Pain Management MULT-8310-611 Page 1 of 11 BOTHWELL REGIONAL HEALTH CENTER MANUAL: Multidisciplinary Manual

EFFECTIVE: May, 2001

REVIEWED: 8-11

REVISED: 8-04, 11-07, 01-09

APPROVAL: Quality and Patient Safety Committee

DEPARTMENT: Hospital wide

SUBJECT: Management

I. PURPOSE : To establish guidelines for assessment, evaluation and documentation of .

II. POLICY : 2.1 Patients have the right to appropriate assessment and management of pain. 2.2 It is the patient’s responsibility to discuss and inform medical/nursing personnel of pain management issues (i.e., ask for pain relief when pain begins and if it is not relieved). 2.3 Nursing staff will assess patients for pain in the initial nursing assessment and throughout the course of their visit/stay. 2.3.1 Nursing will assess for any co-morbid condition that may cause discomfort in conjunction with their admitted diagnosis or procedure in the initial assessment and will minimize any impact on that condition when possible. 2.3.2 Patients will be educated throughout their stay regarding pain associated with their procedures or acute condition; chronic conditions will be addressed as a separate issue. 2.4 Patients will be educated about pain and use of the . 2.5 Patients will be assisted in making pain management goals for comfort or for individual functional ability. 2.6 Patients will be evaluated for proper pain control/relief at appropriate intervals. 2.7 Interventions will be reviewed to evaluate if individual patient goals are being attained.

III. PROCEDURE : 3.1 Use of the Pain Scale : 3.1.1 The patient’s self-report of pain will be considered the single most valuable indicator of pain. 3.1.2 Pain will be evaluated using a pain scale(s): 3.1.2.1 Horizontal or vertical 0-10 point pain scale - used for patient cognitive age seven or above (see appendix A). 3.1.2.2 Wong-Baker face scale 0-10 point pain scale – used for patient cognitive age 3 and older or non-English speaking patient (see appendix B). 3.1.2.3 The NIPS is used for Neonatal-Infant patients (see appendix C). 3.1.2.4 The FLACC Behavioral Pain Assessment scale – used for Pediatric patients (see appendix D).

Pain Management MULT-8310-611 Page 2 of 11 3.1.2.5 Bothwell Regional Health Center Physiologic/Behavioral Pain Scale – used for patients of any cognitive age or unresponsive patients (see appendix E). 3.1.3 Patient and/or family member will be taught at admission to use the appropriate pain scale to report pain intensity. 3.2 Setting of Goals : 3.2.1 The comfort/function goals of pain management for patients experiencing acute or will include: 3.2.1.1 Educating the patient regarding what comfort/function goal means. Explain that the rating is the goal the patient determines for him/herself for recovery or performing activities and is determined during the initial assessment. 3.2.1.2 Review with patient that the comfort/function goal is part of their pain assessment/reassessment process and allows the health care team to evaluate their pain individually. 3.2.1.3 Explain that if pain rating goes above the comfort/function goal, then appropriate intervention will be implemented by the health care team. 3.2.1.4 Educate patient that the comfort/function goal is diverse and can be changed at any time. However, if the goal is unrealistic, patient should be educated about their pain and process of pain management. 3.3 Pain Definitions : 3.3.1 Pain may be defined and divided into different categories: 3.3.1.1 Acute pain : Pain relatively short in duration and most commonly caused by damage to tissues and organs. Acute pain quickly subsides as the healing process decreases the pain-producing stimuli in normal circumstances. 3.3.1.2 Chronic pain : This is pain that lasts beyond the normal time for healing (usually accepted as duration of greater than 3 months). 3.3.1.2.1 Chronic non-malignant pain : This may be pain persisting beyond normal healing times from an acute injury, pain related to a chronic disease state, neuropathic pain or pain without an identifiable organic cause. 3.3.1.2.2 Chronic malignant pain : Pain associated with cancer/malignancy. 3.4 Pharmacological Pain Control : 3.4.1 Pharmacological methods of pain control will be ordered by the attending/consulting physicians. 3.4.2 The pharmacy will be notified of patients needing pharmacological pain management through physician orders. 3.4.3 The pharmacist on duty will be available as an additional resource for medical/nursing staff. 3.4.4 Patients will be assessed for allergies and previous adverse reactions to pain medications prior to the initial dose of medications. 3.4.5 Narcotics ordered for pain control will be administered as ordered. Refer to the IV Therapy/Patient Controlled Analgesia (PCA) policy for IV route following manufacturer’s directions for alternative routes. 3.4.6 PCA pumps will be assembled and ordered drug given per policy Pain Management-PCA. 3.4.7 Epidural pain control will be administered/managed per policy Pain Management-Giving Epidural Narcotics for Chronic Pain via Indwelling

