Michigan Nurses Association
Debra Nault MSN, RN
2013
Expires February 2015
Purpose: This educational module will inform nurses
and enhance their knowledge regarding patients’
right to effective pain/symptom management, their
responsibility as healthcare providers for pain
management, and the Joint Commission’s standards.
Objectives: Participants will be able to:
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Recognize the right of patients to appropriate
assessment and management of pain
Identify how to screen patients for pain during
their initial assessment and when ongoing, periodic
re-assessments are clinically required.
List three best practices and approaches to improving
the quality of pain management.
 At
a fundamental level, improving pain
management is simply the right thing to do
 As an expression of compassion, it is a
cornerstone of nursing and health care’s
humanitarian mission
 It is just as important from a clinical
standpoint, because unrelieved pain has
been associated with undesirable outcomes
such as delays in postoperative recovery,
and development of chronic pain conditions
Evidence-based pain management, one of the
first Agency for Healthcare Research and Quality
guidelines introduced, occurred in 1992
 The guidelines are a compilation of the best
available evidence, but implementation of these
guidelines was voluntary
 The American Pain Society cited the need to
‘‘move beyond traditional education and
advocacy to focus on increasing pain’s visibility
in the clinical environment”
 In 1999, the Joint Commission approved
standards for acute care pain management to be
implemented in 2001
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 Historical
under-treatment of pain among
inpatients resulted in a national requirement
for pain practice standards
 On January 1, 2001, pain management
standards went into effect for Joint
Commission accredited ambulatory care
facilities, behavioral health care
organizations, critical access hospitals, home
care providers, hospitals, office-based
surgery practices, and long term care
providers
 Congress declared the decade beginning on
January 1, 2001, as the “Decade of Pain
Control and Research”
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For most accreditation programs, the pain
management standards appear in the Provision of
Care, Treatment and Services (PC) and the Rights and
Responsibilities of the Individual (RI) chapters of The
Joint Commission’s accreditation manuals.
For the behavioral health care program, the pain
management standards appear in the Care,
Treatment and Services (CTS) chapter.

“Speak Up: What you should know about pain management” is a patient education brochure that
provides questions and answers to help patients talk with their doctor, nurse and other caregivers
about how to treat their pain. Free downloadable files of all Speak Up brochures (including Spanish
language versions) are available on The Joint Commission website at
http://www.jointcommission.org/speakup.aspx.

Joint Commission Resources (JCR), a not-for-profit subsidiary of The Joint Commission, offers a
number of resources on pain management. For more information, visit JCR’s website,
www.jcrinc.com, or request a catalog from the JCR Customer Service at (877) 223-6866.
The pain management standards were developed
in collaboration with the University of Wisconsin
– Madison Medical School and were part of a
project funded by the Robert Wood Johnson
Foundation
 The Joint Commission worked with a panel of
pain experts to develop the standards addressing
pain management
 Health care professionals, professional groups
and associations, including the American Pain
Society, consumer groups and purchasers were
involved in the development of the standards

The pain management standards require that
patients be asked about pain, depending on the
service the organization is providing
 There are some services that do not require a
pain assessment, for example, if a patient is
being x-rayed.
 However, if a patient is experiencing pain,
appropriate care should be made available
 The organization’s response to a patient’s pain is
based on the services it provides
 If screening indicates that pain exists, the
organization may assess and treat the pain,
assess the pain and refer the patient for
treatment, or refer the patient for further
assessment.
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Optimal pain care for hospitalized patients continues to
remain elusive
Results of the Hospital Consumer Assessment of Healthcare
Providers and Systems Survey (HCAHPS) show that only 6374% of hospitalized patients nationwide reported that their
pain was well controlled (Summary of HCAHPS Survey
Results, 2011)
Although pain research has resulted in a better
understanding of pain modalities and the development of
new treatments, patients report little increase in
satisfaction with the management of their pain while
hospitalized (Department of Health and Human Services,
2011)
Recognize the right of patients to appropriate
assessment and management of pain
 Screen for the presence and assess the nature
and intensity of pain in all patients
 Record/document the results of the assessment
in a way that facilitates regular reassessment
and follow-up
 Determine and ensure staff competency in pain
assessment and management by providing
education, and address pain assessment and
management in the orientation of all new
clinical staff

