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.86 contact hours pain management enhancing your nursing practice by lynne palamara msn rn aocn® cns this program made possible by the cancer prevention and research institute of texas and livestrong.

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acknowledgement and disclosure i acknowledgement and disclosure accreditation statement texas nurses association/foundation provider unit is accredited as a provider of continuing nursing education by the american nurses credentialing center s commission on accreditation the nurse oncology education program noep part of texas nurses association/foundation provider unit wishes to thank the following for their contributions and support in the production of this continuing nursing education activity cancer prevention and research institute of texas cprit livestrong disclosure to participants pain management enhancing your nursing practice requirements for successful completion the learning goal/purpose of this educational activity is registered nurses in all fields of practice will acquire an updated knowledge regarding pain management especially as related to cancer registered nurses will learn current strategies to assess and manage acute and chronic pain utilizing pharmacologic non-pharmacologic and adjuvant therapies by incorporating this knowledge into their clinical practice registered nurses in all fields of practice will be able to provide the highest level and quality of pain management to patients the objectives of this education activity are 1 2 3 4 5 discuss pain as a biopsychosocial experience identify barriers that hamper effective pain management discuss the essential elements of an individualized nursing pain assessment discuss the pharmacologic and non-pharmacologic nursing management of pain apply pain management principles utilizing clinical case scenarios to receive contact hours for this continuing education activity the participant must · · · read the content in this module carefully complete the course test questions at www.noep.org you must attain a passing score of at least 80 on the test to receive credit if you do not pass the test you will be notified of your score and given the opportunity to retake the test once you have successfully completed the course test questions follow the prompts to complete the evaluation/registration form and print your certificate of successful completion once successful completion has been verified a certificate of successful completion will be awarded for .86 contact hours conflicts of interest the following activity planning committee members and faculty/content specialists have submitted conflict of interest disclosure forms planning committee joni watson msn rn ocn gina kuenstler bsn rn ocn planning committee kristin hamlett ma msle lisa watson planning committee shirley lavergne faculty/content specialists lynne palamara msn rn aocn cns the planning committee members and faculty/content specialists of this cne activity have disclosed no relevant professional personal or financial relationships related to the planning or implementation of this cne activity commercial support this cne activity received no sponsorships or commercial support this cne activity is grant funded through the cancer prevention research institute of texas cprit and livestrong non-endorsement of products texas nurses association/foundation provider unit s accreditation status via the american nurses credentialing center ancc refers to the continuing education activity only and does not imply either real or implied endorsement by texas nurses association tna or ancc of any commercial product service or company referred to or displayed in conjunction with this activity nor of any company subsidizing costs related to this activity off-label product use this educational activity does not include any information about off-label use of a product for a purpose other than that for which it is approved by the u.s food and drug administration fda expiration date for awarding contact hours this activity expires december 1 2012 reporting of perceived bias the american nurses credentialing center ancc is interested in the opinions and perceptions of attendees at accredited continuing nursing education activities especially in the presence of actual or perceived bias in continuing education therefore ancc invites attendees to access their ancc accreditation feedback line to report any noted bias or conflict of interest in the educational activity any concerns complaints or opinions any great experiences any unpleasant experiences or your thoughts on the process the toll free number is 1-866-262-9730.