Pain Management MULT-8310-611 Page 3 of 11 Epidural Catheter and Pain Management – Monitoring Acute, Postoperative Patients Receiving Narcotics. 3.4.8 Notify physician of ineffective pain management following administration of analgesic prescribed. 3.4.9 Administer as prescribed to prevent severe pain from reoccurring and prophylactically prior to activities associated with discomfort. 3.4.10 Plan activity around peak time of pain control. 3.4.11 Monitor for allergic reaction, exaggerated response and adverse reactions to pain medications. See Medication Administration policy. 3.5 Alternative Pain Control Methods : 3.5.1 Alternative pain control methods can be used to treat pain either instead of, or in addition to, pharmacological treatment. These interventions should be individualized and used as indicated. 3.5.1.1 Unit/floor based activities (see appendix F). 3.5.1.2 Activities or treatments available through Occupational, Physical, Recreational and Speech Therapy (see appendix G). 3.5.1.3 Pain Clinic treatments and adjunctive therapies (see appendix H). 3.5.2 A patient who requires alternative pain control methods indicated in appendix G and H will be referred by their attending/consulting physician. 3.6 Initial Assessment : 3.6.1 Patients will be assessed for presence or absence of pain upon admission to Bothwell Regional Health Center’s facility or clinics. If findings are positive, further evaluation will be done. The evaluation will include: 3.6.1.1 O: Onset/duration – When did pain start; how long did it last? 3.6.1.2 P: Provoke/Aggravates – What provokes pain; what makes it worse? 3.6.1.3 Q: Quality/Description/Location – What type of pain is it (i.e., burning, sharp); where does it start; does it go anywhere else? 3.6.1.4 R: Relief of pain – What makes the pain better? 3.6.1.5 S: Severity/Intensity – How severe is the pain (use appropriate scale). 3.6.1.6 T: Treatments, current/previous – What makes the pain better; any medicines taken; what has worked in past? 3.6.2 Documentation of assessment will be on the initial nursing assessment and/or in the appropriate disciplinary notes. 3.6.3 If patient unable to provide a self-report using the chosen pain scale, the Physiologic/Behavioral scale will be used. 3.6.4 Any patient report of new or different pain will require a complete reassessment of the pain and will be documented in the appropriate disciplinary notes. 3.7 Ongoing Assessment of Pain/Interventions : 3.7.1 One chosen pain scale will be utilized for documentation of pain assessment and reassessment for evaluation of the level of pain relief obtained. 3.7.2 Nurses will administer pharmacological pain methods as per physician orders and will document on the Medication Administration Record (MAR) and the nurses notes as per Medication Administration policy. 3.7.3 Nurses will administer non-pharmacological adjunctive pain therapy, if indicated, and document the patient response/results in the nurses notes. 3.7.4 When pharmacological or non-pharmacological intervention is required, pain will be reassessed at suitable intervals after each intervention. 3.7.5 If the pain relief does not meet the patient goal for function and comfort, continued assessment and intervention are required. 3.7.6 A multi-disciplinary approach will be used as indicated in individual patients who require multifaceted pain control.

