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Pain Management and
River Valley Health
The following educational presentation offers the
healthcare provider a deeper foundation for successful
pain management.
There are five sections in this presentation.
A quiz will follow each section and will be used as a
indicator of learning.
Good Luck and Enjoy!
Acute Pain Services
SECTION 1
MISSION
PHILOSOPHY
GOALS
PAIN MANAGEMENT!!
…but WHY??
RVH MISSION
STATEMENT
River Valley Health (RVH) values effective
pain management.
Pain Management is a priority and we strive
for effective pain management through
evidence-based pain assessment and pain
management strategies providing appropriate
education for patients, families and health
care professionals.
Pain Management
Philosophy
Patients have a right to pain
management
Patients have a right to be assessed
Patients have a right to be involved
Patient’s self-report is most reliable
Pain management is a team approach
and,
is an ethical responsibility.
RVH Goals to Pain
Management
To assess on a individualized level
To encourage patient participation
To address barriers to effective pain
management
To promote an interdisciplinary
approach
To ensure medication safety
Individualized Pain
Assessments
Systematic and thorough pain
assessments provide a
baseline for pain
management.
Patient Participation
IS CRUCIAL
Patients need to know the
benefits of pain management
as well as the importance of
self reporting.
Barriers to Pain Management
Barriers will be addressed through:
Literature reviews
Mentoring
Family involvement
Education of patients, family and health
care providers
Knowledge and attitude assessments
Interdisciplinary
Approach
Interdisciplinary teams will be involved in
customizing and optimizing each
patient’s pain management plan.
Multimodal approaches will be used
combining pharmacology and nonpharmacology interventions.
Patient Safety
Medication and other treatment
modalities will consider all
aspects of patient uniqueness
such as age and health status.
SECTION I
SECTION II
Pain Assessment
INITIAL COMPREHENSIVE
ASSESSMENTS
DOES THE PATIENT REPORT PAIN?
DEVELOP A BASELINE FOR PAIN
MANAGEMENT
ADDRESS CRUCIAL COMPONENTS
“P” “Q” “R” “S” “T” & “M”
CRUCIAL
COMPONENTS!
“P” - Provoking or precipitating factors
“Q” - Quality (aching, throbbing etc.)
“R” - Region and/or radiation
“S” - Severity and symptoms
“T” - Timing (occasional, intermittent, constant)
“M” - Medication (use and adverse effects)
Observe the patient for non-verbal
indicators of pain, eg. frowning,
grimacing, or reluctance to move/cough.
Consider using words such as
soreness, discomfort, aching when
assessing for the presence of pain.
Use behavioral indicators to identify the
presence of pain in nonverbal patients.
Comprehensive Pain Assessments
include:
physical examination
relevant laboratory and diagnostic tests
medication usage and adverse effects
understanding of current illness
effect of pain on function and ADL’s
coping responses to stress and pain
psychological – social variables (anxiety, depression)
personal preferences and expectations/beliefs/myths
about pain and its’ management
history of chronic pain
past success or failure with management, including
non-pharmacological interventions
socio-cultural variables (e.g. ethnicity, cultural beliefs) that
may affect pain behavior and treatment, and
caregiver or family reports of pain.
Self-Reports
Self-report is the primary source of assessment
for verbal, cognitively intact persons.
Family and care provider reports of pain are
included for children and adults unable to give
self report.
Frequency of Reassessment
Pain will be reassessed on a regular basis according to
the type and intensity of pain and the treatment plan.
At least once per shift for inpatients.
Before and after any known pain producing
procedure.
With each new report of pain
When intensity increases
When pain is not relieved by previously effective
strategies.
Note: Pain is reassessed after the intervention has
reached peak effect
Pharmacological Interventions,
Medication Routes and Reassessment Times
Pharmacological Intervention/Medication route
Optimal Reassessment Time (Peak effect)
IV therapy
SC or IM therapy
15-30 minutes
15-40 minutes
Immediate release oral therapy
Sustained release oral therapy OR
transdermal patch therapy
1 hour
4 hours
Epidural or patient controlled analgesia (PCA)
**At least every two hours for the first 24 hours; then every 4
hours while on the Acute Pain Service.
