Transcript document

Pain: Understanding & Assessment
Cathleen Rawlings MS, CRNP
Interventional Radiology
443-481-1385
Objectives
 Define the terms pain, addiction, dependence and pseudo addiction.
 Identify the Joint Commission guidelines for pain assessment and
management.
 Review the following topics covered in AAMC pain management policies:
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Pain assessment policy
Range order policy
PCA policy with respect to PCA by proxy & PCA orders
IVP Dilaudid restrictions and Dilaudid PCA prescribing restrictions
Multiple narcotic orders
Definitions of Pain
International Association for the Study of Pain
and The American Pain Society:
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.”
International Association for the Study of Pain (www.iasp-pain.org)
Margo McCaffery, RN, Pain Management Educator
and Consultant
“What the patient says it is.”
McCaffery, M. & Pasero, C. (1999). Pain: Clinical Manual, 2nd ed. St. Louis: Mosby.
Commonly Misused and Misunderstood Terms
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Addiction
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Addiction is a primary, chronic, neuro-biologic 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.
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Physical Dependence
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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.
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Pseudo addiction
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Pseudo addiction is a term which has been used to describe patient behaviors
that may occur when pain is undertreated. Patients with unrelieved pain may
become focused on obtaining medications, may “clock watch”, and may
otherwise seem inappropriately “drug seeking” Even such behaviors as illicit
drug use and deception can occur in the patient’s efforts to obtain relief. Pseudo
addiction can be distinguished from true addiction in that the behaviors resolve
when the pain is effectively treated
JC Mandate #1
• Recognize the patient’s right to appropriate
assessment and management of their pain.
AAMC Pain Assessment Policy
• Patients will be initially screened for the presence of pain
upon entering AAMC utilizing the appropriate tool.
• Pain screening data will be documented according to the
location in which the patient enters the AAMC system.
• If pain is identified during screening, pain is
subsequently assessed by a licensed healthcare provider
which may include nurse, physician, Nurse Practitioner
or Physician Assistant.
NAP12.1.18 - Pain assessment, management and resources
JC Mandate #2
Screen ALL patients for pain
AAMC Pain Tools:
• PAINAD
• Used for cognitively impaired
or non verbal adults
• PAINAD evaluates 5 nonverbal behaviors and scores
them according to severity.
The computed score provides
an indication for the presence
of pain.
NAP12.1.18 - Pain assessment, management and
resources
• Neonatal/Infant Pain Scale
(NIPS)
▫ Behavioral assessment tool for
measurement of pain in
preterm and full-term
neonates.
• Children's Hospital Eastern
Ohio Pain Scale (CHEOPS)
▫ Behavioral assessment tool for
measurement of pain in
children ages 1-7 years.
JC Mandate #3
• Administer EFFECTIVE Pain Control
▫ If pain is not being effectively controlled in your patient, you may
collaborate, as indicated, to formulate and implement an effective
pain management plan.
▫ Request/Obtain order for a Pain Management Service or PharmD
consult for pain management. A Pain Management Service
consult requires an MD, DO, CRNP or PA-C order either entered
by the requesting medical staff provider or entered on their behalf
as a verbal order. A Pain Management Service consult may not be
ordered “per protocol.” PharmD pain consults may be ordered
“per protocol” when appropriate.
NAP12.1.18 - Pain assessment, management and resources
JC Mandate #4
• Reassess pain at an appropriate interval.
It is AAMC policy that if pain is documented during
the initial pain assessment, pain will then be
assessed at least every 8 hours or more often if
necessary.
Reassessment of pain will occur within one hour
of PRN pain medication
The documentation of pain reassessment in the
medical record is regularly audited by the quality
team.
JC Mandate #5
Patient, family , SO are provided with Pain Management
Education
▫ Risks for pain
▫ Importance of
effective pain
management
▫ Assessment process
▫ Management plan
AAMC Range order Policy
• The order must contain all the elements of a complete medication
order.
