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Deb Gordon RN, DNP, FAAN

Nursing Orientation

debrag3@uw.edu

Introduce & Discuss:

• HMC policy overview

• Pain screening, assessment, reassessment

• IV PCA, Epidural, PNC analgesia

• Pain Relief Service

• Joint Commission pain standards

• Improving patient satisfaction

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Reasons for pain control• Humane and ethical

• Negative physiological and psychological consequences

• It’s required by regulatory agencies

neuro-endocrine immune response

…untreated pain can sensitize the nervous system

…function & quality of life issues

• Patients have the right to appropriate assessment and management of pain

• Patients’ self-report is the gold standard

• Age and condition appropriate assessment tools

• One identified, minimum assessment =

location, severity, character, goal for pain relief

• Patient and family education and involvement is essential

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• Numerical Rating Scale (for adults and children >10 years of age)

• 0-10 where zero is no pain and 10 is the worst pain imaginable

• Descriptive Scale (for adults and children >10 years of age)

• None, mild, moderate, severe, very severe, unbearable

• Oucher Score (for children 4-10 years of age)

• 0-10 using pictures or numbers where 0 is no hurt and 10 is the biggest hurt you could ever have

• FLACC behavioral observational Score (for children <4 years of age)

• 0 – 10 where each parameter, face, legs, activity, crying, consolability is given a 0 – 2 and added together for the total score

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FLACC PAIN SCALE

CategoriesScoring

0 1 2

Face No particular expression or

smile, eye contact and interest in surroundings

Occasional grimace or frown, withdrawn, disinterested,

worried look to face, eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed

Frequent to constant frown, clenched jaw, quivering chin,

deep furrows on forehead, eyes closed, mouth opened, deep lines around nose/lips

Legs Normal position or relaxed

Uneasy, restless, tense, increased tone, rigidity, intermittent flexion/extension of limbs

Kicking or legs drawn up, hypertonicity, exaggerated flexion/extension of limbs,

tremors

Activity Lying quietly, normal position, moves easily and freely

Squirming, shifting back and forth, tense, hesitant to move,

guarding, pressure on body part

Arched, rigid, or jerking, fixed position, rocking, side to side head movement, rubbing of

body part

Cry No cry/moan (awake or asleep)

Moans or whimpers, occasional cries, sighs, occasional

complaint

Crying steadily, screams, sobs, moans, grunts, frequent

complaints

Consolability Calm, content, relaxed, does not require

consoling

Reassured by occasional touching, hugging,

or ‘talking to’. Distractible

Difficult to console or comfort

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2 which results in a total score between zero and ten. Used for children < 4 years of age.

• Behavioral indicators:• Facial indicators (grimacing/frowning/wincing, drawn

around mouth and eyes, teary/crying, wrinkled forehead

• Movements (no movement, slow/decreased/ hesitant/cautious, restlessness, seeking attention through movements)

• Vocalizations (“ouch”, “that hurts”, cursing during movement, or exclamations of protest: “stop”, “that’s enough”)

• Posturing/Guarding (rigid, splinting, tense/stiff)

• Physiological indicators (not always reliable):• ↑↓ heart rate

• ↑↓ blood pressure

• ↑↓ respiratory rate

• Perspiration

• Pallor

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Assessment is ongoing…

The frequency of assessment …different for each patient!

• Screen for regularly for pain

• Frequent at initiation and at change of treatment plan

• With new reports of new or worse pain- i.e. post-op

• At Appropriate interval following intervention

• Task reminder 15-30 min after IV, 45-60 min after PO

• Per specific pain management protocols (e.g. epidurals, IV PCA, ketamine)

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• “My Pain is 20/10!!!!!” • Tight rope of over-sedation and pain, avoiding

respiratory depression

• Tolerance to opioids does not always make it safe

• Behavior patterns sometimes challenging

• Pay attention to your own beliefs and judgments

• Communicate respect and empathy

• Develop trust and rapport

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Acute Care – Sedation Assessment Score

ICU – Richmond Agitation/Sedation Score (RASS)