Establish policies and procedures that support
the appropriate prescribing or ordering of pain
medications
 Ensure that pain does not interfere with a
patient’s participation in rehabilitation
 Educate patients and their families about the
importance of effective pain management
 Address patient needs for symptom management
in the discharge planning process
 Incorporate pain management into performance
activities (i.e., establish a means of collecting
data to monitor the appropriateness and
effectiveness of pain management)
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The hospital provides patient education and training based
on each patient's needs and abilities.
Important points:1) Acute care patients are discharged
with instructions for self-care 2) Patient education
influences the patient’s outcome and promotes healthy
behaviors 3) The organization needs to assess the patient’s
learning needs and use educational methods and
instruction that match the patient’s level of understanding
Based on the patient's condition and assessed needs, the
education and training provided to the patient by the
hospital include any of the following: one of these relates
to pain:
Discussion of pain, the risk for pain, the importance of
effective pain management, the pain assessment process,
and methods for pain management
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First, make sure your nursing practice reflects the
Joint Commission’s pain management standards,
national standards on pain management, your state's
nurse practice act, and your facility's policies
Remember that patients have the right to adequate
pain assessment and management, and they rely on
you to advocate for them
If your care deviates from the standards, thoroughly
document the reason
For example, if a patient refuses pain medication,
document the refusal and the reason, notify the
prescriber, and request an alternative pain
medication if appropriate
Document the actions you take to obtain another
pain medication and your patient teaching
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As a Person With Pain, You Have:
The right to have your report of pain taken seriously and to
be treated with dignity and respect by doctors, nurses,
pharmacists and other healthcare professionals
The right to have your pain thoroughly assessed and promptly
treated
The right to be informed by your doctor about what may be
causing your pain, possible treatments, and the benefits, risks
and costs of each
The right to participate actively in decisions about how to
manage your pain
The right to have your pain reassessed regularly and your
treatment adjusted if your pain has not been eased.
The right to be referred to a pain specialist if your pain
persists
The right to get clear and prompt answers to your questions,
take time to make decisions, and refuse a particular type of
treatment if you choose
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Pain Care Bill of Rights, page 1 of 1 Created: 04/09 NYU
PAIN CARE BILL OF RIGHTS
Patient’s Rights
As a person with pain, you have the right to:
 be treated by staff committed to pain prevention
 have your report of pain respectfully acknowledged by all members of your healthcare
team
 have your pain assessed regularly and responded to quickly
 get clear and prompt answers, take time to make decisions, and refuse a particular type
of treatment
 receive education on the importance of pain management and set goals for pain relief.
 be referred to a pain specialist if needed
Patient’s Responsibilities
As a patient, you are responsible for:
 taking an active role as a team member in reporting your pain and any related information
 sharing with the healthcare team, your history and experience with pain relief (with or
without medication)
 participating in making decisions about how to manage your pain
 working with your healthcare team to set goals for pain relief and develop a plan
 asking your healthcare team what you can expect in relation to your pain
 asking questions sharing concerns about the plan, side effects, risk of addiction, cost, etc.
 Pain
is one of the major reasons patients
seek care
 However, hospitals continue to struggle with
the issue
 According to Joint Commission officials at
the 2009 Executive Briefings, pain
assessment and reassessment is a top 10
most-cited standard under PC.8.10 for which
hospitals received RFIs in 16% of surveys in
2007 and the first quarter of this year
Poor pain management practices, poor
documentation, poor practitioner knowledge
 Erroneous individual myths and beliefs about
pain management and a critical lack of
knowledge perpetuate inaccuracies and bias in
pain management practice
 Knowledge used for pain management may
reflect the same knowledge nurses learned in
their basic programs
 In fact, younger, less experienced nurses have
scored better on pain management knowledge
and attitude tests
 Lack of organizational support

Administrative priority only when patient pain
satisfaction declines or fails to meet expected
standards of care
 Lack of physician cooperation has long been
identified as a barrier
 Lack of time, staffing, and resources
 The process involves complex decision making,
adequate nurse-patient communication,
planning, and evaluation in a busy, hectic
environment
 Studies have also suggested a connection
between unit culture and pain management
practice