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1 pain management enhancing your nursing practice the american pain society defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage while it is unquestionably a sensation in part or parts of the body it is always unpleasant and therefore an emotional experience 2008 although this definition was originally articulated in 1986 by the international association for the study of pain almost twentyfive years later a consistent and comprehensive approach to pain management still does not exist despite the fact that interest in pain and pain relief has increased over the past decade pain continues to be a major health problem with high costs in health care dollars and in patient quality of life in fact 76 million americans report pain lasting greater than 24 hours and 42 of these have pain lasting one year or more national center for health statistics 2006 more than 73 million surgeries are performed each year in the u.s and more than 80 of patients have moderate to severe pain during the first 2 weeks after surgery apfelbaum chen mehta gan 2003 pain in cancer patients is very common 24-50 in patients actively receiving anti-cancer treatment and 62-86 of patients with advanced disease report pain in fact one third of these patients rate their pain as moderate or severe van den beuken-van everdingen et al 2007 nurses have a unique and important opportunity to improve pain management in their patients by increasing their knowledge of pain physiology assessment and comprehensive interventions they can become strong advocates for optimal pain management in their patients categories and pathophysiology of pain descriptions of pain often describe it in terms of its intensity e.g mild moderate severe duration acute or chronic and type of syndrome e.g cancer fibromyalgia migraine pain is typically classified and treated according to the duration of the pain acute or chronic as well as the source of the pain the cause of acute pain which is timelimited and diminishes as healing takes place is typically known in contrast chronic pain often lasts more than three to six months beyond normal healing time has no apparent function is cyclical and often associated with autonomic adaptation dahl gordon paice stevenson brown 2008 an understanding of the pathophysiology of pain is essential for thorough assessment and management nociception refers to the process by which pain is consciously perceived pasero paice mccaffrey 1999 the four processes involved in nociception include transduction transmission perception and modulation transduction is the conversion of noxious stimuli into electrical energy nerve impulses nociceptors are free nerve endings with the capacity to distinguish between noxious and innocuous stimuli dahl et al 2008 when nociceptors are exposed to noxious stimuli such as pressure extremes of heat or cold mechanical insults or irritant chemicals in sufficient quantities chemical

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2 categories and pathology of pain substances are released that facilitate the movement of the pain impulse from the periphery to the spinal cord pasero paice et al 1999 transmission is the conduction of pain impulses from the nociceptors to the spinal cord and brain via two types of primary afferent neurons a-delta fibers myelinated rapid acute sharp `first pain and c fibers unmyelinated slower conduction more diffuse dull aching `second pain from the nociceptor the action potential travels to the dorsal root ganglia and then to the dorsal horn of the spinal cord with the help of primary afferent neurons release of neurotransmitters into the spinal cord spinal neurons are activated that send axons across the spinal cord and up secondary afferent neurons via the spinothalamic tracts to the thalamus the thalamus then sends the pain impulse to central structures where pain can be processed dahl et al 2008 melzack 1999 pasero paice et al 1999 perception is the end result of the neural activity of pain transmission and is the point at which pain is recognized by a conscious person perception occurs in the cortical structures the somatosensory cortex the parietal lobe the frontal lobe and the limbic system polomano 2009 sensory information about the pain e.g location intensity character is combined with emotional cognitive and socio-cultural determinants to create the pain experience dahl et al 2008 therefore perception is the phase in which cognitive-behavioral strategies can be applied to reduce the sensory and affective components of pain pasero paice et al 1999 modulation is the fourth process involved in nociception in which the brain inhibits pain impulses neurotransmitters such as endogenous opioids also called endorphins and enkephalins norepinephrine and serotonin can stop the nociceptive impulse from being communicated to the next neuron by binding to opioid receptor sites however since endog enous opioids degrade quickly and serotonin and norepinephrine are normally taken up by the body none of these endogenous substances are considered effective analgesics some antidepressants which interfere with the reuptake of serotonin and norepinephrine e.g amitriptyline and duloxetine can decrease pain utilizing the modulation phase by inhibiting pain impulses pasero paice et al 1999 pain classification there are two primary types of pain they are nociceptive pain and neuropathic pain nociceptive pain is the normal processing of stimuli that damages normal tissue or has potential to do so it may be further divided into somatic pain and visceral pain somatic pain results from activation of nociceptors in bone joint muscle skin or connective tissue the quality of somatic pain is usually sharp aching or throbbing and is well localized a-delta fibers are responsible for this type of pain which usually responds well to either nonopioids or opioids visceral pain is related to activation of nociceptors in internal organs such as the gastrointestinal tract or pancreas and may be referred to a distant site such as gallbladder pain referred to the scapula visceral pain that results from obstruction of a hollow viscus e.g bowel obstruction is usually cramping in nature and poorly localized however when stretching or pressure of an organ capsule occurs tumor involvement of the liver the resulting pain is more aching in nature and can be somewhat localized c fibers are responsible for visceral pain which also usually responds well to nonopioids or opioids pasero paice et al 1999 neuropathic pain is the abnormal processing of sensory input by the peripheral or central nervous system neuropathic pain may be divided into centrally generated neuropathic pain and peripherally generated neuropathic pain there are two types of centrally generated neuropathic pain deafferenta-