Note: Level of sedation will be assessed with opioid therapy.
Assessment Tools
The RVH standard assessment tool is the 0-10
pain intensity scale.
Appropriate Tools
Assessment tools should consider:
• age (developmental appropriateness)
• cognitive function (impairment)
• language impairment, and/or language
barriers.
NOTE: If an alternate tool is used, the tool selected will be reliable, valid geared
toward the individual. The health record will clearly state which pain
assessment tool was used.
Assessment of Unexpected Pain
Unexpected pain will be immediately
evaluated in the context of the patient’s
current health status, and will include a
thorough assessment of the patient
presenting problem, and recent
intervention's).
Assessment in the Paediatric
Population
Children may need encouragement to report pain. Fear of the
consequences of reporting pain, such as receiving an injection is
common.
Self-report tools are useful and reliable in the paediatric population.
Children as young as 3 years of age can reliably rate pain intensity.
For pediatric patients, the Wong-Baker 0-10 FACES scale is used.
For children, consider the following:
Ask the parent/guardian's) the words a child might use to describe
pain, and observe the child for signs/behaviors indicative of pain.
Assessment of pain in the
cognitively impaired
Patients with cognitive impairment CAN provide an accurate report of
pain/ discomfort.
For the frail elderly, non-verbal or non-cognizant
persons, screen the patient to assess if the following
markers are present:
•
•
•
•
•
•
•
Patient states he/she has pain.
Change in the patient’s condition.
Patient is diagnosed with a chronic painful disease.
History of chronic unexpressed pain.
Patient has received pain medication for >72 hours.
Distress related behavior or facial grimacing is present.
Family/ caregivers indicate that pain is present.
SECTION II
SECTION III
Intervention
for Pain
Management
The RVH Pain Care Committee
has reviewed the current literature
for effective pain management
and provides the following
guidelines for clinicians
ADVOCATE…TAILOR…CONSIDER
Advocate for the use of the most effective analgesic
dosage and least invasive pain management
modalities.
Tailor the route to the individual and care setting.
Consider the options.
Note: The oral route is the preferred route for persistent pain and for acute pain as healing occurs.
IV administration is the parenteral route of choice after major surgery, usually via bolus and
continuous infusion. A butterfly injection system is often used to administer intermittent
subcutaneous analgesics.
REFERRALS
Refer persons with persistent pain whose
pain is not relieved after following standard
principles of pain management.
Refer to a multidisciplinary team member with the
expertise in the area of concern, the complex
emotional, psycho/social, spiritual and
concomitant medical factors involved.
DRUGS
The three major classes of drugs that are
used alone or, more commonly, in
combination to manage pain are:
non-opioid analgesics
opioid analgesics, and
adjuvant medications.
Step-wise Approach
Select the analgesics which are appropriate to match the
intensity of pain (unless contraindicated due to age,
renal impairment or other issues related to the drug).
Mild to moderate pain - acetaminophen or NSAIDS (unless
the person has a history of ulcers or a bleeding disorder.
Moderate to severe pain - initially use an opioid analgesic,
taking into consideration previous opioid use and
adverse effects.
Note: The use of the WHO Analgesic ladder
is recommended for the treatment of
chronic cancer pain.
TIMING is everything!
Recognize that opioids should be administered
on a regular time schedule according to the
duration of action and depending on the
expectation regarding the duration of severe
pain.
• If severe pain is expected for 48 hours post-operatively, routine
administration may be needed for that period of time.
• Late in the post-operative course, analgesics may be effective given
on an as needed basis.
• In persistent cancer pain, opioids are administered on an around the
clock basis, according to their duration of action. Long acting opioids
are more appropriate when dose requirements are stable.
Intramuscular route…
is not recommended because it is painful and
absorption is not reliable. So….avoid this
route when possible.
Note: Meperidine is not recommended for the treatment of pain, it is
contraindicated in persistent pain due to the buildup of the toxic
metabolite normeperedine, which can cause seizures and dysphoria.
Meperidine toxicity is not reversible by naloxone.
Equianalgesic Table
Use a table to ensure equivalency when
switching analgesics.