“Many doctors seem to have a lack of concern
about others’ pain. I've seen physicians
perform very painful treatments without giving
sedatives or pain medicine in advance, so the
patient wakes up in agony. When they do order
pain medicine, they're so concerned about
overdosing that they often end up
underdosing.”
 Require
comprehensive initial and frequent
assessments
 Need reliable and valid instruments along
with assessment-based interventions
 Re-assessment, and further intervention as
required
 Compliance with EBPM is evaluated through a
review of nursing documentation
 The practice environment and nurses’
clinical expertise offer insight into the
factors influencing the implementation
 The
process of integrating good pain
management practices into an organization’s
everyday life requires a comprehensive
approach that includes—and goes beyond—
performance improvement to overcome
barriers and to achieve fundamental system
changes.
 Researchers and pain management experts
have identified a core set of activities
characterized by using an interdisciplinary
approach to facilitate these system changes.
 Form
a multidisciplinary committee of key
stakeholders
 Identify unit-specific nursing and physician
leaders as champions of pain management
 Analyze current pain management practice
performance
 Make improvement through continuously
evaluating performance
Nursing Today!
Nursing back when …
 Pain
is population specific, varying with
factors such as age, cultural diversity, and
cognitive impairments
 It takes understanding to sense, using verbal
and nonverbal communication, the level of
pain a patient is experiencing, especially
when he or she is ventilated or cognitively
impaired, such as a patient with Alzheimer’s
 Pain is in the eye of the beholder – as pain
management pioneer Margo McCafferey
wrote in 1968, “Pain is what the patient says
it is, and it’s as bad as the patient says.”
 Know
how to educate those who are caring
for a population that cannot communicate its
pain
 The Joint Commission brochure focuses on
adult pain management quite well, but does
not specifically address the pediatric
population
 With pediatric medication errors so high, it
will benefit your facility to take the time to
understand the pain management and pain
assessment needs for children, particularly
those too young to explain their own pain
 New
Pediatric Standard for 2012
 The hospital involves the family, when
appropriate, in identifying signs of pain
 Pediatric PROCEDURAL PAIN REQUIREMENT
 Elements of Performance 6:
 In order to reduce stress and pain related to
procedures, the hospital intervenes before
the procedure using pharmacologic and
non-pharmacologic (comfort) measures
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The key is knowledge -- we must educate everyone
involved with the patient
Nurses, physicians, respiratory therapists, physical
therapists, dietitians, residents, and even counselors
should receive education on how to assess and
manage pain in their patients
Most healthcare providers do well when it is expected
that the patient will experience pain, like after
surgery, for example
However, without cues such as an incision site,
providers may forget to ask about pain
It boils down to assessment and reassessment
If you don’t educate staff on pain pathophysiology,
they will not be able understand the entire process
 Policy
– when it comes to pain management,
an RFI can be a self-inflicted wound!
 Is your pain assessment and management
policy too tight?
 Does it need to be clarified or simplified?
 Did staff members have input into its design?
 Like
any policy, a pain assessment policy that
is too stringent can leave your organization
open to an RFI simply because it is
impossible for staff members to reasonably
comply with it
 Speak with frontline staff members
 Listen to how they assess pain and the steps
they go through to determine the level of
pain in their patients and develop an
effective policy from that information
 There
are many factors that affect pain
perception including pain threshold which is
described as the lowest intensity of a
stimulus that causes the subject to recognize
pain
 Another factor includes the release of
endorphins by the patient which is specific to
the individual
