SUBJECT: PAIN MANAGEMENT 1. PURPOSE: COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 317 Effective Date: August 31, 2006 This nursing policy will provide guidelines for appropriate assessment, evaluation, and treatment of pain. a. To provide an organized and comprehensive approach for the assessment and management of pain b. To provide support and care for persons experiencing pain c. To reduce the incidence and severity of their pain d. To educate the Individuals about the importance of asking promptly for pain evaluation in order to receive effective treatment (since pain is easier to prevent than to try and control once it becomes intolerable) 2 POLICY: 1. Pain assessment is considered the 5 th Vital Sign, and shall be included each time that a Individual s temperature, pulse, respiration and blood pressure (T-P-R, B/P) are assessed and recorded. 2. All Individuals shall be assessed by a Registered Nurse for the presence of pain on admission on the Initial Nursing Assessment, when a significant change in condition has occurred, and/or at least monthly. 3. All nursing staff are responsible for the screening of pain. If during the screening process it is determined the Individual has current pain, or has had pain in the recent past, the Individual will be referred to the Registered Nurse for further assessment. 4. The Registered Nurse shall assess each Individual for pain when screening questions are affirmative for pain, when a significant change in conditions occurs. The Individual may have more than one pain site of pain. Each site will be assessed independently. 5. At the time of admission, all Individuals shall be informed of their rights to have relief from pain. All Individuals will receive information about treatment of pain upon admission to CSH and annually thereafter on a 1:1 basis, or in Therapeutic Community meeting. The Pain Management Brochure will be utilized to assist with this education. 6. Nursing personnel are expected to provide Individual teaching/instruction regarding pain management to assist with gaining Individual cooperation with the procedure and to promote Individual involvement and partnership - 1 -
in their treatment. All Individual teaching shall be documented on the Wellness and Recovery Individual/Family Health Education Record. 7. When pain is an identified problem, a nursing care plan will be established. Individualized pain management goals will be identified and regular assessments will take place until the problem is resolved. Pain assessment includes: location, precipitating factors, quality of pain, radiation, severity, timing including onset and duration, character (includes intensity), and frequency, effects of pain assessment should also include other dimensions such as age specific, cultural, psychological and/or spiritual distress. SOAP format will be used to describe the pain management status. 3. GENERAL INFORMATION: Fear and reality of pain are major problems for the Individual and the Individual s family. Pain may arise from actual or potential tissue damage, from disease, trauma or from surgical procedures. Substances released from injured tissues can cause breakdown of body tissue, increased metabolic rate, water retention, blood clotting, and delayed healing (i.e. Individual may not cough due to chest pain or digestive and bowel function may be impaired do to pain). According to the American Pain Society (APS), pain is the most common reason individuals seek medical attention and pain is often under treated. According to the International Association for the Study of Pain, Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage or both. Pain may include a range of physical and mental sensations, such as aching, tightness, numbness, and burning. These sensations may vary in severity, persistence, source, and management. Unrelieved pain can have negative physiological and psychological effects. For example, pain interferes significantly with mobility, sleep, eating, concentration, and social interactions, impairments of activities of daily living, causing anxiety and distress, as is the case with long term hospitalized Individuals. The Nursing Practice Act, Section 2725, states that the registered nurse provides direct and indirect Individual care services that insure the comfort of Individuals. The nursing function of appropriate pain management includes, but is not limited to assessing pain and evaluating response to pain management interventions using a standard pain management scale based on Individual self-report. Each Individual experiences pain in a different way. It is felt that the Individual knows bet about the intensity of this pain an dhow effectively different therapies relieve the pain. There are many important assessment areas staff must check when asking Individuals about their pain. Some people fear that if - 2 -
they admit that the pain is increasing, their conditions is worsening. Some Individuals feel that if they admit their pain is being relieved that their pain medication will be stopped and then their pain will return. Other aspects to consider, a Individual with chronic pain may not show severe pain in the way a Individual first experiencing pain might. Also, some cultures teach people to not tell others if they are experiencing pain. Some Individuals and staff have a fear of addiction, tolerance and side effects. Some clinicians have inaccurate and exaggerated concerns about addiction, tolerance, respiratory depression, and other opioid side effects, which lead them to be extremely cautious when using these drugs. Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with psychological dependence (addiction). Addiction is a pattern of compulsive drug use characterized by a continued craving for an opioid and a need to use the opioid fro effects other than pain relief. Tolerance for side effects of opioid medications except for constipation. Any Individual on an opioid medication needs to have a bowel care plan in place. 