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harmful effects of uncontrolled pain 3 tion pain and sympathetically maintained pain deafferentation pain elimination of sensory impulses is pain related to damage or dysfunction of the central or peripheral nervous system e.g phantom limb pain sympathetically maintained pain is associated with dysregulation of the autonomic nervous system there are also two types of peripherally generated neuropathic pain polyneuropathies and mononeuropathies painful polyneuropathies involve pain that is felt along the distribution of many peripheral nerves e.g diabetic neuropathy painful mononeuropathies are usually associated with a known peripheral nerve injury and pain is felt at least partly along the distribution of the damaged nerve e.g nerve root compression trigeminal neuralgia polomano 2009 although there is a great deal of variability in patient-reported sensations some common descriptors include burning stabbing shooting electric-like shock tingling and lancinating cutting tearing dahl et al 2008 two manifestations of neuropathic pain include hyperalgesia which refers to an exaggerated response to a painful stimulus and allodynia which is defined as a painful sensation in response to a stimulus which does not normally provoke pain e.g light touch in general neuropathic pain is poorly responsive to both nonopioid and opioid analgesics and is best treated with adjuvant medications such as antidepressants or anticonvulsants pasero paice et al 1999 harmful effects of uncontrolled pain although healthcare providers routinely consider the possible side effects of pain-relieving analgesics or the potential adverse outcomes of invasive procedures such as regional analgesia equal consideration is not typically given to the negative physiologic consequences of unrelieved pain although impaired functionality and quality of life are more commonly associated with persistent pain uncon trolled acute pain can have similar effects because it can result in sleep disturbances decreased appetite anxiety fear depressed mood and decreased socialization dahl et al 2008 essentially all body systems are impacted by pain because it triggers the stress response and activates the sympathetic nervous system see table 1 table 1 clinical consequences of uncontrolled acute pain system clinical consequences increased heart rate increased cardiac output increased systemic vascular resistance hypertension increased myocardial oxygen consumption hypercoagulation decreased gastric and bowel motility decreased urinary output urinary retention hypokalemia depression of immune response fluid overload glucose intolerance hyperglycemia insulin resistance gluconeogenesis hepatic glycogenolysis muscle protein catabolism increased lipolysis muscle spasm impaired muscle function fatigue immobility reduction in cognitive function confusion impaired ability to reason and make decisions altered pain processing resulting in increased sensitivity decreased tidal volume atelectasis hypoxemia decreased cough infection cardiovascular gastrointestinal genitourinary immunologic metabolic musculoskeletal neurologic respiratory adapted from dahl et al 2008

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4 barriers to effective pain management for example within the endocrine system unrelieved acute pain results in increases in acth cortisol adh epinephrine norepinephrine renin aldosterone interleukin-1 and catecholamines and decreased insulin and testosterone dahl et al 2008 pasero paice et al 1999 the metabolic consequences of these endocrine changes include fluid overload glucose intolerance hyperglycemia insulin resistance gluconeogenesis hepatic glycogenolysis muscle protein catabolism and increased lipolysis barriers to effective pain management in order for nurses to become successful pain management advocates they must become knowledgeable about existing barriers to pain management both healthcare providers and patients may lack the information necessary to assure that pain is optimally managed obstacles to effective pain management arise out of the healthcare and regulatory environment in which care is provided and from misunderstandings and unrealistic expectations on the part of patients and their families nurses may find themselves in similar situations nursing curriculums include more pain assessment and management topics than in previous decades but when students enter into nursing practice they can be negatively influenced by preceptors and charge nurses whose pain management practices do not reflect current evidence-based approaches controlled substance restrictions many regulations enacted to prevent prescription drug abuse misuse and diversion create disincentives for physicians to provide adequate pain management joranson d ryan k gilson a dahl j 2000 in texas for example opioids such as morphine and hydromorphone are classified as schedule ii substances by the texas controlled substance act texas department of state health services 2010 texas health safety code 1989 this law requires that prescribers utilize an official prescription form which must be purchased from the state department of public safety dps and which requires in-depth prescription and prescriber information the requirements for maintaining the security of these forms are stricter than for standard forms morphine hydromorphone oxycodone fentanyl and levorphanol in any and all formulations are included in the schedule ii category the only exceptions are codeine in no more than 90 milligrams per dosing unit and hydrocodone in no more than 15 milligrams per dosing unit concerns about escalating prescription drug abuse misuse addiction and diversion joranson et al 2000 create a further disincentive to prescribing these medications in such a climate physicians fearful of scrutiny by dps or of being reported to the state medical board for misuse of the official form may simply limit patients opioid pain relief options to codeine and hydrocodone much work needs to be done to balance controlled substance monitoring to prevent abuse and diversion with the need to provide a variety of options to patients who require opioids to manage their cancer-related pain healthcare and regulatory environment lack of education traditionally education regarding pain management in undergraduate and postgraduate medical education curriculums has focused primarily on post-operative acute pain fishman 2009 although some medical schools are starting to broaden the scope of pain management education residents may find themselves working under the direction of staff physicians whose pain management practices have not changed in the last 15-20 years despite advances in medical knowledge.

