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The PAIN Problem

The PAIN Problem. Most common reason for medical appointments in the U.S. 50 million people affected by pain 1 out of 3 people affected by pain 140 million visits annually $120 billion in annual health costs Pain affects quality of life Patient’s fear addiction to treatment meds

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The PAIN Problem

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  1. ThePAINProblem • Most common reason for medical appointments in the U.S. • 50 millionpeople affected by pain • 1 out of 3people affected by pain • 140 millionvisits annually • $120 billionin annual health costs • Pain affects quality of life • Patient’s fear addiction to treatment meds • Healthcare provider’s fear treatingmalingering patients. Our GOAL is to manage the patient’s PAIN effectively!

  2. Be believed when pain is reported Have pain relief Be told how much pain to expect & how long it will last Have pain prevented & controlled when it occurs Be asked acceptable level of pain Rate pain using appropriate scales Develop a pain plan with the doctor & care delivery staff Know the risks, benefits & side effects of treatments Know what alternative pain treatments may be available Ask for changes in treatments if pain persists Receive pain medication in a timely manner Include family & others in decision making about pain management Considerate, respectful care, & made to be comfortable Given respectfor personal values & beliefs Receive informationabout the pain causes & prevention Refuse, accept, or suggest pharmacological or non-pharmacological interventions Patient’sRights

  3. Pain, the Fifth Vital Sign

  4. Barriers to Pain Management

  5. At Risk Populations for Under Treatment of Pain • Patients with history of addiction or alcohol abuse • Nonverbal (intubated, unconscious) • Cognitively impaired • Elderly • Neonates, infants, children • Ethnic, racial minorities

  6. Numeric Pain Scale For use in adults, adolescents & cognitively-appropriate pediatric patients No Pain Distressing Pain WORST Pain 01 23 4 5 6 7 8 9 10 Mild Pain [1,2,3] Moderate Pain [4,5,6] Severe Pain [7,8,9,10] No Pain Unbearable Pain May use FACES Scale if patient has difficulty with use of numeric scale

  7. Numeric Pain Scale -Spanish For use in adults, adolescents & cognitively-appropriate pediatric patients No me Duele El Dolor me Mortifica No Aguanto el Dolor 0 1 2 3 4 5 6 7 8 9 10 Dolor Leve [1,2,3] Dolor Moderado [4,5,6] Dolor Furte [7,8,9,10] May use FACES Scale if patient has difficulty with use of numeric scale

  8. Wong-BakerFACES Pain Rating Scale English Spanish

  9. Pharmacological Pain Management

  10. FLACCPain Rating Scale For infants to 7 years of age CategoryScoring 012 FaceNo particular expression Occasional grimace or frown Frequent-constant quiveror smile withdrawn, disinterested chin, clenched jaw Legs Normal position, relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal Squirming, shifting back & Arched, rigid or jerking position, moves easily forth, tense Cry No cry (awake or asleep) Moans or whimpers; Crying steadily, screams, occasional complaint sobs; frequent complaint Consolabilty Content, relaxed Reassured by occasional Difficult to console or touching, hugging, or being comfort talked to, distractible

  11. N-PASS Neonatal Pain, Agitation, & SedationScale + 3 if < 28 weeks gestation/corrected age + 2 if 28-31 weeks gestation/corrected age + 1 if 32-35 weeks gestation/corrected age Premature Pain Assessment

  12. Non-verbal PainScale Not validated but useful tool for pt’s who cannot communicate • Procedure • Assess pt. according to each 5observation categories • Assign points according to criteria • Total the points • Apply point total to the0-10 numeric scale • Reassess frequently to compare scores & determine changes in pain level

  13. Non-verbal Pain Scale Used in Health Connect for Documentation Movement 0= Positive response to interaction and touch 1= Startling, guarding, generalized tension 2= Thrashing, restless squirming Position 0= Restful position, joints relaxed, hands open 1= Finger curled, initial resistance to position change 2= Clenched fists, knees pulled up, strong resistance to positioning Facial Cues 0= Placid expression, smile, relaxed jaw 1= Frown, fearful expression, brow lowering 2= Scowling, clenched jaw, stern look Emotion 0= Pleasant, serene, cooperative, sleeping 1= Uncooperative, anxious, confused 2= Irritable, combative Verbal Cues 0= Agreeable responses, humming, singing to self, quiet 1= Moaning, groaning, monotone, muttering 2= Screeching, screaming, crying

  14. RASS Sedation Scale Richmond Agitation Sedation Scale used in Health Connect Use PASS Score of Procedural Sedation Score Term Description +4Combative Overly combative, violent, immediate danger to staff +3 Very Agitated Pulls or removes tubes, catheters; aggressive +2 Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious, movements not aggressive 0 Alert & Calm -1 Drowsy Not fully alert, has sustained awakening (eye-opening/contact) to voice >10secs -2 Light Sedation Briefly awakens w/eye contact to voice <10sec -3 Moderate Movement or eye opening to voice Sedation(no eye contact) -4 Deep Sedation No response to voice, movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation • Observe Pt. • Alert, restless, agitated (0 - +4) • Not alert, state pt’s name, ask to “open eyes & look at me” • Pt. awakens w/eyes open & contact (-1) • Pt. awakens w/eyes open & contact unsustained(-2) • Pt. has movement in response to voice but not eye contact (-3) • No response to verbal, physically stimulate pt. • Pt. has movement (-4) • Pt. has no response (-5)

