/publications/guidelines/Analgesia%20Following%20Elective%20or%20Emergency%20Surgery%20i
n%20Children.pdf.
Other supporting guidelines are:The use of intranasal diamorphine in childrenhttp://pharmweb/publications/guidelines/Intranasal%20Diamorphine%20Administration%20to%20Children%20in%20t
he%20Emergency%20Department.pdf
The use of sucrose in neonates –
http://pharmweb/publications/guidelines/Sucrose%20as%20Pain%20Relief%20and%20Pain%20Management%20in
%20Neonates.pdf
Older patients.
The physiological, psychological and cultural changes associated with ageing affect the perception and reporting of
pain by elderly patients. Older people are at particular risk of under or over treatment, increased sensitivity to the
analgesic and side-effects of opioids and gastric and renal toxicity from Non-steroidal Anti-Inflammatory Drugs
(NSAIDs) because of reduction in renal clearance and other pharmacokinetic changes associated with getting older.
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Because elderly patients often receive multiple drugs for their multiple diseases this greatly increases the risk of drug
interactions as well as adverse reactions and may affect compliance.
If the patient has dementia the use of The Abbey Pain Scale may be more appropriate then the Wessex Pain Scale.
Other supporting guidelines are:http://www.porthosp.nhs.uk/ClinicalGuidelines/Delirium%20diagnosis%20and%20management%20in%20Older%20People%20in%20a%20general%20h
ospital%20setting.doc
Opioid tolerant patients/substance misuse disorder
Opioid tolerant patients are those with chronic cancer or non-cancer pain being treated with opioids or patients with a
substance misuse disorder either using illicit opioids or an opioid maintenance treatment program. These patients can
be complex to effectively manage their pain due to the presence of the drug (or drugs) of abuse, medications used to
assist with drug withdrawal (ie buprenorphine) and the presence of tolerance, physical dependence and the risk of
withdrawal. Opioid requirements are usually significantly higher in these patients.
For the patient on prescription opioids their usual regimens should be maintained where possible or appropriate
substitutions made.
Effective analgesia may be required for longer periods and often requires a significant deviation from standard
treatment protocols in the patient with a substance misuse disorder. Inappropriate behaviours can be prevented by
the development of a respectful, honest and open approach to communication. If the patient is on a methadone
program it should be continued as usual at the same dose and pain relief given for admission pain. Advice should be
sought from the local substance misuse service where applicable.
Palliative Care
Accurate diagnosis of the cause(s) of pain is necessary for a rational approach to therapy. It must not be assumed
that pain has been caused by the primary diagnosis; debility, previous treatment and unrelated causes must also be
considered. All pains have significant psychological component, and fear, anxiety and depression will all lower the
pain threshold. Remember also the likely effects of life changes associated with terminal disease including loss of
financial security, altered body image and compromised sexual function.
http://www.porthosp.nhs.uk/ClinicalGuidelines/Continuous%20Subcutaneous%20Infusion%20guideline%20Pan%20Trust.doc
http://pharmweb/publications/guidelines/Medicines%20used%20in%20syringe%20drivers%20for%20palliative%20car
e.pdf
End of Life/Liverpool Care Pathway
The LCP generic document guides and enables healthcare professionals to focus on care in the last hours or days of
life. This provides high quality care tailored to the patient’s individual needs, when their death is expected. The
recognition and diagnosis of dying is always complex, irrespective of previous diagnosis or history. Uncertainty is an
integral part of dying. There are occasions when a patient who is thought to be dying lives longer than expected and
vice versa. Seek a second opinion or specialist palliative care support as needed.
http://pht/Departments/EndOfLifeCare/The%20Liverpool%20Care%20Pathway/Algorithms%20updated%20for%2012t
h%20edition%20approved%20by%20education%20committee.doc
Neuropathic Pain
Neuropathic pain develops as a result of damage to, or dysfunction of, the system that normally signals pain. It may
arise from a group of disorders that affect the peripheral and central nervous systems. Common examples include
painful diabetic neuropathy, post-herpetic neuralgia and trigeminal neuralgia. People with neuropathic pain may
experience altered pain sensation, areas of numbness or burning, and continuous or intermittent evoked or
spontaneous pain. Neuropathic pain is an unpleasant sensory and emotional experience that can have a significant
impact on a person's quality of life.