Parenteral
(IM/SC/IV)
(over ~4h)
Opioid
Mu Agonists
Oral
(PO)
(over ~ 4 h)
Onset
(min)
Peak
(min)
Duration
(h)
Morphine
10 mg
20-30 mg
30-60 (PO)
5–10 (IV)
10-20 (SC)
10-20 (IM)
60-90 (PO)
15-30 (IV)
30-60 (SC)
30-60 (IM)
3-6 (PO)
3-4 (IV)
3-4 (SC)
3-4 (IM)
Fentanyl
100 ug/h parenterally and transdermally ≅ 4 mg/h morphine
parenterally;
______
1-5 (IV)
7-15 (IM)
12-16 h (TD)
3-5 (IV)
10-20 (IM)
24 h (TD)
0.5-1 (IV)
1-2 (IM)
48-72 (TD)
1 ug/h transdermally ≅ morphine 2 mg/24 h orally
Hydromorphone (Dilaudid)
2mg
4-6mg
Up to 7.5 mg
15-30 (PO)
15-30 (R)
5 (IV)
10-20 (SC)
10-20 (IM)
30-90 (PO)
30-90 (R)
10-20 (IV)
30-90 (SC)
30-90 (IM)
3-4 (PO)
3-4 (R)
3-4 (IV)
3-4 (SC)
3-4 (IM)
Meperidine (Demerol)
75 mg
300 mg NR
NR=not
recommended
30-60 (PO)
5-10 (IV)
10-20 (SC)
10-20 (IM)
60-90 (PO)
10-15 (IV)
15-30 (SC)
15-30 (IM)
2-4 (PO)
2-4 (IV)1.3
2-4 (SC)
2-4 (IM)
Codeine
130 mg (Usually 30-60 mg dose given)
200 mg
NR=not
recommended
30-60 (PO)
10-20 (SC)
10-20 (IM)
60-90 (PO)
UK (SC)
30-60 (IM)
3-4 (PO)
3-4 (SC)
3-4 (IM)
Oxycodone
* Not given parenteral
10-30mg
10-15 (po)
2-4 (po)
Monitor
...patients taking opioids for potential toxicity.
Watch for unacceptable adverse effects:
myoclonus
confusion
delirium refractory to prophylactic treatment.
Note: In the presence of inadequate pain relief advocate for a change in
treatment plan as required.
Anticipate
…that individuals taking opioids may have
common adverse effects such as nausea and
vomiting, constipation and drowsiness. Institute
prophylactic treatment as appropriate.
Recognize
…that anti-emetics have different
mechanisms of action and selection of the
right anti-emetic is based on this
understanding and etiology of the
symptom.
Constipation
Use prophylactic measures for the
treatment of constipation unless
contraindicated.
Laxatives should be prescribed and
increased as needed to achieve the
desired effect as a preventative measure
routine administration of opioids.
Addiction? Tolerance?
Dependence?
Clarify the difference between addiction,
tolerance and physical dependence to
alleviate misbeliefs that can prevent
optimal use of pharmacological methods
for pain management.
Addiction
Addiction is a psychological dependence
and is rare with persons taking opioids for
persistent pain.
Tolerance
Persons using opioids on a long term
basis for pain control may be on the same
dose for years, but may require upward
adjustments of dosage with signs of
tolerance.
Tolerance is usually not a problem and
people can be on the same dose for years.
Dependence
Persons who no longer need an opioid after
long term use need to reduce their dose
slowly over several weeks to prevent
withdrawal symptoms because of physical
dependence.
Safe Medication Prescription and
Ordering
The implications of medication treatments on
specific patient populations will be taken into
consideration, including, but not limited to:
•
•
•
•
•
•
the elderly
paediatric populations
patients with polypharmacy
patients with addiction issues
patients who are cognitively impaired, and
patients with a history of sleep apnea
Interdisciplinary
Approach
The care of persons experiencing pain may be carried
out by an interdisciplinary team member:
physicians
nurses
pharmacists
psychologists
social workers,
and other therapeutic services.