ACUTE PAIN CHRONIC PAIN

• Facilitate recovery from the underlying injury, surgery, or disease

• Reduce neuroendocrine stress

• Minimize impact of pain on recovery activities

• Control and reduction of pain to acceptable level

• Minimize pharmacologic side effects

• Prevent chronic pain

• Restore function• Physical, emotional, social

• Decrease pain • Treat underlying cause

where possible• Minimize medication use

• Correct secondary consequences of pain

• Postural deficits, weakness, overuse

� Maladaptive behavior, poor coping

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“It is generally not possible or safe to eliminate all pain, but our goal is to reduce your pain to a reasonable level as well as manage any unpleasant side effects of pain medicines and help you recover.”

Adapted from Gottschalk A, et al.. Am Fam Physician. 2001;63:1979-1984.

Although analgesics are the mainstay, cognitive and physical strategies are essential

Cognitive•Education/instruction•Distraction•Relaxation•Music…

Physical•Cold•Heat•Massage…

Pain

Trauma

Opioids αααα2-Agonists Centrally acting analgesicsAnti-inflammatory agents

Local anestheticsOpioids αααα2-Agonists Anti-inflammatory agents

Local anesthetics

Local anesthetics Anti-inflammatory agentsOpioids

•Patients often feel judged

•Understand tolerance may be present

•Clear communications between staff and patient and family

•Avoid parenteral opioids if possible

•Avoid short-acting PRN formulations

•When possible, use schedule and long-acting opioids

•Combine opioids with nonopioids and other multimodal strategies

•Consider resources: PRS, Rehab Psych

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• Wrong dose and improper monitoring are most common issues

• Risk factors for respiratory depression• obesity, very young or old age, very ill, concurrent

CNS depressants

• Do not rely on pulse oximetry alone to detect respiratory depression• can suggest adequate oxygenation in active

respiratory depression, especially when supplemental oxygen is used

• When used oximetry should be continuous rather than intermittently

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• Assess/document every 2 hrs for 8 hrs, then Q 4 hrs

• Resp rate and depth (full minute before stimulation)

• Serial sedation levels

• Pain intensity

• Side effects

• Total PCA dose is documented every 8 hrs, pump cleared

• PCA-by-proxy - instruct family/friends NOT to assist the patient with IV PCA

• A 2-person (RN) independent double check of PCA settings/medication is required at initiation of PCA therapy and following any changes (and at start of each shift for peds)

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•Use of basal infusion•Use of concurrent CNS depressant•Increased age•Obesity•Upper abdominal or thoracic surgery•Sleep apnea•Impaired hepatic, renal, cardiac or pulmonary function•Frequent RN IV boluses •PCA by proxy

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Stimulate the patient!!

Call 222 – provide O2, may need mechanical assist with ventilation (bag-valve mask)

Administer Naloxone (Narcan) IV (with order)Draw up 1 ampule (0.4mg or 400mcg) in 10mL syringe and add NS up to 10 mL mark- give 2-3mL increments every 3-5 minutes

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•Assess/document every 2 hrs for 24 hrs, then Q 4 hrs

• Resp rate and depth (full minute before stimulation)

• Sedation level

• Pain intensity

• Side effects

•If Local Anesthetic: Assess/document BP, HR, sensory

level and motor strength every 30 minutes for 2 hrs,

hourly for 4 hrs, then every 4 hrs

•Vasodilation common results in orthostatic BP

•Assess the site/position of the catheter every shift

•May reinforce the dressing around tegaderm; do NOT

replace to avoid dislodgement of catheter

•Bolus doses via pump only: except (fentanyl) see policy22

• Avoid disconnections

• Use separate Alaris (brain) for PNC/epidural infusions

• Use “PNC/Epidural drug library” (listed on second page); drugs are listed under Guardrails Fluids

• Fluids library – caution with bolus dosing

• Epidural filter/yellow striped portless tubing

• Must have patent IV for 24 hrs after epidural removed

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There are centimeter markings on epidural catheter

