Download pain management care evaluation and planning

PAIN MANAGEMENT CARE EVALUATION AND PLANNING
Excerpted from MCM 11-88 Pain Management Policy
A. Pain Management Care Planning: An interdisciplinary, multimodal approach should be used for
effective pain management throughout the patient’s continuum of care.
1. Clinical decisions related to pain control are to be made based upon the following assumptions:
a. Prevention is the primary goal of pain management.
b. The most reliable indicator of pain is the patient’s self-report.
c. Complete pain control is not possible in all situations. Pain that is established and severe
is difficult to control.
d. A pain rating of 3 or less on the 0-10 Numeric Rating Scale (NRS) is defined as pain
under control.
e. When the cause of acute pain is uncertain, establishing a diagnosis is a priority, but
symptomatic treatment of pain should be initiated while the investigation proceeds. It is
rarely justified to defer analgesia until a diagnosis is made (from: Pace and Burke, 1996,
American Pain Society, 2003).
f. The same principles of pain management that guide care of the nonaddicted should be
applied to the addicted patient (Newshan, 2000).
g. Lack of pain expression does not mean absence of pain. Pain will be actively assessed; it
is not acceptable to wait for the patient’s report (VHA Directive, 2003).
h. The deceptive use of placebos and the misinterpretation of the placebo response to
discredit the patient’s pain report are unethical and should be avoided (American Pain
Society, 2003). Placebos should not be used by any route of administration in the
assessment and management of pain in any patient regardless of age or diagnosis
(American Society of Pain Management Nurses Position Statement, Use of Placebos,
2001).
2. The Interdisciplinary Team (IDT) includes as indicated, nurses, medical staff, pharmacists, social
workers, chaplains, physical medicine and rehabilitation, and other clinical staff. The IDT is
responsible to screen, assess and educate patients, document a plan of care and manage the
treatment of pain. It is the responsibility of the IDT to include the patient’s family or significant
others in this process when possible.
3. Chaplain Service will provide spiritual evaluation, support and counsel to patients who
experience spiritual distress related to pain or pain management issues.
4. Mental Health Service clinicians will serve as a resource to the IDT for patient assessment and
the provision of psychotherapeutic interventions related to pain management care.
B. Referral to Pain Consultative Services: Physical Medicine and Rehabilitation Service physiatrist will
see complex pain management patients in clinic by referral and serve as a resource for pain
management care planning to other providers. Pain management continues to be the responsibility of
the patient’s primary care provider or attending physician in conjunction with appropriate
consultations.
C. Pain Scoring: Patients are asked whether they are experiencing pain and if positive, then asked to
rate the intensity of their pain using the 0 – 10 NRS. The number reported is the pain score. Any
clinical staff member may conduct pain scoring.
1. Scoring for pain intensity will be done using the NRS at the following times:
a.
b.
c.
d.
e.
f.
g.
h.
Each time vital signs are taken.
At the time of admission, transfer or discharge.
At regular assessment and reassessment times designated by unit or service procedure.
At each report of pain and after intervention to document effectiveness.
Before and after pain medication is administered.
Before, during and after procedures that are expected to cause pain.
At every primary care clinic visit
At any clinic visit where the reason for the visit is pain-related or there is an expectation
that pain will result.
i. At any other clinic visit that is the only visit on that day.
j. An exception to these standards is when a clinical protocol calls for vital signs to be taken
at more frequent intervals than would be appropriate for rating pain. Example: Vital signs
ordered q 5 min. for purposes of monitoring an unstable patient: in that situation,
frequency of scoring and documentation of pain intensity will be based on the scoring
standards other than vital signs.
2. The NRS has been chosen by VHA as the tool for pain scoring because a large body of research
supports its reliability and validity as an index of pain intensity and severity. The NRS is scored
0 – 10, with 0 representing no pain, 1 –3 mild pain, 4 – 6 moderate pain and 7 – 10 severe pain.
Some patients may not relate well to the NRS and may only be able to state that pain is “mild”,
“moderate” or “severe” or to answer “yes” or “no”. The NRS may not be useful for these
patients, and alternative methods of pain scoring may be necessary. The preferred alternative to
the NRS is the Faces Scale.