4. DEFINITIONS: Pain can be classified as either acute or chronic, acute pain is usually causes by an injury and lasts less than six months. Chronic pain is a persistent pain state existing beyond an expected time for healing, usually lasting six months or longer. Acute pain is the normal, predicated physiological response to an adverse chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and acute illness. It is generally time-limited and is responsive to opioid therapy, among other therapies. Chronic pain requires a comprehensive treatment; relying on the adequacy of past and present pain treatment geared toward treatment planning. It includes assessment of physiological, sensory, affective, cognitive, behavioral and sociocultural components. Pain Management is comprehensive, Wellness and Recovery approach to care for the needs of a Individual in acute, chronic, or cancer pain. When clinicians consistently observe a disparity between Individuals verbal selfreport of their pain and their ability to function, further assessment should be performed to ascertain the reason for the disparity. Severe pain should be considered a medical emergency, and timely aggressive management should be provided until the pain becomes tolerable. Pain Assessment: - 3 -
Pain screening assessment is now required as a fifth vital sign and is to be assessed at the same time as other vital signs are taken. Pain is to be assessed and treated promptly, effectively, and for as long as the pain persists. Pain assessment is performed in a manner that is appropriate to the Individual. The pain assessment shall be noted in the Individual s chart in a manner consistent with other vital signs. The Individual has the right to appropriate pain assessment and management. The Individual s self-assessment of his or her pain is included in the pain assessment and/or reassessments. ATTATCHMENT A PAIN ASSESSMENT GUIDELINES provides the pain management process of action steps to take when there is no pain, pain rating level 1-4, pain 5 or greater, and ongoing, chronic pain. Use of a pain scale lets the Individual describe pain in a way that is meaningful to the Individual. Some Individuals respond best to word scales; others find that pictures or number scales help them describe their pain intensity accurately. The scale helps the Individual quantify their current levels of pain. Pain assessment scales on a 1-10 scale are provided for standardized use. Pain scales used at CSH are the Nonverbal/Descriptive Pain Scale, Numeric Rating Scale, Wong-Baker FACES Scale, and the Visual Analog Scale. (SEE ATTACHMENT B Pain Scales) The Wong-Baker FACES Scales is most particularly used on the hearing impaired u nit. It is best used for cognitively impaired Individuals and those with limited language skills. Pain intensity rating scales: Non-Verbal/Descriptive Pain Scale Rating Observations 0 No signs of pain. Relaxed, calm expression 2 Least pain. Stressed, tense expressions; Only aware of pain when thinking about it 4 Mild pain. Guarded movement, grimacing; Can be ignored somewhat. Does not interfere with daily activities 6 Moderate pain. Moaning, restless; Able to continue with some physical activity. 8 Serious. Increased intensity of above behavior; Can t concentrate and can only do simple things. 10 Excruciating-Perspiration on upper lip/body; Cannot function. Must take care of pain - 4 -
Numeric Rating Scale 0 1 2 3 4 5 6 7 8 9 10 No Worst Pain Possible Pain WHEN IS PAIN SCREENED and/or ASSESSED? Whenever staff take a set of vital signs (blood pressure, temperature, pulse, respiration s) the Individual s physical pain level must be established When the Individual verbalizes having pain and/or when staff observe the Individual is in distress When pain medication is given, a pain rating is obtained before the PRN is given, within one hour after the PRN medication was given, and follow-up rating two hours after the medication. Appropriate follow-up action is needed if pain persists. When the Individual sustains an injury After surgery or dental extraction Monthly weights and vital signs Individual being prepared for Sick Call or to be seen by the MOD All health care staff are required to record pain screening results each time vital signs are recorded for each Individual. Using the zero to ten pain screening scale, if a Individual develops or complains of new pain (pain rating 1-4) the Registered Nurse will assess the Individual using the seven dimensions of pain assessment, document using SOAP format and notifies a physician. (See ATTACHMENT C for SOAP not writing criteria). The SOAP Note format is designed to guide the RN to evaluate the seven dimensions of pain assessment. SUBJECTIVE - provides for the Individual s self-report of pain from their perspective and perception using the seven dimensions Using the PQRST or OLD CART acronym focuses on the dimensions of pain evaluation. LOCATION of pain: Individual identifies where the pain is located - 5 -
PRECIPITATING Factors: any factors that relieve or aggravate the pain; quote Individual directly. Record their perception of whether medications or treatments have been effective. QUALITY of pain: What does the pain feel like? RADIATION of pain: Does the pain radiate to other parts of the body? SEVERITY of pain: Have the Individual evaluate the intensity of their pain by showing the Individual pain rating scales (1-10). TIMING of pain: onset, duration EFFECTS of pain on Individual s functioning: Individual identify effects of pain on daily functioning, daily activities OBJECTIVE = Observed physical responses to pain by staff, set of Vital Signs; assessment of physical pain site; physical symptoms observed psychosocial, cultural, or age-specific responses to pain; affect/mood/behavior. ASSESSMENT = Area of pain; baseline of behavior that seems to indicate pain PLAN = Action steps taken; physician notification; nursing care plan initiation if not open, or review/update current care plan; change of shift report; ID Team notification; provide summation for the Treatment Planning Conference Report. If a Individual develops or complains of new pain (pain rating 5 or greater) or if he or she is being treated for ongoing acute or chronic pain but it is not controlled, the RN will initiate the Registered Nurse PAIN EVALUATION tool CSH 7315 (SEE ATTACHMENT D) and notify the physician. Place evaluation in IDN sequence. Provide NCR copy for physician. Explore these points with the Individual: (Utilize the Pain Assessment Descriptive Prompts tool to assist with the pertinent descriptions. See ATTACHMENT E) Does the pain have a pattern? If so, does it vary? When was the pain most intense in the past 24 hours? Does anything relieve the pain or make it worse? Does the Individual take pain medication to manage the pain? If so, is it effective? Does it cause any unpleasant adverse reactions? Does the pain interfere with your daily activities: for example, sleeping or eating? - 6 -