Single marks = 1 cm

When grouped together each mark = 5

For example three clustered marks = 15

Know how to check length

•Assess/document every 1 hrs for 4 hrs, then Q 4 hrs

(and after an increase in rate or concentration)

• BP, HR

• Pain intensity

• Neuro-vascular check of affected extremity: color, temp, sensation, motion

• Observe/report signs of systemic local anesthetic toxicity

• Very rare – ringing in ears, periorbital paresthesia, nausea

• May reinforce the dressing around tegaderm; do NOT replace to avoid dislodgement of catheter

• Managed by PRS including catheter removal

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• Search “Ambit” on intranet for video and quick reference card on Clin Ed website

• No need to lock

• Programs in mLs

• Designed for take-home use

• Reprocess bottom only (not cassette and tubing)

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Drugs Brand Names Duration of AnalgesiaLidocaine Xylocaine 3-5 hours, variable

MepivacaineCarbocainePolocaine

Wound infiltration 45-90 minutesNerve block 4-6 hours

BupivacaineMarcaineSensorcaine

Wound infiltration 2-4 hoursNerve block 8-18 hours

Ropivacaine Naropin Wound infiltration 2-6 hoursNerve block 8-15 hours

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Questions to Consider

• What kind of nerve block does the patient have?• What is the extent of the motor and sensory block?• Will this block affect blood pressure, heart rate,

bowel function, ability to ambulate?• How long will this block last?• Is it likely that other nerves were blocked too, for

example, those to the face, vocal cords, diaphragm, bladder?

• Do I need to restrict use of systemic opioids, anti-coagulants, non-steroidal anti-inflammatory analgesics (NSAIDs)?

• Who do I call for more information or help?

• Consult service that “TAKES OVER”

• Require a provider-to-provider consult

• Automatic consult• epidurals, peripheral nerve catheters, ketamine

• In-depth pain history/assessment

• Write orders for analgesia and side effects

• All PRE-EXISTING analgesia and sedation orders discontinued by PRS

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•NMDA antagonist� At low doses analgesic � At high dose general

anesthetic� Max on med-surg floor

12mg/hr•Only the Pain Relief Service may order•BP, HR, RR, pain, sedation every 30 min X 1 hr, then every 2 hrs X 8 hours, then every 4 hrs•Not compatible with IV Lactated ringers or potassium

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Policy Statement:• Deep sedation requires a licensed anesthesia

provider• Minimal/Moderate sedation requires a Specialty

trained RN

HMC RN procedural sedation/airway training• Sedation Core = 8 hours• Sedation Update = 2 hour annually• Classes offered in April & October• Taught by Chief CRNA

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• Critical Care

• Radiology

• Echocardiology Lab

• Emergency Department (ED)

• Post Anesthesia Care Unit

• Ambulatory Procedure Area (APA)

• Multi Interventional Procedure Suite (MIPS)

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• Gamma Knife Unit• Endoscopy • Dental/Oral Surgery Clinic • Infusion Lab/Oncology• Spine Clinic

�All other areas need to arrange for a STAT or PACU nurse to

administer sedation

Be prepared to answer:

• When and how do you assess for pain?

• How do you reassess and document after a pain management intervention?

• How do you determine which dose to give from a range order?

• What are the risk factors for respiratory depression?

• How do you monitor for respiratory depression?

• What do you do when pain is uncontrolled?

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• How well was your pain controlled?

• How often did the staff do everything they could to help you with your pain?

• How often was your pain well-controlled?

HMC scores range below local, regional, national �

34http://www.medicare.gov/hospitalcompare/

• Individualize patient care to partner with patients

• Use key words “I want to do everything I can to make you

as comfortable as possible. I care about your pain control. ”

• Alleviate anxiety (explain rounding)

• Tell the patient when next dose of pain medicine is coming

• Use the whiteboard and encourage communication

• Address pain at handovers

• Provide complete explanation for new/modified

interventions

• Seek alternatives to pain medicine

• Reposition the patient (basic comfort measures)

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Thanks for your attention and welcome!