Neuropathic pain is often difficult to treat, because it is resistant to many medications and/or because of the adverse
effects associated with effective medications. A number of drugs are used to manage neuropathic pain, including
antidepressants, anti-epileptic (anticonvulsant) drugs, opioids and topical treatments such as capsaicin and lidocaine.
Many people require treatment with more than one drug, but the correct choice of drugs, and the optimal sequence
for their use, has been unclear.
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Supporting guidance:
http://pharmweb/publications/guidelines/Peripheral%20Neuropathic%20Pain%20Management%20in%20Adults.pdf
7. Supporting Evidence
Acute Pain Management: Scientific Evidence. 2010. Australian and New Zealand College of Anaesthetists and
Faculty of Pain Medicine. http://www.anzca.edu.au/resources/collegepublications/Acute%20Pain%20Management/books-and-publications/acutepain.pdf
Best practice in the management of epidural analgesia in the hospital setting (2010). British Pain Society.
http://www.britishpainsociety.org/pub_prof_EpiduralAnalgesia2010.pdf
Cancer Pain Management (2010) http://www.britishpainsociety.org/book_cancer_pain.pdf
Commission on the Provision of Surgical Services. Report of the Working Party on Pain After Surgery. London. Royal
College of Surgeons of England and Royal College of Anaesthetists. 1990.
Help the Aged - Pain in Older People: Reflections and Experiences from an older person's perspective (2008).
http://www.britishpainsociety.org/book_pain_in_older_age_ID7826.pdf
International Association for the study of Pain (IASP) www.iasp-pain.org/
Opioids for persistent pain: Good Practice (2010) British Pain Society
http://www.britishpainsociety.org/book_opioid_main.pdf
Pain Management Services. Good Practice. The Royal College of Anaesthetists and The Pain Society. May 2003.
Recommendations for the appropriate use of opioids for persistent non-cancer pain. A consensus statement
prepared on behalf of the pain Society, the Royal College of Anaesthetists, the Royal College of General Practitioners
and the Royal College of Psychiatrists. March 2004.
The Palliative Care Handbook. Advice on clinical management. 7 th edition. The Rowans Hospice. Portsmouth and
Hampshire Specialist Palliative Care Team.
http://pht/Departments/EndOfLifeCare/The%20Green%20Book/PC%20Handbook%207th%20Edition%20Oct%20201
0%20published.pdf
The recognition and assessment of acute pain in Children (2009)
http://www.rcn.org.uk/__data/assets/pdf_file/0004/269185/003542.pdf
The use of drugs beyond licence in palliative care and pain management. A position statement prepared on behalf of
the association for palliative medicine and the British pain Society. November 2005.
http://www.britishpainsociety.org/book_usingdrugs_main.pdf
8. Training
The Acute Pain Service provides training for all staff that work in the areas that are covered by the APS.
This training comprises of compulsory attendance to the internal ‘Acute Pain Study Day’ run by the department and
the completion of the relevant competency packs. To maintain competency a study day should be attended once
every 3 years.
PHT Pain Management Guideline
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Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
The Palliative Care Service provides external study days, updates and is available for informal teaching and advice
(resource dependent). The green ‘Palliative Care Handbook’ is a useful resource tool to refer to.
Training for Health Care Professionals in those areas not covered by the APS is the responsibility of the Modern
Matrons, senior nurses and consultants and an “Analgesia competency is available to guide practice” (see Appendix
5).
Appendix 1







Use of the Abbey Pain Scale
The Abbey Pain Scale is best used as part of an overall pain management
plan.