• The maximum allowable difference between the high and the low
dose is 4x the lowest dose. Exception: Post Anesthesia Care Unit
(PACU) orders may contain ‘prn’ opioid dose ranges greater than 4x
the lowest dose at the Anesthesiologists’ discretion.
• Orders containing time interval ranges are to be discouraged. For
range orders that are written containing a time interval, AAMC will
interpret the order as the medication being available for
administration at the lowest time interval.
MED16.1.04 - Range orders
AAMC PCA Policy
• PCA orders must utilize the standard PCA order set.
• When a PCA is ordered, all other narcotics are
automatically discontinued unless the order specifically
indicates otherwise.
• AAMC does NOT allow PCA by Proxy per our PCA
Policy. Please educate family members, friends and
significant others about the increased risk of respiratory
depression when anyone but the patient pushes the
bolus button.
• AAMC does not allow nurse proxy dosing.
MED16.1.16 - Patient controlled analgesia
AAMC Dilaudid Policy
• The administration of IVP and IM Hydromorphone/
Dilaudid at are only approved for administration in the
ED, OR, PACU, CCU and Interventional Radiology.
• To facilitate timely pain management, a physician who is
not privileged to order Hydromorphone PCA may only
order the standard dose setting. Then they must consult
the PharmD after initiation.
• Physicians privileged to order Hydromorphone PCA can
write for any dose and/or setting, and may or may not
consult for the Clinical Pharmacist as the follow-up
provider.
AAMC Dilaudid Policy
• Only Dilaudid Credentialed providers and PharmD’s
may make changes to a Dilaudid PCA
• Providers may complete the Dilaudid competency by
accessing the global share drive and searching for
Dilaudid Competency. Follow the directions at the end of
the competency for submission and approval.
MED16.2.08 - Hydromorphone parenteral administration
Multiple Narcotic Orders
• There are two situations in which multiple
narcotics may be ordered:
• To offer the patient several short-acting options
for analgesia.
• To treat breakthrough pain for a patient on one or
more long-acting narcotics
• Requirements for Offering Several Short-Acting
Options
• Multiple short-acting narcotic options are to
be used one at a time.
Multiple Narcotic Orders
• The orders must indicate the following:
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Medication, Dose, Route
Interval between doses
Date order written
The indication(s) for use.
Guidelines for which option to use under what
circumstance
▫ That only one option may be given at a time.
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MED16.1.29 - Use of multiple narcotics
References and Resources
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AAMC Policies (Available on AAMC Intranet):
Pain Assessment, Management & Resources
policy; Range Orders policy; PCA policy;
Multiple Narcotics policy; Continuous opioid
infusion policy; Narcotic storage, security ,
documentation and waste policy.
McCaffery, M. & Pasero, C. (1999). Pain: Clinical
Manual, 2nd ed. St. Louis: Mosby
McCaffery, M. & Pasero, C. (1999). Pain: Clinical
Manual, 2nd ed. St. Louis: Mosby.
Pasero, C. McCaffery, M. (2000). When patient’s
can’t report pain. AJN, 100(9): 22-23
Pasero, C. McCaffery, M. (2001).The patient’s
report of pain. AJN, 101(12): 73-74
Weissman, D. E. (2002). Is it Pain or Addiction?
Fast Facts #068. Available at End of Life
Physician Education Resource Center:
www.eperc.mcw.edu. Accessed March 3, 2003
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American Pain Society
(www.ampainsoc.org)
American Pain Foundation
(www.painfoundation.org)
American Academy of Pain Management
(www.aapainmanage.org)
American Academy of Pain Medicine
(www.painmed.org)
National Foundation for the Treatment of
Pain (www.paincare.org)
The Pain Society (www.painsociety.org)
Partners Against Pain
(www.partnersagainstpain.com)
Pain Medicine and Palliative Care
(www.stoppain.org)
Pain and Policy Study
(www.medsch.wisc.edu/painpolicy)
Pain Net, Inc. (www.painnet.com)