Pain Management MULT-8310-611 Page 4 of 11 3.7.7 If pain relief is satisfactory, document response using chosen pain scale in the appropriate disciplinary notes. 3.7.8 The patient does not need to be awakened for reassessment of pain. 3.7.9 The presence of pain will be assessed at regular intervals during the visit/stay. The results of the pain reassessment will be documented (including reports of ‘0’ pain) in the appropriate disciplinary notes. 3.8 Patient Education : 3.8.1 Patients will be given Patient Education for Pain Management in their patient handbook (see appendix I). 3.8.2 Patients will be educated about their pain, its cause and expected duration. 3.8.3 Patients will be educated about setting comfort/function goals regarding their pain and reaching comfort/functioning levels. 3.8.4 Patients will be taught the goal of pain management is prevention, when possible, and that early intervention in the course of pain is important. Patients will be encouraged to ask for analgesic intervention early rather than waiting until pain is severe. 3.8.5 Patients will be taught about their prescribed pain medication, its action and expected effects on pain. 3.8.6 Patients will be informed they will be regularly assessed regarding level of pain. 3.8.7 Patients will be informed that they need to notify staff of increasing discomfort or dissatisfaction with management of pain. 3.9 Pain Management at Discharge : 3.9.1 A pain level will be assessed at time of discharge and will be recorded in discharge note in nurses notes. 3.9.2 Patients who are able to rate their pain higher than their function/comfort goal at discharge will be provided with written instructions for follow-up should pain continue to be an issue. They will be instructed to contact their physician should pain change, continue or become uncontrollable. 3.9.3 The discharge nurse will take measures to assure patients are provided with a prescription for pain control medication.

IV. NEW EMPLOYEE ORIENTATION/STAFF EDUCATION : Education department will coordinate new employee orientation and staff updates regarding pain and pain management issues. See the current pain management education plan.

V. CONTINUOUS QUALITY IMPROVEMENT : The Continuous Quality Improvement (CQI) records of statistics, examples of surveys and results of chart audits are available. See the current pain management CQI plan. See Appendix J.

VI. REFERENCES 6.1 Agency for Health Care Policy and Research (1992). Acute Pain Management: Operative of Medical Procedures and Trauma-Clinical Practice Guideline . (AHCPR 92-0032). Rockville, MD. 6.2 Agency for Health Care Policy and Research (1994). Management of : Adults . (AHCPR 94-0593). Rockville, MD. 6.3 American Pain Society (1999). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (4 th ed). Glenview, IL. 6.4 Bosek, M. (1993). The ethics of pain management. Med Surg Nursing , 2(3), 218-220. 6.5 Christoph, S. (1991). Pain assessment. Critical Care Nursing Clinics of North America , 3(1), 11-16. 6.6 McCaffery, Margo; Pasero, Chris, Pain: Clinical Manual (2 nd ed, 1999).

Pain Management MULT-8310-611 Page 5 of 11 6.7 U.S. Department of Health and Human Services, Agency for Health Care Policy and Research (1992). Acute pain Management: Operative or Medical Procedures and Trauma. 6.8 1999-2000 Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) . Patient Rights and Organization Ethics Chapter-R1. 1.2.7. to Continuum of Care Chapter- CC.6.1. 6.9 American Academy of Pediatrics recognizes NIPS as scoring guide for infants, April, 2008. 6.10 Merkel, Sandra, MS,RN; Voepel-Lewis, Terri, MS, RN; Malviya, Shobha, MD; AJN, October 2002, Vol. 102, No. 10, Pain Assessment in Infants and Young Children: The FLACC Scale.

VII. APPENDICES : 7.1 Appendix A: Horizontal/Vertical Pain Scale 7.1.1 An example of a 10 point scale that patient marks for an OT/PT evaluation of pain. This line can be horizontal, vertical or a verbal number between 0-10 subjectively based on patients perception of pain.

Extreme pain

No pain

7.1.2 Utilized by OT/PT, actually measure the centimeters for comparison.

Pain Management MULT-8310-611 Page 6 of 11 7.2 Appendix B: Wong-Baker Face Scale

0 1 2 3 4 5 6 7 8 9 10 Absent Mild Moderate Severe Worst

Pain No Tienes Poquito Dolor Dolor Peor Dolor Dolor Moderado Fuerte Dolor 0 1,2,3 4,5,6 7,8,9 10

7.3 Appendix C: NIPS Neonatal-Infant Pain Scale The International Association for the Study of Pain defines pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. The interpretation of pain is subjective. A neonate is unable to report pain and, therefore, pain can only be ascertained through the recognition of the neonate’s associated behavioral and physiologic response to pain. Pain in the neonate is real and exposure to prolonged or severe pain may increase morbidity. Pain can be assessed and treated. The goal is to provide optimal pain management with minimal risk of any adverse event.

