Sonoma Valley Hospital Sonoma Valley Healthcare District Policy and Procedure Organizational. Page: 1

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1 Title: PAIN MANAGEMENT Sonoma Valley Hospital Organizational Number: PC-104 Page: 1 Effective Date: 3/96 Mary Kelly, R.N., M.P.A. 12/07 Approved By Date Revision Dates: 07/01, 02/02 Signature on file Signature Review Dates: 05/01, 10/07 PURPOSE The relief of pain and suffering is integral to the mission of Sonoma Valley Hospital. Pain management and relief is a priority for the institution. We are committed to serving the people of the Sonoma Valley Health Care District. POLICY All patients have the right to have their pain relieved in a timely manner. The standard is to relieve the physical and psychosocial symptoms associated with pain, while maintaining the patient s level of function. Pain is intimately linked to overall quality of life. The relief of pain is also contingent upon treatment of the side effects associated with analgesia. Pain Intensity Scale used at SVH: No Mild Moderate Severe Worst Pain Pain Pain Pain Possible Pain The Wong-Baker Faces (see below) and CRIES scale (Attachment A) is used as well to assess pain in cognitively impaired adults, pediatrics and neonatal patients. PROCEDURE A. Assessment: The effective treatment of pain is contingent upon appropriate pain assessment. The features of pain assessment include: 1. The patient s report of pain is accepted as a gold standard. Pain is an extremely subjective experience and such; the patient is the best judge of the intensity and relief of pain. Lack of response, (i.e. neonate, cognitively impaired adult, preverbal pediatric patient) does not indicate a lack of pain perception. 2. Pain should be assessed on initial admission to the hospital or other setting. Pain assessment includes pain history, physical exam, and ratings of pain intensity and relief. 3. Ongoing pain assessment is necessary to evaluate the changing nature of pain, as well as the effectiveness of treatments for pain. Pain should be reassessed before and after each intervention.

2 Title: PAIN MANAGEMENT Sonoma Valley Hospital Organizational Number: PC-104 Page: 2 4. Nurses, physicians and other health care professionals providing direct care to the patient should assess pain. Assessments of pain should be communicated using both verbal report and written documentation. B. DOCUMENTATION 1. Pain assessment documented on admission. 2. Pain reassessed after intervention. C. PHARMACOLGICAL PAIN MANAGEMENT Pharmacological interventions continue to be the mainstay of pain management. Drug options include non-steroidal anti-inflammatory drugs (NSAIDS), opiates, and antidepressants. Optimum pain management requires a thorough investigation of the type, location, intensity, and duration of pain. The plan of care must be individualized, reevaluated and updated during hospital stay. D. NON-DRUG INTERVENTIONS: The relief of pain includes both drug and non-drug interventions for pain including interventions such as heat, cold and relaxation. These non-drug methods can enhance the patient s sense of control and add to the effectiveness of the pharmacological interventions. Non-drug interventions are not intended to replace analgesics, but rather are to be used as adjuncts to medicines. 1. Non-drug interventions are provided by many disciplines including physicians, nursing, physical therapy, occupational therapy, social work, and clinical psychology. 2. The responsibility for assessing the use of non-drug interventions and making suggestions for additions for non-drug treatments is that of the primary nurse caring for the patient. E. PROFESSIONAL EDUCATION 1. All patient care staff should be familiar with the standard of care for pain management. 2. All patient care staff is encouraged to be familiar with the standards of care for pain management and staff are to develop discipline specific education to be provided on an annual basis. 3. Pain education should be an ongoing activity to update the knowledge of staff. Pain education is to be provided to all new employees and students. F. PATIENT EDUCATION 1. Upon admission, each patient will receive an information pamphlet about pain. The admitting nurse will document receipt of information on the yellow education record. 2. Patient care staff to educate the patient/family/significant other about pain management including assessment, pain scale, planning, intervention, evaluation and patient s responsibilities to report pain. 3. The nurse and patient will collaboratively establish a desirable Comfort Zone utilizing a pain scale. PRN medications are to be given around the clock. Literature supports that the best way to manage pain is to prevent pain. 4. Instruct patients on side effects of analgesics: Nausea, constipation, and loss of appetite and methods to prevent complications.