Identify the Individual s acceptable level of pain. Utilize the Pain Management Flow Sheet CSH 7317 (SEE ATTACHMENT F) to document the non-pharmacological and/or pharmacological intervention(s). Identify the pain rating prior to giving medication or providing treatment(s). Evaluate the pain rating one-hour after and then again two-hours after the medication or treatment(s). Notify the physician if the pain rating remains above Individual s acceptable rating. The Individual is encouraged to be a part of their treatment. Provide the Individual the Personal Pain Control Record (SEE ATTACHMENT G). With this document, Individual is able to monitor the effectiveness of their pain medications and/or treatment(s). ASSESSING NON-VERBAL INDIVIDUALS: Although nothing is more reliable than the Individual s self-report of pain, nursing staff must rely on other information if the Individual cannot use a painrating scale. If, for example the Individual has a painful condition, or has undergone a painful procedure, nursing staff my have enough information to justify administering analgesics. Other pain indicators include: Distressed facial expressions and behavior- frowning, grimacing, crying, and expressions of fear or sadness. Look for muscle contraction around the mouth and eyes. Unusual movements (such as restlessness or slow, guarded, or rigid movements) or the absence of movement Attention-seeking behavior, such as repetitive banding or outbursts Vocalizations, such as groaning, moaning, crying, or noisy breathing. First, try to determine a baseline of behavior that seems to indicate pain. Evaluate changes in behavior after administration of an analgesic. After giving pain medication, evaluate the Individual s response in 30 to 60 minutes (depending on the drug and administration route) and follow-up again in two hours. Cultural aspects of pain management: Be sensitive to age-specific and culturally appropriate assessments. Keep in mind that cultural mores and personal values can affect the Individual s beliefs about pain and response to pain. Even if the Individual bears pain stoically, the Individual may admit to having pain if you ask the Individual directly, so always ask, and believe what he or she says. The Individual s self- - 7 -
report is the most accurate indicator of the existence and intensity of pain. Don t second-guess your Individual or assume that he or she is exaggerating because he or she is laughing or sleeping. Culture is the framework that directs human behavior in a given situation. The meaning and expression of pain and influenced by people s cultural background. Pain is not just a physiologic response to tissue damage but also includes emotional and behavioral responses based on an individuals past experiences and perceptions of pain. Not everyone in every culture conforms to a set of expected behaviors or beliefs, so cultural stereotyping (assuming a person will be stoic or very expressive about pain) can lead to inadequate assessment and treatment of pain. Many studies have shown that Individual from minority groups and cultures different from that of health care professionals treating them receive inadequate pain management. Healthcare professionals need to be aware of their own values and perceptions as they affect how they evaluate the Individual s response to pain and ultimately how pain is treated. Even subtle cultural and individual differences, particularly in nonverbal, spoken, and written language between healthcare providers and Individual s impact care. To be culturally competent, you must: Be aware of your own cultural and family values Be aware of your personal biases and assumptions about people with different values than yours Be aware and accept cultural differences between yourself and Individuals Understand the dynamics of the difference Adapt to, and respect diversity You must Listen with empathy to the Individual s perception of their pain. Explain you perception of the pain problem. Acknowledge the differences and similarities in perceptions, Recommend treatment, and Negotiate agreement. Questions that staff can use to help assess cultural differences in order to better assess and work out an appropriate pain management plan with a Individual include: What do you call your pain? Do you have a name for it? What do you think caused your [pain]? Why do you think it started when it did? What does your [pain] do for you? How severe is your [pain]? Will it have a long or short course? What are the most important results you hope to receive from the treatment? What are the main problems your [pain] has caused you? What do you fear most about your [pain]? - 8 -
Individual teaching key points: Help the Individual to understand why effective pain management is important and how uncontrolled pain can hamper recovery. Be open and flexible when assessing and planning for Individual (AND FAMILY IF APPROPRIATE) teaching and teach on the Individual s level. Consider his or her values and beliefs, culture, literacy, education level, language, emotional barriers to pain, relief, physical and cognitive function and limitations. Assess the Individual s level of comprehension and retention, and plan followup teaching sessions as appropriate. Document testing and the Individual s response to teaching in the IDN. Staff teaching key points: An overview of pain management will be provided during New Employee Orientation and WorkSite orientation to the policies and procedures for pain management. Updates and training awareness programs will be provide during National Pain Awareness Week (last week of February/first week of March). - 9 -