ASSESSMENT OF PAIN: NIPS 0 No Pain No Interventions NIPS < 2 Mild pain May be managed with non-pharmacologic measures NIPS 2-4 Mild-Moderate pain May be managed with non-pharmacologic measures but may need the addition of pharmacologic support NIPS >4-7 Moderate to severe pain May need pharmacologic intervention in addition to comfort measures Pharmacologic interventions require a physician’s order. Neonatal Infant Pain Scale (NIPS) Variable Finding Points Facial Expression Relaxed Muscles (Neutral Expression) 0 Furrowed Brow, chin, jaw (Tight facial muscles) 1 Cry No cry (Quiet, not crying) 0 Mild, intermittent cry 1 Vigorous crying (Loud scream) or silent cry 2 Breathing Pattern Relaxed (Usual pattern for this infant) 0 Change in breathing (Irregular, faster than usual, 1 gagging, breath holding) Arms Relaxed (No muscular rigidity, occasional random 0 movements of arms) Flexed/extended (Tense, straight arms, rigid and/or rapid 1 extension, flexion)

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Legs Relaxed (No muscular rigidity, occasional random leg 0 movements) Flexed/Extended (Tense, straight legs, rigid and/or rapid 1 extension, flexion) State of Arousal Sleeping/Awake, Quiet 0 Fussy (restless and thrashing) 1

Assess each infant on an individual basis. Using the NIPS pain scale a score is determined and appropriate interventions initiated for pain management.

Non pharmacologic Measures: Reducing light/noise levels Sequencing care interventions to prevent overstimulation Nesting to provide boundaries Swaddling/containment Offering an age appropriate pacifier to encourage non-nutritive sucking Skin-to-skin contact when possible Gentle stroking/holding

Sucrose pacifiers are intended for procedural pain and are not routinely used for the irritable infant. Sucrose should be administered 2-5 minutes before the painful procedure. • Infants greater than or equal to 26 weeks may receive 24% sucrose for painful procedures using the following guidelines: • Maximum frequency of use is twice per 12 hr shift or 4 times per day. • Whenever possible, sucrose should be administered via pacifier for additive effect. Dosing consists of 2 dips of a pacifier per procedure. • Large pacifiers are estimated to hold no more than 0.2ml; small pacifiers are estimated to hold no more than 0.1ml. • Remember that it’s not the volume that affects analgesia, it is the taste. Therefore the sucrose does not have to be swallowed to have an effect. • Term infants who are NPO and other ill term infants may receive the dipped pacifier only before procedures and should not receive the larger volume.

Pharmacologic Measures Moderate to severe pain should be treated with a combination of non-pharmacologic and pharmacologic interventions. Pharmacologic interventions will vary depending on the clinical status of the infant and severity of pain involved. Pharmacologic interventions require a physician’s order. Pain management should be individualized in each case, taking into account the risks and benefits 1. Medications: a. L-M-X Cream: • L-M-X contains a 4% concentration of lidocaine in a topical cream. • Common side effects are erythema, blanching, or slight edema. Guidelines for use: L-M-X may be used for term infants and infants greater than 30 weeks and greater than 750 grams, with intact skin, undergoing circumcision, PICC insertion or lumbar puncture. Do not use alcohol to cleanse skin prior to application. The dose of L-M-X is 0.5 ml applied to skin for one hour. Dose is limited to one application per 24-hour period. An occlusive dressing may be used but is not necessary b. Acetaminophen (Tylenol™):

Pain Management MULT-8310-611 Page 8 of 11 • May be used to treat mild to moderate pain or as an adjunct for moderate to severe pain. • Contraindication: G6PD deficiency Documentation of Pain Assessment and Interventions • Document assessment of pain on the flow sheet. • Document nonpharmacologic and pharmacologic interventions as pain relief measures. • Evaluate and document the infant’s response to the intervention(s) via reassessment on the flowsheet. • Record all medications. • Record all interactions with physician.