The Pain Scale is an instrument designed to assist in the assessment of
pain in patients who are unable to clearly articulate their needs. This
could be due to their learning disabilities and/or dementia.
This Pain Scale may not be appropriate for all patients with dementia or
a learning disability. If further support is required regarding patients with
a learning disability, please contact the Learning Disability Liaison
Nurses on extension 5825 and in the interim use the Vital Pac 0-3 Smiley
faces equivalent as below.
The scale does not differentiate between distress and pain, so measuring
the effectiveness of pain-relieving interventions is essential.
It is recommended that the Abbey Pain Scale be used as a movementbased assessment. The staff recording the scale should therefore observe
the patient while they are being moved, e.g. during pressure area care.
Document corresponding 0-3 scale on vital Pac and ensure appropriate
action is taken in response to results of assessment.
A second evaluation should be conducted 1 hour after any intervention
taken in response to the first assessment, to determine the effectiveness
of any pain-relieving intervention and so forth until patient is recording
scores of 0-1.
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Use of the Abbey Pain Scale
For measurement of pain in patients with dementia and/or learning disabilities who
cannot verbalise.
How to use the scale: While observing the patient, score questions 1 to 6.
Q1. Vocalisation e.g. whimpering, groaning, crying
Absent
0 Mild 1 Moderate 2 Severe 3
Q2. Facial Expression e.g. looking tense, frowning, grimacing, looking frightened
Absent
0 Mild 1 Moderate 2 Severe 3
Q3. Change in body language e.g. fidgeting, rocking, guarding part of the body,
withdrawn
Absent
0 Mild 1 Moderate 2 Severe 3
Q4. Behavioural change e.g. increased confusion, refusing to eat, alteration in usual
patterns
Absent
0 Mild 1 Moderate 2 Severe 3
Q5. Physiological change e.g. temperature, pulse or blood pressure outside normal limits,
perspiring, flushing or pallor
Absent
0 Mild 1 Moderate 2 Severe 3
Q6. Physical changes e.g. skin tears, pressure areas, arthritis, contractures, and previous
injury
Absent
0 Mild 1 Moderate 2 Severe 3
Add scores for Q1 to Q6 together for total pain score =
Now document on Vital Pac using corresponding 0 – 3 score
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Abbey Score
0-2
3-7
8-13
14+
Vital Pac score
0
1
2
3
No pain
Mild
Moderate
Severe
Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, Lowcay B. The Abbey Pain Scale. Funded by the JH and JD
Medical Research Foundation 1998-2002
Appendix 2
FLACC Scale
Category
Scoring
1
2
3
Face
No particular expression
or smile
Occasional grimace or frown,
withdrawn, disinterested
Frequent to constant quivering
chin, clenched jaw
Legs
Normal position or
relaxed
Uneasy, restless, tense
Kicking, or legs drawn up
Activity
Lying quietly, normal
position, moves easily
Squirming, shifting back and forth, tense
Arched, rigid or jerking
Cry
No cry (awake or asleep)
Moans or whimpers; occasional
complaint
Crying steadily, screams or
sobs, frequent complaints
Reassured by occasional touching,
hugging or being talked to, distractible
Difficult to console or comfort
Consolability Content, relaxed
Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from
0-2, which results in a total score between zero and ten.
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Appendix 3
Please note-Incomplete forms will be returned to the referring doctor for completion.
In Patient Referral Form to Chronic Pain Department
Name:
DOB:
Hospital number:
Date of referral:
Estimated date of discharge:
Ward -……………… Speciality-…………………………Consultant in charge………………………………………..
Referrer’s Name -…………………………………. Grade-…………………… Bleep -…………………..
Alternative contact details- Name -…………………………………. Grade-…………………… Bleep ……………
Diagnosis /Reason for admission ……………………………………………………………………………………………….
Clinical details ………………………………………………………………………………………………………………
………….