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barriers to effective pain management 5 lack of access in some circumstances patients have very limited or no access to appropriate analgesics in remote rural areas the nearest pharmacy may be 100 miles away and stock only a limited variety of analgesics other pharmacies with the resources to stock a wide assortment of opioids may choose not to due to the regulatory restrictions described above such limitations on access pose another nonpatient-specific barrier which results in inadequate pain treatment for patients in need of prescribed analgesia inadequate assessment physicians pain assessment often focuses on diagnosing the cause of pain rather than development of pain management strategies questions such as the effect on quality of life and the patient s typical coping strategies are not consistently asked or documented nurses pain assessment may be limited by personal social and or structural system-wide motivations and abilities nurses may not have the knowledge personal positive peer support social or accountability social/structural to perform adequate pain assessment when healthcare institutions implement electronic medical records the systems may introduce another structural barrier in the form of limitations on the type of and number of data fields available for example if location character and intensity are the only required fields of documentation information about the timing of pain intermittent versus constant or effect of pain on ability to perform activities of daily living may not routinely be assessed or documented mcgonigle caplin 2003 attitudes and misconceptions about pain in general many healthcare providers still overestimate the risk of addiction to opioids when legitimately taken for pain the shift of drug abuse from illicit to prescription drugs in the united states contributes to this overestimation fishman 2009 some surveys that have examined prevalence rates of addiction in patients prescribed opioids for acute pain have found less than a 1 incidence mcgonigle caplin 2003 in general though studies that have looked at this issue are difficult to evaluate due to inconsistent definitions of addiction and substance abuse another common fear among providers is that opioids will cause life-threatening respiratory depression although clinically significant respiratory depression is uncommon more frequent and careful monitoring is essential in high-risk groups such as geriatric patients infants patients with underlying pulmonary dysfunction those receiving other central nervous system depressants such as general anesthesia or anti-anxiety agents and patients who are opioid-naïve dahl et al 2008 lack of accountability some clinicians assume that patients who are experiencing pain will always ask for pain relief thereby placing sole responsibility on the patient the joint commission on accreditation of healthcare organizations jcaho released pain management guidelines in 2000 however joint commission reviewers continue to focus more on nursing assessment and documentation of effectiveness rather than physician assessment and documentation therefore nurses must take a lead role in pain management by routinely assessing patient pain and the factors that exacerbate or alleviate the pain it is important too that nurses follow-up with patients at regular intervals to reassess and assure that the patient s pain is being managed to their satisfaction confusion regarding terminology the differences between addiction physical dependence and tolerance are not well understood and the terms are sometimes incorrectly used interchangeably the american academy of pain medicine the american pain society and the american society of addiction medicine collaboratively developed a public policy statement which addresses the terminology confusion and clarifies definitions inconsistent use of the terms addiction dependence and tolerance often