7.4 Appendix D: FLACC Behavioral Pain Assessment Scale The FLACC Behavioral Pain Assessment Scale Scoring Categories 0 1 2 No particular Occasional grimace or Frequent to A. Face expression or smile frown; withdrawn, constant frown, disinterested clenched jaw, quivering chin Normal position or Uneasy, restless, tense Kicking or legs B. Legs relaxed drawn up Lying quietly, normal Squirming, shifting back Arched, rigid, or C. Activity position, moves easily and forth, tense jerking No cry (awake or Moans or whimpers, Crying steadily, D. Cry asleep) occasional complaint screams or sobs; frequent complaints Content, relaxed Reassured by occasional Difficult to E. Consolability touching, hugging, or console or comfort being talked to; distractible Each of the five categories is scored from 0-2, resulting in a total score between 0 and 10 FLACC: behavioral scale was developed by Sandra Merkel, MS, RN, Terri Voepel-Lewis, MS, RN, and Shabha Malviya, MD, at C.S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI.

7.4 Appendix E: Physiologic/Behavioral Pain Scale: Pain level Patient Behavior Pain rating Absent Relaxed, calm expression 0 Mild Stressed, tensed expression 1,2,3 Moderate Guarded movement, grimacing 4,5,6 Severe Moaning, restless 7,8,9 Worst Pain Crying out, increased intensity of the 10 above behaviors

7.5 Appendix F: Unit based activities 7.5.1 Relaxation, breathing activities

Pain Management MULT-8310-611 Page 9 of 11 7.5.2 Diversional activities, focal points 7.5.3 Exercise (e.g., ambulation) 7.5.4 Positioning (e.g., elevation, pillow use) 7.5.5 Massage, therapeutic touch 7.5.6 Heat/cold therapy 7.5.7 TV, music 7.6 Appendix G: Activities/Treatments available 7.6.1 Occupational therapy: 7.6.1.1 Exercise 7.6.1.2 Modalities: Heat, cold, electrical stimulation, ultrasound, phonophoresis, iontophoresis and paraffin 7.6.1.3 Joint protection 7.6.1.4 Positioning 7.6.1.5 Pressure relief 7.6.1.6 Relaxation training 7.6.1.7 Splinting 7.6.1.8 Stress management 7.6.1.9 Posture, body mechanics and functional training to protect joints 7.6.1.10 Soft tissue and joint mobilization (upper extremities) 7.6.1.11 Wheelchair, cushion, pressure relief assessment 7.6.2 Physical Therapy: 7.6.2.1 Aquatic exercise 7.6.2.2 Cervical and pelvic traction 7.6.2.3 Exercise 7.6.2.4 Joint protection training 7.6.2.5 Modalities: heat, cold, electrical stimulation, ultrasound, whirlpool, phonophoresis and iontophoresis 7.6.2.6 Positioning 7.6.2.7 Posture, body mechanics and functional training to protect muscles and joints 7.6.2.8 Relaxation training 7.6.2.9 Soft tissue and joint mobilization 7.6.2.10 Stress management education 7.6.2.11 Transcutaneous electrical nerve stimulation (TENS) 7.6.2.12 Wheelchair, cushion, pressure relief assessment 7.6.3 Recreational Therapy: 7.6.3.1 Diversion 7.6.3.2 Exercise 7.6.3.3 Yoga 7.6.3.4 Relaxation training 7.6.3.5 Stress management education 7.6.3.6 Tai Chi 7.6.3.7 Leisure education, awareness 7.6.4 Speech Therapy: 7.6.4.1 Assessment for appropriate food consistency 7.6.4.2 Assessment for positioning and exercises for appropriate swallow 7.6.4.3 Voice, vocal hygiene