......……………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………
Has the patient been diagnosed with a chronic pain Yes/No
condition prior to this hospital admission?
If yes what is the diagnosis?
……………………………………….
Has the patient been treated for a chronic pain
condition in the past?
Yes, at the QAH /Yes, at a different hospital
/No
Was the patient on any analgesic or adjuvant pain
medications prior to the current hospital admission?
Please tick.
Amitriptyline
Gabapentin
Pregabalin
Morphine
Buprenorphine
Fentanyl
Others……………………………………………….
Please state reasons for referral?
Acute flare up of the chronic pain problem.
Acute pain unrelated to the chronic pain diagnosis
Advice regarding analgesic and adjuvant medication titration
For urgent interventional Pain procedure
Other, Please specify- ……
Please fax or deliver the completed form to the Acute Pain service in the department of Anaesthetics, E
level, QAH. Fax no: 6681 for the attention of sister Rosy Barnes. For routine referrals as outpatients
please contact chronic pain secretaries.
Seen by APS:
For inpatients visit
For outpatient appointment:
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
REFERRAL POLICY:
HOSPITAL SPECIALIST PALLIATIVE CARE TEAM
Services offered by the Specialist Palliative Care Team
A Multi-professional team of Consultant, and Clinical Nurse Specialists offering support and advice
alongside hospital ward teams. The service is available to people with cancer and to those with nonmalignant disease, who would benefit from specialist palliative care, at any time from the point of
diagnosis.
Referral to the service can be made according to the following criteria:




Those patients with persistent symptoms not responding to routine therapy.
Those patients and their carers having difficulties in adjusting to their disease, including the need for
psychologist assessment with high levels of depression and anxiety.
Health care professionals who require specialist advice and support with case management.
To assess the need for further specialist Inpatient care.
How to refer:



Referrals are accepted with patients’ consent, from hospital consultants and other staff acting on their behalf.
Contact with the patient cannot be made until a written referral has been completed. However, telephone advice
can be sought on 02392 286132 (0900-1700 Monday – Friday).
Out of hours please contact The Rowans Hospice inpatient unit on Tel. No. 023 92 250001.
All hospital referrals need to be faxed through to the Hospital Specialist Palliative Care Service, on the
appropriate contact numbers below and a copy of the referral form needs to be retained in the patient’s notes,
prior to contact with the patient.
Standards for initial contact:
Our aim is to see patients within 5 working days
How to contact us:
Hospital Specialist Palliative Care Team:
Tel No: 023 92 286132 (Ext 6132)
Working Hours: 0900-1700 (Monday-Friday) Fax No: 023 92 283332 (Ext 3332)
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Telephone: 02392 286132 (Ext: 6132)
Fax to: 02392 283332
REFERRAL FOR ASSESSMENT BY SPECIALIST PALLIATIVE CARE TEAM
IN ORDER TO PRIORITISE PATIENT VISITS, PLEASE PROVIDE AS MUCH DETAILED INFORMATION AS
POSSIBLE
Referred By: (Full name & position)
Has the patient consented to be seen by
Date of Referral:
the Specialist Palliative Care Team ?
Extension No:
Bleep No:
YES
NO
Patient's name and Preferred Title:
Home Address:
Hospital No:
NHS No:
Date of Birth:
Home Telephone No:
WARD:
GP:
Address:
Telephone No:
DIAGNOSIS:
EXTENT OF DISEASE:
ANY OTHER SIGNIFICANT MEDICAL
CONDITIONS
Date of original diagnosis:
WHAT HAS THE PATIENT BEEN TOLD-ABOUT:
Current condition and likely prognosis
REASONS FOR REFERRAL (MUST BE COMPLETED)
Please give further details including current and failed management:
(a) Persistent Symptoms (please give details)
(b) Psychological Issues (please give details)
(c) Support for Health Care Professional (please give details)
(d) Assessment for Specialist In-patient Care (please give details)
SOCIAL AND FAMILY SITUATION:
Next of Kin:
Ethnicity:
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
Religion:
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Competency Statement: The Registered Nurse, Midwife or Practitioner will be competent in the administration of basic analgesia.