3. Patients who are unable to express themselves, confused, or otherwise cognitively impaired also
need to have a pain score determined and documented. The Pain Assessment in Advanced
Dementia (PAINAD) tool, a five-item observational tool with a range of 0-10 was developed to
determine the pain score in non-communicative persons with advanced dementia. The PAINAD
tool has been tested for interrater reliability and construct validity and was found to facilitate the
detection and measurement of pain in persons with advanced dementia (Warden, Hurley &
Volicer, 2003).
4. Determining a numeric pain score for a patient who cannot give a report may not be possible;
however, a decision may be made about whether the patient is in pain by using other sources of
information. The following sources of data about a patient’s pain are listed in order from most to
least reliable:
a.
b.
c.
d.
e.
The patient’s report.
Presence of pathologic conditions or procedures expected to cause pain.
Patient behaviors (Use PAINAD).
Proxy reports by family or significant others.
Physiologic measures.
NOTE: Items b through e may be used alone or in combination to determine whether a patient is in
pain, ONLY IF THE PATIENT IS UNABLE TO REPORT.
5. Behaviors potentially indicative of pain:
a.
b.
c.
d.
e.
Crying
Moaning
Yelling
Facial grimacing
Body posturing
f.
g.
h.
i.
j.
Guarding
Restlessness
Agitation/aggressiveness
Frequent ambulation
Withdrawal
6. The Pain Assessment Scale and the PAINAD Tool are approved for use to score pain throughout
the Medical Center. Both include instructions for use. (See Attachments 1 & 2)
7. Documentation of pain scores in a systematic and consistent manner is an important mechanism
for promoting identification of unrelieved pain at the individual patient care level. It is also the
first step toward implementation of a single standard of care and a medical center-wide approach
to improving pain management. Availability of pain scores provides important information about
the presence and intensity of pain problems and serves as an index for monitoring improvement
in pain management.
Pain scores will be documented in the electronic medical record through use of the CPRS vital
sign package. In the Intensive Care Unit, numeric pain scores are documented electronically
using the CareVue System.
8. A pain score of 4 or greater, or a lessor score that is unacceptable to the patient, will require a
comprehensive pain evaluation or a pain reevaluation. In this situation, the score must be
reported to clinical staff that can complete a pain management plan.
D. Pain Evaluation: All patients with a new report of pain will have a comprehensive pain evaluation at
that time. A licensed clinician must complete the comprehensive pain evaluation which includes the
following components:
1. Clinical interview: Comprehensive evaluation of pain is based on a model that emphasizes
biopsychosocial contributors to the experience of pain. The primary mode of evaluation is the
clinical interview which consists of the following elements:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Intensity (Current pain score)
Location
Onset
Quality
Associated symptoms
Aggravating and alleviating factors
Current treatment
Effectiveness of current treatment
Effect of pain on function
The patient’s goal for pain relief (On the NRS 0 – 10)
Patient’s knowledge, expectations and preferences for pain management methods,
considering their cultural, spiritual and/or ethnic beliefs
l. Education about pain and pain management
2. Psychological assessment including presence of symptoms such as anxiety or depression,
availability of psychosocial support systems and coping responses to stress or pain.
3. Patient education (including significant others when possible) includes the following:
a. Pain management is a part of treatment.
b. Instructions of how, when and to whom to report about pain and pain relief.
c. A patient who chooses a goal for pain control greater than 3 will be educated about the
associated risks.
4. Specific timeframe for reevaluation, i.e., pain score >3. (See Attachments 3,4 & 5 Pain
Algorithms)
E. Pain Management Assessment and Plan: This is completed by the appropriate provider, taking the
information contained in the pain evaluation into account and contains the following additional
components:
1. A thorough physical examination that focuses on the reported pain.
2. Additional medical diagnostic procedures.
3. Patient education (including significant others when possible) including the following:
a. Information about available and appropriate methods of pain relief, including both
pharmacological and nonpharmacological interventions, and the possible positive and
negative outcomes of each.
b. General information about pain and pain management.
c. The pain management plan.
d. How to reach the healthcare provider when pain management is not effective.
4. Summary of impressions and diagnosis.
5. Detailed plan of pain management/treatment.
F. Reevaluation: Ongoing data collection, comparing the most recent data with previously collected
data, based on the treatment regimen and the patient’s response. Reevaluation occurs:
1. When there is a change in the patient’s condition;
2. When current pain management interventions are ineffective, thus placing the patient at risk for
pain not under control; and
3. At times designated by evaluation protocols which vary according to clinical setting and differ
among primary, acute, mental health and long-term care settings. (See Attachments 3, 4 & 5 Pain
Algorithms)