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6 barriers to effective pain management results in misunderstandings between regulators healthcare providers patients and the general public regarding the use of medications for the treatment of pain because of these misunderstandings pain is often under-treated and individuals may be stigmatized because of their use of opioids for medical purposes american academy of pain medicine 2001 it is imperative that nurses have a clear understanding of these definitions so they can educate patients and family members as well as physician and nurse colleagues addiction is a primary chronic neurobiologic disease with genetic psychosocial and environmental factors influencing its development and manifestations it is characterized by behaviors that include one or more of the following impaired control over drug use compulsive use continued use despite harm and craving physical dependence is a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation rapid dose reduction decreasing blood level of the drug and/or administration of an antagonist tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug s effects over time american academy of pain medicine 2001 in the context of pain medication healthcare providers frequently confuse physical dependence with addiction in fact the withdrawal syndromes associated with pain medication are little different from other instances in which drugs are tapered to avoid adverse physiologic symptoms the widely used practice of tapering steroids illustrates this point and may be used to counter this misconception about pain management similarly tolerance is also easily confused with addiction so when nurses are providing patient and family education they need to emphasize that development of tolerance to the pain-relieving effects of any opioid is an expected outcome of chronic opioid use patient and family knowledge gaps patients and their families may lack information about pain and pain management that lead to misconceptions or unrealistic expectations these expectations ­ either that pain cannot be treated or that it can be entirely eliminated can present a barrier to adequate pain management understanding the knowledge gap about this subject can help nurses appropriately educate patients and their families and result in better pain control reluctance to report pain patients may be reluctant to report pain for a variety of reasons some cultures and religions view complaining about pain to be associated with shame or weakness of character in fact some people believe that pain is a punishment for wrongdoings so they will try to endure it rather than report it polomano 2009 patients who tend to want to please everyone fail to report pain because they don t want to be viewed by their caregivers as the `bad patient or the `demanding patient american cancer society n.d a n.d b expectation that pain is inevitable some patients may believe that pain is an expected consequence of certain medical conditions such as cancer or surgical procedures and that nothing can be done to significantly relieve the pain therefore they fail to report it to their medical team this is an area where nurses play an integral role in helping patients to understand that they are the best judge of their pain and its severity patients may need to be informed that their description of the pain will help their medical team know how to best treat their symptoms american cancer society n d a n.d b one tool that nurses can share with patients to assist them in reporting their pain to their medical team is the brochure titled speak up what you should

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pain assessment 7 know about pain management jcaho 2008 prior personal or family experience with poor pain management if a patient or close family member has been significantly undertreated for severe pain in the past has experienced unacceptable side effects of a pain medication or a pain-relieving invasive procedure or whose prior reports of pain were not believed barriers such as fear anxiety and anger may keep them from reporting pain in the future nurses are instrumental in helping patients to understand that it is their right to receive pain management that they deem adequate nurses should help patients understand how to self-advocate and to know that if their medical team is not adequately controlling their pain they have the right to seek help from another healthcare provider american cancer society n d a fear of side effects and addiction patients and their family members often possess the same fears about opioid side effects and risk of addiction as healthcare providers however they may express their concerns as fear of over-sedation or of feeling `not in control rather than concern about the risk of respiratory depression some patients even avoid opioids because of their constipating side effects not understanding that interventions to counteract this side effect can be provided american cancer society n d a once again public awareness of increased prescription drug abuse in the united states may result in patients being unwilling to take appropriately described opioids for documented pain nurses should play a key role in educating these patients about the difference between drug abuse and legitimate use pain assessment principles of pain assessment the most important principle of pain assessment is that the patient s self-report is the single most reliable indicator of pain because pain is a subjective phenomenon the patient s self-report should be utilized whenever possible when patients are unable to report pain clinicians can infer the presence of pain from information about the patient s conditions or recent procedures family members or other caregivers who know the patient well can serve as proxies for patient report by helping to identify patient behaviors that indicate the presence or absence of pain these proxy pain ratings are not intended to be utilized in patients who can self-report a second principle of pain assessment is that pain assessment should be routinely performed whenever pain is reported or suspected accordingly pain should be re-assessed after every intervention during initial doses of opioid analgesics and whenever pain intensity is escalating there is a change to a different opioid analgesics doses are increased and any time there is heightened concern about the patient s pain condition or side effects of pain treatment for consistency it is important to use the same rating scale every time pain is assessed or re-assessed each assessment should be documented so that the effectiveness of treatment can be measured and communicated among the treatment team frequent assessment of analgesic side effects should be made to assure optimal pain relief and patient compliance components of pain assessment a comprehensive pain assessment includes a number of essential elements establishing the locations of pain is a key first step many patients have co-morbidities which result in pain of different types at different locations for example a patient may be admitted to the hospital for a partial colectomy resulting in new acute post-operative pain however this same patient may also have chronic pain such as neuropathic pain secondary to diabetic peripheral neuropathy or chemotherapy-induced peripheral neuropathy,