 Finally, pain tolerance is considered one of
the key perception factors and interventions
are necessary to expand the medication
tolerance times
 The
first element of the patient pain
requirement is that a pain assessment is
performed
 It must be all inclusive
 Relates to the care, treatment and services
regarding the patient's overall condition
 Second, the organization needs to use
appropriate means for pain assessment
 Must be in line with the patient’s condition
and age
 Chronicity
 Severity
 Quality
 Contributing/associated
factors
 Location/distribution or etiology of pain, if
identifiable
 Mechanism of injury, if applicable
 Barriers to pain assessment
 The
third element of performance indicates
that patients should regularly reassess that
patient's pain
 The fourth element of performance requires
the health care organization treat the
patient’s pain effectively
 Or at the very least, refer the patient to
another facility for treatment
 Identify
patients with pain in an initial
“screening assessment”
 When
pain is identified, perform a more
comprehensive pain assessment, making sure
to address language and/or health literacy
barriers
 Record the results of the assessment in a way
that facilitates reassessment, follow-up and
data extraction for purpose of improvement
 Recognize the multi-dimensional nature of
pain, and use a multi-disciplinary treatment,
including non-pharmacologic modalities
Used for neonates/infants: FLACC
Assessment
0
1
2
Smiling/
expressionless
Frowning
Legs
Normal
movement/
Relaxed
Restless/Tense Legs drawn
up/Kicking
Activity
None/Lying
quietly
Squirming/
Tense
movements
Arched back/
Rigid/Jerking
Cry
None
Occasional
whimper
Crying
constantly/
Screaming
Consolability
Relaxed
Easily
distracted or
reassured
Difficult to
distract/
reassure
Face
Clenched jaw/
Anguish
 Use
pain management protocols and order
sets, treating until patients reach target
comfort levels
 Establish policies and procedures that
support appropriate prescribing or ordering
of effective pain medications
 Use multi-disciplinary treatment, including
non-pharmacologic modalities
 Streamline the delivery of timely pain
assessment and treatment process
Pain should be reassessed after each pain
management intervention, once a sufficient time
has elapsed for the treatment to reach peak
effect or with major change in status
 For example, 15 to 30 minutes after a parenteral
medication and 1 hour after oral medication or a
non-pharmacologic intervention
 Reassessment should include:
1. whether the patient's goal for pain relief was
met, for example, pain intensity, effect on
function (physical or psychosocial)
2. patient satisfaction with pain relief
3. whether side effects had occurred and were
tolerable
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1.
2.
3.
Reassess and document pain relief, side effects and
adverse events produced by treatment, and the
impact of pain and treatment effects on patient
function once sufficient time has elapsed to reach
peak effect, such as 15 to 30 minutes after
parenteral drug therapy or 1 hour after oral
administration of a PRN (as-needed) analgesic or
nonpharmacologic intervention.
Reassessments may be performed less frequently
for patients with chronic stable pain or for patients
who have exhibited good pain control without side
effects after 24 hours of stable therapy.
Pain assessment for IV PCA: every 2 hours for first 8
hours, then every 4 hours; epidural or intrathecal
analgesia: every 1 hour for 24 hours, then every 4
hours.
 Establish
unit-based auditing system with
effective monitoring and feedback
 Establish efficient institutional system of
care in pain management
 Review mistakes and sentinel events using
root cause analysis
 Address patient needs for symptom
management in the discharge planning
 Ensure clinician and staff competence and
expertise in pain management
 Educate relevant providers in pain
assessment and management
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Promise patients a prompt response to their reports of pain
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All patients at risk for pain should be informed that:
1) effective pain relief is important to treatment
 2) their report of pain is essential
 3) staff will promptly respond to patient requests for pain