Competency Indicators
1st Level
a) Locate and discuss Trust policy
with regards to drug
administration.
b) Identify and describe Wessex
Pain Score and give rationale of
use on ViEWS/MEOWS chart
and admission documentation.
c) Discuss and demonstrate
general and specific monitoring
of patients taking opioid
analgesia, Paracetamol and
NSAID’s.
d) Discuss the causes of pain in
relation to each patient you deal
with and differentiate between
local and referred pain.
e) Demonstrate correct
administration techniques
include confirmation and
checking of drug, patient route
and rate.
f) Demonstrate the ability to
complete the prescription chart
and completion of all appropriate
paperwork.
g) Demonstrate appropriate
handover to personnel including,
Nurses, Acute Pain Team,
Medical Staff, Physiotherapists
and Pharmacists.
Competency Indicators
2nd Level
Competency Indicators
3rd level
Competency Indicators
4th level
All of Level 1 plus:
All of Levels 1 & 2 plus:
All of Levels 1,2 & 3 plus:
a) Discuss actions to be taken if
analgesia is insufficient.
b) Discuss how you would
recognise an allergic reaction
and an anaphylactic reaction
and the action to be taken.
c) Discuss the rationale for
discontinuing specific analgesic
drugs and the subsequent pain
management plan.
d) Discuss and demonstrate the
procedure to be taken in the
event of a drug error or adverse
incident.
e) Aware of alternative forms of
pain-relieving techniques
including positioning and
distraction.
a) Demonstrate the ability to the
teach the Acute Pain Study Day
with emphasis on ‘Drugs in the
cupboard’.
b) Lead the overall management of
the Surgical Division patients on
basic analgesia.
c) Lead development of Clinical
Guidelines and Policies.
d) Carry out Audit.
a) Discuss NMC Guidelines –
‘Standards for the
Administration of
Medicines’ and ‘The Scope
of Professional Practice and
‘Code of Professional
Conduct.
b) Discuss the criteria for
selection of analgesic and
administration route.
Identifying which routes
would be appropriate for
each patient.
c) Discuss the actions, side
effects, doses and potential
complications for each drug
prior to administration and
how to deal with these
complications.
d) Ensure patients’ dignity is
maintained during sensitive
administration routes.
e) Discuss and implement
interventions (non drug)
that may alleviate the
patient’s pain.
f) Discuss the resources
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
available (internal and
external) that can be
accessed for advice
regarding analgesic drugs.
Education resources to support Competency Achievement
HCSW & St/N to attend Acute
Pain Study Day.
Attend study day every 3 years
& update yearly via The Acute
Pain Website Training
Package.
Registered Nurses to complete Drug
Pack.
The Pharmacology of Pain Control
Session 8 Open Learning
Programme for Health Care
Workers. Stalker, N.
Post Operative Analgesia.
Anaesthetics Milner, Q. 2000
Author:
Claire Wyman
Department:
Acute Pain Team
Review Date: October 2013
Record of Achievement.
To verify competence please ensure that you have the appropriate level signed as a record of your achievement in the boxes below.
Level 1
Date:
Level 2
Date:
Level 3
Date:
Level 4
Date:
Signature of Educator/Trainer
Signature of Educator/Trainer
Signature of Educator/Trainer
Signature of Educator/Trainer
Date:
Date:
Date:
Date:
Signature of Workplace
Assessor
Signature of Workplace
Assessor
Signature of Workplace
Assessor
Signature of Workplace Assessor
References to Support Competency
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
Acute Pain Study Day Lecture Booklet ‘Drugs in the Cupboard’
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL GUIDELINE
PHT Pain Management Guideline
v1
Issued 14 June 2012
Review Date: June 2014 (unless requirements change)