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8 pain assessment as well as somatic joint pain secondary to osteoarthritis all types and locations of pain should be addressed on an ongoing basis the quality of pain should also be assessed by asking patients to describe the type of pain they are experiencing this can assist in pain management as well as identifying the cause of the pain for example a patient who uses words like aching or throbbing when describing the pain in his ankle is probably experiencing somatic pain secondary to muscle or soft tissue injury and should therefore respond well to anti-inflammatory drugs however if the same patient also reports numbing or burning type of pain in his ankle he could have some inflammation or compression of nerves secondary to the injury and may require adjuvant medications for the neuropathic pain obtaining information about aggravating and relieving factors will enable the nurse to provide prophylactic interventions in a timely manner to optimize pain relief timing duration and frequency of pain is an extremely important component of pain assessment it is very important to remember that pain that occurs intermittently should be approached very differently than pain which is continuous or predictably returnable e.g present 70-80 of the time people experience pain differently and determining the effect of pain on the patient s functioning is a key component of assessment ascertaining the extent to which the pain interferes with the patient s mobility sleep appetite normal work routine mood and relationships with other people serves important purposes pain that significantly interferes with activities of daily living provides important justification for increasing analgesic doses when clinicians are otherwise hesitant or reluctant identifying these adverse effects enables the patient and their family to have a more practical under standing of the importance of pain control and may increase compliance it is also important to identify any previous interventions for pain it is important to establish whether or not the patient has ever utilized any pharmacologic or non-pharmacologic pain relief measures and whether or not they were successful both the patient s current pain and past pain experiences should be considered so that the clinician will have a thorough understanding of the patient s individual response to pain and to implemented pain management interventions pain has a significant impact on quality of life therefore the psychosocial implications of pain should also be assessed in addition to its physical effects the nurse s psychosocial assessment should encompass the many ways that pain might impact the patient s overall quality of life including its impact on the ability to hold a job engage in personal relationships and perform basic activities of daily living such as bathing dressing toileting and feeding the assessment should measure the impact of persistent pain on both mental and physical health the nurse should probe for information regarding patient and family beliefs concerning the use of controlled substances and addiction as these could impact the acceptance of treatment modalities offered to the patient the nurse should inquire about the subjective meaning of the pain to the patient e.g does the patient view the pain as an indicator of weakness or a punishment for a poor life choice the nurse should assess the patient s understanding of the etiology of the pain and educate the patient and family regarding the underlying causes of the pain to help alleviate fear and anxiety it is important for the nurse to assess how the patient views the pain and whether it is viewed as a temporary setback or the result of a new diagnosis or a serious long-term illness with no possibility of pain relief the patient s past history of coping strategies both

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pain assessment 9 positive and negative are important for the nurse to understand and will help the medical team to be alert for symptoms of depression and ineffective coping particularly in situations of persistent intractable pain the patient s knowledge and expectations about pain and pain management are also critical components of the assessment as these are major components in the achievement of successful psychosocial coping and quality of life for more information on the principles of pain assessment and the variety of pain assessment tools and methodologies available both the city of hope pain and palliative care resource center n.d and the texas pain advocacy and information network txpain formerly known as texas pain initiative 2007 offer further information and resources pain intensity rating scales lastly it is important to assess the intensity of the pain as experienced by the patient a variety of pain intensity rating scales are available and those most commonly used with adults are numerical rating scales ranging between 0 to 5 or 0 to 10 these scales can be verbally presented or provided to the patient as a visual representation that combines both words and numbers as shown in figure 1 below advantages of this type of scale include the fact that many patients who are unable to use the number and word descriptors to report their pain will be able to understand and point to a face that corresponds to their experience the nurse can then obtain and record the equivalent number when questioning a patient about intensity it is important to ask about the worst and best that the pain has been over the previous 24 hours or longer if appropriate as well as to ask about the current intensity for example if the patient reports that her current pain score is 4/10 but it has been as high as 9/10 numerous times in the past 24 hours a different response is called for than if the pain intensity has not varied over the period patients should also be asked to identify a level of pain that is acceptable although it is important not to offer a choice of 0/10 because this may not be realistic the key figure 1 general faces scale