Pain Management MULT-8310-611 Page 10 of 11 7.7 Appendix H: Pain clinic treatments and adjunctive therapies 7.7.1 The Pain Clinic has treated the following diagnoses: 7.7.1.1 Spinal stenosis (lumbar, thoracic, cervical) 7.7.1.2 Lumbar radiculopathy 7.7.1.3 Cervical radiculopathy 7.7.1.4 Thoracic radiculopathy 7.7.1.5 Vertebral fractures 7.7.1.6 Post-herpetic 7.7.1.7 Migraine 7.7.1.8 Trigeminal neuralgia 7.7.1.9 Reflex sympathetic dystrophy (upper and lower extremitities) 7.7.1.10 Failed back syndrome 7.7.1.11 Fibromyalgia 7.7.1.12 Myofascial syndrome 7.7.1.13 Arachnoiditis 7.7.1.14 General neuralgia 7.7.1.15 Herniated disc 7.7.1.16 Protruding disc 7.7.1.17 Bulging disc 7.7.1.18 Post-dural puncture 7.7.1.19 Greater trochanteric bursitis 7.7.1.20 7.7.2 Pain Clinic Treatments: 7.7.2.1 Steroid epidural injections 7.7.2.2 Trigger point injections 7.7.2.3 Narcotic epidural injections 7.7.2.4 Narcotic epidural catheters 7.7.2.5 Sympathetic blocks 7.7.2.6 Intercostal nerve blocks 7.7.2.7 Greater occipital blocks 7.7.2.8 Sphenopalliative blocks 7.7.2.9 Trigeminal nerve blocks 7.7.2.10 Sacroiliac joint injection 7.7.2.11 Interscalene block 7.7.2.12 Ilio-inguinal injections 7.7.2.13 Stellate ganglion blocks 7.7.2.14 Celiac plexus block 7.7.2.15 Blood patch 7.7.2.16 Narcotic pumps 7.7.2.17 TENS units 7.7.2.18 Dorsal column stimulators 7.7.3 Adjunctive Therapies: 7.7.3.1 Medications including but not limited to: 7.7.3.1.1 NSAIDS 7.7.3.1.2 Medrol Dose packs 7.7.3.1.3 Muscle relaxants 7.7.3.1.4 Anti-virals 7.7.3.1.5 Neurontin, Amitriptyline and Lidoderm patches 7.7.3.1.6 Narcotics, rarely - these are usually reserved for cancer patients. 7.7.3.2 Referrals to:

Pain Management MULT-8310-611 Page 11 of 11 7.7.3.2.1 PT 7.7.3.2.2 Psychiatric care 7.7.3.2.3 Orthopedic or neurosurgeons 7.7.3.2.4 Continuing care 7.7.3.3 Diagnostic tests include: 7.7.3.3.1 MRI 7.7.3.3.2 CT 7.7.3.3.3 Xrays 7.7.3.3.4 EMGs 7.8 Appendix I: Pain control benefits and outcomes (Refer to the patient handbook) 7.9 Appendix J: Pain indicators 7.9.1 %PRN vs scheduled pain meds 7.9.2 % of IM/SC vs IV route 7.9.3 % Demerol usage 7.9.4 The patient’s pain level is assessed on initial presentation. 7.9.5 The patient is assessed for pain at least once per shift. 7.9.6 An approved pain measurement scale is used to assess pain. 7.9.7 The patient’s pain is reassessed after each pain-relieving intervention. 7.9.8 If the patient’s pain was not adequately relieved or controlled, further intervention is done. 7.9.9 The patient’s need for continuing pain relief or control is assessed as part of the discharge plan (i.e., patients discharged with pain ratings below 5). 7.9.10 For the first 24 hours postop: 7.9.10.1 The intensity of pain is assessed and documented with a numeric or verbal description. 7.9.10.2 Pain intensity is documented at suitable intervals. 7.9.10.3 Pain is treated by a route other than IM. 7.9.10.4 Pain is treated with regularly administered analgesics. 7.9.10.5 A balanced approach is used to treat pain (i.e., combination of opioid and non-opioids). 7.9.10.6 Pain is treated with non-pharmacologic interventions in addition to analgesics. 7.9.11 Assess for interference of pain in daily activities. 7.9.12 For ambulatory surgery: 7.9.12.1 Pain is assessed in the preop assessment. 7.9.12.2 Pain is assessed minimally at least with assessment and vital signs. Pain is scored on a scale of 0-10 and recorded with the vital signs. 7.9.13 Side effects for analgesics. 7.9.14 For ER: 7.9.14.1 Add a pain section for patients who may go straight home after ER visit. 7.9.14.2 Location 7.9.14.3 Time of onset 7.9.14.4 Duration 7.9.14.5 Quality (dull, ache, pressure, constant, cramping or heavy) 7.9.14.6 Intensity (0-10) 7.9.14.7 Patient satisfaction