treatment
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Patients and their families should be provided appropriate
educational materials that address important aspects of
pain assessment and management
Percent of patients who have their pain assessed
 Percent of patients with severe pain
 No difference in all other measures by
race/ethnicity/language
 Overall amount of opioid use
 Increased patient satisfaction – “How often was
your pain well controlled?”
 “How often did the hospital staff do everything
they could to help you with your pain?”
 Percentage of patients on opioids who have their
bowel movement assessed and documented at
least once per shift
 Unit specific average pain score

Opioid analgesics rank among the drugs most
frequently associated with adverse drug events
 Research shows that opioids such as morphine,
oxycodone and methadone can slow breathing to
dangerous levels, as well as cause other
problems such as dizziness, nausea and falls
 The reasons for such adverse events include
dosing errors, improper monitoring of patients
and interactions with other drugs, according to
The Joint Commission’s data base
 Reports also show that some patients, such as
those who have sleep apnea, are obese or very
ill, may be at higher risk for harm from opioids
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The Joint Commission Alert recommends that health care
organizations take the following actions:

Implement effective practices, such as monitoring patients
who are receiving opioids on an ongoing basis, use pain
management specialists or pharmacists to review pain
management plans, and track opioid incidents
Use available technology to improve prescribing safety of
opioids such as creating alerts for dosing limits, using tall
man lettering in electronic ordering systems, using a
conversion support system to calculate correct dosages
and using patient-controlled analgesia (PCA)
Provide education and training for clinicians, staff and
patients about the safe use of opioids
Use standardized tools to screen patients for risk factors
such as over sedation and respiratory depression
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 Pain
is an internal, subjective experience
that cannot be directly observed by others or
by the use of physiological markers or labs
 Therefore, pain assessment relies largely
upon the use of self-report
 Much effort has been invested in testing and
refining self-report methodology within the
field of human pain research
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The Joint Commission on Accreditation of Healthcare
Organization in the United States has set standards
for the assessment of pain in hospitalized patients
Pain assessment should be ongoing, individualized,
and documented
Patients should be asked to describe their pain in
terms of the following characteristics: location,
radiation, mode of onset, character temporal
pattern, exacerbating and relieving factors, and
intensity
It has been stated that the ideal pain measure should
be sensitive, accurate, reliable, valid, and useful for
both clinical and experimental conditions and able to
separate the sensory aspects of pain from the
emotional aspects
McCaffey has stated that “Pain is whatever the
experiencing person says it is, existing wherever
they say it does.”
 It is the body’s signal of distress and remains one
of the most common reasons people visit their
physician or visit the hospital
 Normal pain sensations involve transmission and
interpretation termed nociception
 The clinician must understand transduction,
transmission, and perception as well as pain
modulation in order to better care for the
patient with pain
 The types of pain are also evaluated when
assigning ICD-9 CM codes to properly portray the
patient condition

Practitioners’ personal biases about the patient’s
pain may interfere with the realization of the
definition when doing a pain assessment
 Sometimes, the intrinsic subjectivity of pain is
often disregarded
 Practitioners who would likely not judge the
character of a patient who needs increased
amounts of medication to treat hypertension
may believe that a patient whose persistent
pain does not respond to standard medications is
‘drug-seeking,’ a narcotic abuser, or has a
current need to ‘escape reality’
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Acute pain: Defined as intermittent pain
occurring for less than 90 days (Occupational
Medicine Practice Guidelines, 2009) and resulting
from trauma, impact, burns, or surgery. It is
abrupt, intermittent, and nociceptive.
 Chronic Pain: Defined as over occurring for at
least 3 months by the AMA and over 6 months by
the American Psychological Association. Both
concur there is no active disease or unhealed
tissue injury. This type of pain may be caused by
faulty processing of sensory input by the nervous
system. Pain interventions may be ineffective
resulting in frustration, anger, and depression
(Rosdahl, 2010).
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Somatic Pain: Defined as localized pain that becomes
increasingly uncomfortable with movement and very
tender when palpated. It is sometimes referred and
described as, per the Occupational Medicine Practice
Guidelines, sharp, throbbing, shooting, pinching, and
deep aching that includes bone, post-op, and muscle
pain.
Neuropathic Pain: Defined as difficult to cite the
source of pain as it tends to follow dermatome
pathways. Palpation tends to send pain to nerve
endings distally. This pain is described as burning,
radiating, and numbing at times with limb
“heaviness.” There may be swelling, redness, and
mottling with skin temperature fluctuations
(Occupational Medicine Practice Guidelines, 2008).
Visceral Pain: Defined as constant and localized
but may be referred like diaphragmatic pain
refers to the right shoulder and cardiac pain
which can refer to the left arm and the jaw.
 Cancer Pain: Defined as pain due to a malignancy
which is described as very severe, chronic, and
intractable causing resistance to many
medications, thus long and short term analgesics
are usually required to prevent “breakthrough
pain) (Rosdahl, 2010). Hospice nurses are usually
very skilled at pain management because of
cancer pain needs.

 Standard:
1) a criterion established by
authority or general consent as a rule for the
measure of quality, value, or extent; or 2)
for purposes of accreditation, a statement
that defines the performance expectations,
structures, or processes that must be
substantially in place in a organization to
enhance the quality of care
 Standards typically are used by accrediting
bodies such as the Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO) to evaluate health care
organizations and programs
Criteria: defined as a means for judging or a
standard, a rule, or a principle against which
something may be measured
 Guidelines: systematically developed statements
to assist practitioner and patient decisions about
appropriate health care for specific clinical
circumstances
 Consensus statements and position papers:
expressions of opinion or positions on health care
issues generally prepared by professional
societies, academies, and organizations and
generated through a structured process involving
expert consensus, available scientific evidence,
and prevailing opinion