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10 pain assessment thing to remember is that patients experience pain differently and different patients reports should never be compared to each other but only with their own reports over time this is true also of patients pain goals a patient who requests to achieve a pain goal of 5/10 should not be considered `tougher or a `better patient than one who requests to achieve a goal of 2/10 a patient s reported pain intensity is meaningful only in comparison to their goal assessment of pain in special populations pain assessment of pre-verbal patients is a challenge and several different scales for assessing pain in this population are available one example is the flacc faces legs activity cry consolability pediatric behavioral pain scale which has been tested in children ages 3 months to 7 years merkel voepel-lewis shayevitz malviya 1997 each of the five categories is scored from 0-2 and the scores are added to up to get a total from 0 10 figure 1 shown on page 11 many other assessment scales including those specific to premature infants are available such as the neonatal pain agitation and sedation scale npass shown in figure 2 there is evidence that some adult patients with mild to moderate cognitive dysfunction can use numerical rating scales with the word anchors and face rating scales attached american geriatrics society panel on persistent pain in older persons 2002 a behavioral assessment scale should be utilized with adults with moderate-to-severe cognitive impairments who are unable to communicate at all one such scale is the checklist of nonverbal pain indicators cnpi figure 3 feldt 2000 figure 2 categories face legs activity cry consolability flacc behavioral scale 0 no particular expression or smile normal position or relaxed lying quietly normal position moves easily no cry awake or asleep content relaxed scoring 1 occasional grimace or frown withdrawn disinterested uneasy restless tense squirming shifting back and forth tense moans or whimpers occasional complaint reassured by occasional touching hugging or being talked to distractible 2 frequent to constant quivering chin clenched jaw kicking or legs drawn up arched rigid or jerking crying steadily screams or sobs frequent complaints difficult to console or comfort note each of the five categories face f legs l activity a cry c and consolability c is scored from 0-2 scored from 0-2 which results in a total score between 0 and 10 which results in a total score between 0 and 10 source merkel s voepel-lewis t shayevitz j malviya s 1997 the flacc a behavioral scale source merkel s voepel-lewis t shayevitz j malviya s 1997 the flacc a behavioral scale for scoring for scoring postoperative pain in young children pediatric nursing 23 3 293-297 postoperative pain in young children pediatric nursing 23 3 293-297 note each of the five categories face f legs l activity a cry c and consolability c is

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pain assessment 11 this and other scales to assess pain through behavioral observations are available from the university of iowa geriatric education center s website at figure 3 http tinyurl.com/6d6cm56 and from the national institute of health pain consortium at http tinyurl com/6yc7qg2 n-pass neonatal pain agitation sedation scale premature pain assessment +1 if <30 weeks gestation/corrected age crying irritability no cry with painful stimuli moans or cries no sedation minimally no pain signs with painful stimuli arouses minimally to stimuli little spontaneous movement minimal expression with stimuli weak grasp reflex ¯ muscle tone no sedation no pain signs irritable or crying at intervals consolable restless squirming awakens frequently high-pitched or silent-continuous cry inconsolable arching kicking constantly awake or arouses minimally no movement not sedated any pain expression continual continual clenched toes fists or finger splay body is tense behavior state no arousal to any stimuli no spontaneous movement facial expression extremities tone mouth is lax no expression no grasp reflex flaccid tone no sedation no pain signs no sedation no pain signs any pain expression intermittent intermittent clenched toes fists or finger splay body is not tense 10-20 from baseline sao2 76-85 with stimulation ­ quick recovery vital signs hr rr bp sao2 no variability with stimuli hypoventilation or apnea 10 variability from baseline with stimuli no sedation no pain signs 20 from baseline sao2 £ 75 with stimulation ­ slow recovery out of sync with vent source hummel p 2009 neonatal pain and agitation and sedation scale retrieved may 20 2010 from http www.n-pass.com/index.html.

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