3 Title: PAIN MANAGEMENT Sonoma Valley Hospital Organizational Number: PC-104 Page: 3 REFERENCES 1. World Health Organization 2. American Pain Society 3. Agency for Health Care Policy and Research ACCOUNTABILITY/RESPONSIBILITY FOR REVIEW ADON, CNO

4 Sonoma Valley Hospital Department of Nursing-OB Title: Pain Assessment in Newborns Number: PC (OB) Page: 1 Effective Date: 09/04 Jerome Smith, MD 1/08/08 Approved By Date Revision Dates: Signature on file Signature Review Dates: 12/07 PURPOSE To adequately assess pain in the neonate and, if necessary, provide interventions to alleviate pain. POLICY All infants need to be evaluated for pain like all other patients throughout the hospital. PROCEDURE A. All infants will be evaluated for pain with each set of vital signs using the attached Neonatal Infant Pain Scale (NIPS). The NIPS score will be documented on the unit specific flowsheet. B. In addition, a pain assessment score using the NIPS scale will be done each time a painful procedure is done on an infant and documented on the flowsheet. The score should be done before, during and after each painful procedure. These painful procedures may include, but are not limited to, heelsticks for blood glucose or newborn screening, IV catheter placement, intramuscular injections, or circumcision. C. When the NIPS score exceeds 2, identify source of pain and use appropriate nonpharmacological interventions: breastfeeding or bottle feedings, pacifier if parents consent, wrap in tight swaddle, rock in vertical position, reduce environmental stimulation, reposition to side-lying or prone position. After 15 minutes of intervention, repeat NIPS score. See Pain Assessment Algorithm. Record all interventions and infant s response on the back side of the unit specific flowsheet. D. If the infant has an elevated NIPS score, but has not undergone a recent painful procedure, remember to address the basic care needs first. The infant may appear to be in pain, but upon further investigation may simply be communicating his need for a diaper change or a feeding.

5 Sonoma Valley Hospital Department of Nursing-OB Title: Pain Assessment in Newborns Number: PC (OB) Page: 2 Face Cry Breathing Patterns Arms Legs State of Arousal Neonatal Infant Pain Scale (NIPS) Relaxed Muscles Grimace Restful face, neutral Tight facial muscles, expression furrowed brow, chin, jaw (negative facial expression-nose, mouth, and brow) No Cry Quiet, not crying Relaxed Usual patterns for this baby Relaxed/ Restrained No muscular rigidity, occasional random movements of arms Relaxed/ Restrained No muscular rigidity, occasional random movements of legs Sleeping/ Awake Quiet, peaceful, sleeping or alert and settled Whimper Mild moaning, intermittent Change in Breathing In-drawing, irregular, faster than usual, gagging, breath holding Flexed/ Extended Tense, straight arms, rigid and/ or rapid extension, flexion Flexed/ Extended Tense, straight legs, rigid and/ or rapid extension, flexion Fussy Alert, restless, and thrashing Vigorous Cry Loud screaming, rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated, as evidenced by obvious mouth, facial movement) REFERENCES UCSF Intensive Care Nursery Manual, Gallo, A. (2003). The Fifth Vital Sign: Implementation of the Neonatal Infant Pain Scale. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32, ACCOUNTABILITY/RESPONSIBILITY FOR REVIEW Manager of Perinatal Services

6 Attachment A NATIONAL INSTITUTES OF HEALTH PAIN INTENSITY INSTRUMENTS CRIES Pain Scale Crying - Characteristic cry of pain is high pitched. 0 No cry or cry that is not high-pitched 1 - Cry high pitched but baby is easily consolable 2 - Cry high pitched but baby is inconsolable Requires O 2 for SaO 2 < 95% - Babies experiencing pain manifest decreased oxygenation. Consider other causes of hypoxemia, e.g., oversedation, atelectasis, pneumothorax) 0 No oxygen required 1 < 30% oxygen required 2 > 30% oxygen required Increased vital signs (BP* and HR*) - Take BP last as this may awaken child making other assessments difficult 0 Both HR and BP unchanged or less than baseline 1 HR or BP increased but increase in < 20% of baseline 2 HR or BP is increased > 20% over baseline. Expression - The facial expression most often associated with pain is a grimace. A grimace may be characterized by brow lowering, eyes squeezed shut, deepening naso-labial furrow, or open lips and mouth. 0 No grimace present 1 Grimace alone is present 2 Grimace and non-cry vocalization grunt is present Sleepless - Scored based upon the infant s state during the hour preceding this recorded score. 0 Child has been continuously asleep 1 Child has awakened at frequent intervals 2 Child has been awake constantly Total Score Date/ Date/ Date/ Date/ Time Time Time Time Score Score Score Score *Use baseline preoperative parameters from a non-stressed period. Multiply baseline HR by 0.2 then add to baseline HR to determine the HR that is 20% over baseline. Do the same for BP and use the mean BP. Indications: For neonates (0 6 months) Instructions: Each of the five (5) categories is scored from 0-2, which results in a total score between 0 and 10. The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to CRIES Scale scores. Reference Krechel, SW & Bildner, J. (1995). CRIES: a new neonatal postoperative pain measurement score initial testing of validity and reliability. Paediatric Anaesthesia, 5: CRIES Pain Scale

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