Statute: a law created by a legislative body at
the federal, state, county, or city level.
Commonly called a law or an act, a single
statute may consist of just one legislative act or
a collection of acts
 Regulation: an official rule or order issued by
agencies of the executive branch of government
 Regulations have the force of law and are
intended to implement a specific statute, often
to direct the conduct of those regulated by a
particular agency

Michigan
Public Health
Statute
Public Health Code
MSA 14.15: General
Provisions
04/01/99
01/08/02
Pharmacy
Board
Guideline
Guidelines for the Use
of Controlled
Substances for the
Treatment of Pain
2005
--
Nursing Board
Guideline
Michigan Board of
Nursing Guidelines for
the Use of Controlled
Substances for the
Treatment of Pain
--
--
Joint Board
Guideline
Michigan Guidelines for
the Use of Controlled
Substances for the
Treatment of Pain &
accompanying
statement
late 2003
(1) Effective for the renewal of licenses or registrations issued
under this article and expiring after January 1, 1997 if the
completion of continuing education is a condition for renewal, the
appropriate board shall by rule require an applicant for renewal to
complete an appropriate number of hours or courses in pain and
symptom management. Rules promulgated by a board under
section 16205(2) for continuing education in pain and symptom
management shall cover both course length and content and shall
take into consideration the recommendation for that health care
profession by the interdisciplinary advisory committee created in
section 16204a. A board shall submit the notice of public hearing
for the rules as required under section 42 of the administrative
procedures act of 1969, being section 24.242 of the Michigan
Compiled Laws.
Pain — An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage or described in terms of such
damage
 Acute Pain — Acute pain is the normal, predicted
physiological response to a noxious chemical,
thermal or mechanical stimulus and typically is
associated with invasive procedures, trauma and
disease. It is generally time-limited
 Chronic Pain — Chronic pain is a state in which
pain persists beyond the usual course of an acute
disease or healing of an injury, or that may or
may not be associated with an acute or chronic
pathologic process that causes continuous or
intermittent pain over months or years



Addiction — A primary, chronic, neuro-biologic
disease, with genetic, psychosocial, and
environmental factors influencing its development
and manifestations. It is characterized by behaviors
that include the following: impaired control over drug
use craving, compulsive use, and continued use
despite harm. Physical dependence and tolerance are
normal physiological consequences of extended opioid
therapy for pain and are not the same as addiction.
Physical Dependence — A state of adaptation that is
manifested by drug class-specific signs and symptoms
that can be produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the drug, and/or
administration of an antagonist. Physical dependence,
by itself, does not equate with addiction.



Pseudoaddiction — The iatrogenic syndrome resulting
from the misinterpretation of relief-seeking behaviors
as though they are drug-seeking behaviors that are
commonly seen with addiction. The relief-seeking
behaviors resolve upon institution of effective
analgesic therapy.
Substance Abuse — The use of any substance(s) for
non-therapeutic purposes or use of medication for
purposes other than those for which it is prescribed.
Tolerance — A physiologic state resulting from regular
use of a drug in which an increased dosage is needed
to produce a specific effect, or a reduced effect is
observed with a constant dose over time. Tolerance
may or may not be evident during opioid treatment
and does not equate with addiction.

J Gen Intern Med. 2006 July; 21(7): 689-693

Joint Commission Resources. 2009 Comprehensive Accreditation Manual for Hospitals: The
Official Handbook. Oakbrook

Terrace, IL: Joint Commission Resources Inc; 2009.

Strategies to Improve Pain Management – American Pain Society, www.ampainsoc.org/
education/enduring/downloads/.../ section_5.pdf

Estabrooks CA, Midodzi WK, Cummings GG, Wallin L., Predicting research use in nursing
organizations: a multilevel analysis. Nurs Res. 2007;56(4S):S7–S23.

Van Niekerk LM, Martin F. The impact of the nurse/physician relationship on barriers
encountered by nurses during pain management. Pain Manag Nurs. 2003;4(1):3–10.