  15. PAIN Management Competency Post Test GREAT! EXTRAORDINARY! FEEL GOOD! NEVER BETTER! EXCELLENT!

  16. Pain Management Competency Post Test • 1. Your patient reports that they are still experiencing moderate to severe pain even though they are taking the maximum dose/frequency prescribed by the physician. What is an appropriate nursing action? A. Encourage the patient to “wait and let the medicine take effect” B. Perform a thorough pain assessment and communicate and collaborate findings with the physician C. Assume the patient is displaying drug seeking behaviors • 2. A 45-year-old man arrives in the Outpatient Treatment Center. He is unable to • adequately verbalize information requested. You need to assess his pain. What • pain assessment scale(s) would be best to use? Choose any that could be used. A. Faces B. 0-10 Numeric C. N-PASS D. None of the above

  17. Pain Management Competency Post Test • 3. Patient rights include: relief or control of pain, to be asked about acceptable level • of pain, to know the risks, benefits, and side effects of pain control measures, and to have respect for personal values and beliefs. A. True B. False • 4. When completing a pain assessment or reassessment, approved pain scales • appropriate for the patient must be used. A. True B. False • 5. Once a pain control measure is given, further assessment is not needed. A. True B. False

  18. Pain Management Competency Post Test • 6. Which of the following are validated and approved pain scales? Select all that apply. A. 0-10 Numeric B. Wong-Baker Faces C. FLACC D. 0-5 Pediatric Faces E. N-PASS • 7. A night shift RN notices that an infant is crying more than usual, and wants to assess the newborn’s pain. The RN would use the FLACC pain scale for assessment. A. True B. False

  19. Pain Management Competency Post Test • 8. Populations at risk for under management of their pain: A.Elderly B.History of drug/alcohol abuse C.Neonate D.Cognitively impaired E.Nonverbal F.All of the above • 9. Patients and their caregivers must be provided education about the following: A. Pain scales B. How to control pain C. Consequences of uncontrolled pain D. Various pain control measures and potential side effects E. All of the above

  20. Pain Management Competency Post Test • 10. Which of the following best describes the “5th Vital Sign” initiative? A. Pain should be assessed at least five times a day B. Pain should be assessed after other vital signs C. Pain is the least important vital sign D. Pain information should be recorded at least as frequently as other vital signs • 11. If a pain control measure is given and a re-assessment is completed but not • documented, it really doesn’t matter. A. True B. False • 12. Failure to ask patients about their pain and accepting and acting on the patient’s • reports of pain is probably the most common cause of unresolved treatable pain. A. True B. False

  21. Pain Management Competency Post Test • 13. A 14-year-old male admitted for ambulatory surgery at one of our clinics does • not need pain assessment. • A. True • B. False • 14. Assessment of pain must include location, quality, intensity, duration, • aggravating and alleviating factors, and one other item. What is that item? • Acceptable level of pain or pain goal • 15. Which of the following statements is true regarding opioid therapy? • A. Pain at a level of five or above on a 10-point scale is treatable by opioid agents • B Intensive opioid therapy remains an end-of-live therapy for severe chronic pain • C. Intensive opioid therapy is limited largely to cancer pain • D. Opioid therapy for non-cancer pain exposes the clinician ti regulatory sanction

  22. Pain Management Competency Post Test • 16. A 35-year-old male patient with testicular cancer is joking and playing cards with • his roommate. When assessed by the pain management nurse, the patient rates • his pain as a seven on a numeric pain rating scale of 0 to 10. The nurse • concludes that the patient's behavior: A. is an emotional reaction to the anticipated pain. B. is in anticipation of future pain. C. is more indicative of the need for pain medication than the pain rating. D. may be in conflict with the pain rating, and accepts the report of pain • 17. The pain management nurse notices a male patient grimacing as he moves from • the bed to a chair. The patient tells the nurse that he is not experiencing any • pain. The nurse's response is to: A. clarify the patient's report by reviewing the patient's nonverbal behavior B. confronting the patient's denial of pain C. obtaining an order for pain medication D. supporting the patient's stoic behavior

  23. Pain Management Competency Post Test • 18.When teaching a 65-year-old patient to use a pain scale, a pain • management nurse anticipates that: A. additional time is needed for the patient to process the information B. older adults are unable to use pain scales reliably C. the Pain Assessment in Advanced Dementia Scale is appropriate for the patient D. the patient's family is included in the education sessions • 19. Patients should be encouraged to establish an acceptable level of • pain score or pain relief score goal. A. True B. False

  24. Pain Management Competency Post Test • 20. A 75-year-old female patient comes to the oncology clinic for management of chronic cancer pain. The patient has been prescribed morphine sulfate (MS Contin), 30 mg, every 12 hours. The patient states that she is taking the medicine only when the pain becomes severe because of her husband's concern about addiction. The pain management nurse responds: A. “It is okay to continue doing what you are doing.” B. “The risk of developing addiction when taking opioids for pain is very low.” C. “We need to consider other alternatives for managing your pain.” D. “You must take the medication as prescribed, regardless of your husband‘s concerns.”

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