Download Pain Management PC 104 - Sonoma Valley Hospital

Title: PAIN MANAGEMENT
Sonoma Valley Hospital
Sonoma Valley Healthcare District
Policy and Procedure
Organizational
Number: PC-104
Page: 1
Effective Date:
Mary Kelly, R.N., M.P.A.
Approved By
12/07
Date
3/96
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:
|______|_______|________|________|________|_______|_______|_______|______|______|
0
No
Pain
1
2
3
Mild
Pain
4
5
Moderate
Pain
6
7
8
Severe
Pain
9
10
Worst
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.
Title: PAIN MANAGEMENT
Sonoma Valley Hospital
Sonoma Valley Healthcare District
Policy and Procedure
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.
Title: PAIN MANAGEMENT
Sonoma Valley Hospital
Sonoma Valley Healthcare District
Policy and Procedure
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
Sonoma Valley Hospital
Sonoma Valley Healthcare District
Policy and Procedure
Department of Nursing-OB
Title: Pain Assessment in Newborns
Number: PC (OB)-104.1
Page: 1
Effective Date:
Jerome Smith, MD
Approved By
Signature on file
Signature
1/08/08
Date
09/04
Revision Dates:
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.
Sonoma Valley Hospital
Sonoma Valley Healthcare District
Policy and Procedure
Department of Nursing-OB
Title: Pain Assessment in Newborns
Number: PC (OB)-104.1
Page: 2
Neonatal Infant Pain Scale (NIPS)
Face
0
Relaxed Muscles
Restful face, neutral
expression
Cry
No Cry
Quiet, not crying
Breathing Patterns
Relaxed
Usual patterns for this
baby
Arms
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
Legs
State of Arousal
1
Grimace
Tight facial muscles,
furrowed brow, chin, jaw
(negative facial
expression-nose, mouth,
and brow)
Whimper
Mild moaning,
intermittent
2
Vigorous Cry
Loud screaming, rising,
shrill, continuous (Note:
Silent cry may be scored
if baby is intubated, as
evidenced by obvious
mouth, facial movement)
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
REFERENCES
UCSF Intensive Care Nursery Policy and Procedure Manual, 2004-2005
Gallo, A. (2003). The Fifth Vital Sign: Implementation of the Neonatal Infant Pain Scale. Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 32, 199-206.
ACCOUNTABILITY/RESPONSIBILITY FOR REVIEW
Manager of Perinatal Services
Attachment A
NATIONAL INSTITUTES OF HEALTH
PAIN INTENSITY INSTRUMENTS CRIES Pain Scale
Date/
Time
Score
Date/
Time
Score
Date/
Time
Score
Date/
Time
Score
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 O2 for SaO2 < 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
*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: 53-61.
CRIES Pain Scale