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Susan J. Fetzner PhD, MBA, RN; Joanne G. Samuels PhD, RN Clinical Nurse Specialist: The Journal
for Advanced Nursing Practice October 2009 Volume 23 Number 5 Pages 245 – 251
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2008 Volume 34 Number 9 The Joint Commission Journal on Quality and Patient Safety; Debra B.
Gordon, RN, MS.; Susan M. Rees, MS, RN., CPHQ.; Maureen P. McCausland, DNSc, RN.; Teresa A.
Pellino, PhD, RN; Sue Sanford-Ring, MHA; Jackie Smith-Helmenstine, CPHQ; Dianne M. Danis, RN,
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Bernhofer, E., (October 25, 2011) "Ethics and Pain Management in Hospitalized Patients" OJIN: The
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the evaluation form.
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6.
Historically there have been no problems with pain treatment for
inpatients.
True or False
The Joint Commission was the one entity that worked on developing
pain management guidelines.
True or False
Some services do not require a pain assessment. True or False
Since Congress declared a “Decade of Pain” in 2001, patients have
reported huge increases in satisfaction with management of their pain
while hospitalized.
True or False
According to the Joint Commissions’ standards related to pain
management, healthcare providers must:
a. recognize the right of patients to have an assessment of pain
b. screen for its presence
c. record results of the assessment
d. ensure staff competency
e. all of the above
Joint Commission standards related to pain management include all of
the following concepts but:
a. policies should address appropriateness of prescribing and ordering
b. addressing the need for symptom management after discharge
c. importance of patient and family education
d. data collection for performance measures is not necessary
7. What should be done when a patient refuses pain medication?
a. nothing, it’s the patient’s right to refuse medication
b. just offer an alternative pain management option
c. document refusal, reason, and notify the prescriber
d. educate the patient why he/she shouldn’t refuse
8. According to the “Patient Care Bill of Rights” a person with/in pain:
a. shouldn’t discuss risks, benefits or cost of pain medication
b. is usually too sick to participate in decisions about pain management
c. can’t refuse a type of treatment for pain if it’s recommended
d. can be referred to a pain specialist if their pain persists
9. A major barrier to good pain management practice includes:
a. physicians often perform treatments with too much pain medication
b. nurses know too many different methods of pain management
c. it’s consistently the priority of many administrations
d. lack of time, staffing, and resources
10. Included in evidenced based practice related to pain management
guidelines:
a. all you need is a good performance improvements process
b. any instrument to measure pain is acceptable
c. compliance is evaluated through review of nursing documentation
d. all of the above
11. The main focus of the new Pediatric Standard for 2012 includes:
a. pediatric procedural pain requirement
b. nursing expertise and not utilizing family bias
c. one valid pediatric pain scale for universal use
d. intervening during a painful procedure
12. Many factors affect pain perception and necessary interventions:
a. pain threshold
b. release of endorphins
c. pain tolerance
d. all of the above
13. Concepts in a multidimensional approach to pain management include:
a. only need to identify etiology, or mechanism of injury
b. assessing chronicity or acuteness of pain
c. assessment and reassessment
d. chronicity, severity, quality, contributing factors, location & etiology
14. Pain should be reassessed:
a. after each pain management intervention
b. once a sufficient time has elapsed for treatment to reach peak affect
c. with a major change in the patients’ status
d. all of the above
15. Reassessment should include:
a. only a pain scale and vital signs
b. if the ordering physician’s goal was met for treatment
c. whether side effects occurred and were tolerable
d. none of the above
16. Actual pain is rarely population specific and varies little with age,
cultural diversity or cognitive impairments. True or False
17. When discussing pain which of the following statements is true?
a. Abnormal pain sensations involve transmission and interpretation termed “nocioception”
b. Clinicians just need to understand pain perception to care for patients
c. Pain is so diverse assigning ICD-9 codes is impossible
d. Pain is the body’s signal of distress
18. Match the type of pain with its definition:
a. acute
a. pain due to malignancy
b. chronic
b. difficult to cite source, tends to follow
dermatome pathways
c. somatic
c. no active disease or unhealed injury
d. neuropathic
d. intermittent, abrupt, and < 90 days
e. visceral
e. localized that becomes uncomfortable with
movement and tender with palpation
f. cancer
f. constant & localized, may be referred
19. By definition physical dependence equates with addiction. True or false
20. By definition tolerance is:
a. always equated with addiction
b. always a psychological state resulting from opioid treatment
c. a physiological state resulting form regular use of a drug in which an increased
dose is needed to produce a specific effect
d. nurses obtaining a CE on pain year after year