Provider’s roles and responsibilities are determined by the
organization’s
policies, the providers scope of practice / standards of practice
professional
Non-Pharmacological
Interventions
Non-pharmacologic interventions are
divided into three categories:
physical interventions
cognitive behavioral techniques
family interventions.
Physical Interventions
•
•
•
•
•
…including:
cutaneous stimulation, such as the
application of heat or cold
transcutaneous electrical nerve stimulation
(TENS)
exercise
physical or occupational therapy
massage, and acupuncture.
Cognitive Behavioral
Strategies
Intended to alter belief structures such as
attitudes, pain and suffering.
Strategies include…
• psycho education (info. regarding normal and
abnormal emotional reactions to pain)
• distraction
• relaxation
• guided imagery
• biofeedback
• hypnosis.
Family Interventions
Patient and family education and
counseling.
SECTION III
SECTION IV
Documentation
Documentation
Includes…
• initial comprehensive assessment
• treatments / strategies for pain management
• reassessment according to the patient’s needs,
established RVH pain standards, and the types
of interventions, and
• assessment tool used to measure the patient’s
self-report of pain
• Tracking of the efficacy of the intervention(s),
(example: 0-10 intensity scale)
Forms for Documentation
Pain assessment and management is
documented using:
• specific order sheets for PCA and neuraxial
analgesia
• admission assessment forms and/or electronic
templates
• flow sheets
• progress notes or focus note
• pain flow sheets
• care plans, and
• continuity of care forms.
Components of Documentation
Documentation will facilitate team
communication about pain management
and includes:
pain assessments
admission and ongoing pain interventions
patient’s response to interventions
adverse and side effects
patient’s response to treatment of those effects
interdisciplinary plan of care.
SECTION IV
SECTION V
Education
RVH recognizes that
quality pain management
involves attention to ongoing
educational efforts,
continuous learning, and
sharing of information.
Key Components
• Providing appropriate staff education that takes
into account knowledge and beliefs about pain
management.
• Providing and involving patients and families in
education prior to admission whenever possible.
• Providing patients and family members with
information and brochures.
• Identifying beliefs, values, barriers and
readiness for education of the patient and family.
• Dispelling myths about pain, pain treatment and
addiction.
Staff Education
Educational opportunities related to pain management include:
•
•
•
•
•
•
specific care area / unit orientation
RVH’s Grand Rounds and Nursing Grand Rounds
ethics rounds
RVH’s annual pain conference
clinical education sessions, and
self-learning modules.
Additional resources and information about analgesics and
analgesic dosing is readily available through the acute pain nurse,
Pharmacy, Oncology, and Palliative Care Services. Pain resource
manuals are available on the individual nursing units.
Patient and Family
Education
Ensure that the patient and family have a clear
understanding of the right to appropriate pain
management.
The following are key components:
• Patients have the right to the best pain relief possible.
Reassure the patient that the health care team considers
his/her pain management to be very important.
• Provide education to the patient and his/her their family.
• Explain the benefits of pain management including the
potential for a quicker recovery, shorter hospital stay,
and the potential for improved quality of life.
Patient Information and
Brochures
Patients and/ or family members are provided with information
about pain management.
“Managing Your Pain” booklet – Oncology Service
“Welcome to PCA” video – Surgical Program
“Patient Controlled Analgesia” pamphlet– Surgical Program“
“Epidural Pain Management” pamphlet – Surgical Program
“Managing Pain” pamphlet – Surgical Program and
pain articles in River Valley News.
Barriers to Effective Pain
Management
Identification of Barriers and Attitudes
+ Addressing Barriers and Attitudes
= Quality Pain Management
Ongoing education will address:
• patient reluctance to report pain
• education needs of patient/family regarding effective pain
management
• the importance of an interdisciplinary approach and communication,
physician and nursing attitudes and beliefs that result in hesitancy to
prescribe and administer adequate doses of opioids for pain.
Dispelling Misconceptions
Around Pain
RVH will continue to explore ways to clarify for
patients and clinicians the differences between
addiction, tolerance, and physical dependence.
Fears and misconceptions concerning opioid
medications can prevent optimal use of
pharmacological methods for pain management.
SECTION V