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PAIN ASSESSMENT AND MANAGEMENT POLICY

HCANH CQI Group – November 2010

SOURCE DATA:

VNSNY Center for Health Care Policy and Research (CHAMP)

Center for Medicare and Medicaid Services (CMS) OASIS-C Pain Assessment

McCaffery, M. Pain: Clinical Manual (1999)

World Health Organization

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Member agency polices: Rockingham VNA and Hospice, Community Health and Hospice, Northeast Rehab Home Care Services

PURPOSE:

To provide guidelines for the assessment and management of pain

To support the patient’s right to appropriate assessment and management of pain

BACKGROUND:

Definitions

Pain: an unpleasant sensory and emotional experience described as whatever and whenever the patient feels such discomfort. Pain is multidimensional and is usually characterized according to duration and cause.

• Acute pain – results from injury, surgery or tissue damage and is usually associated with autonomic activity like tachycardia and diaphoresis. It is usually time limited and subsides with healing.

• Persistent pain – persists for a prolonged period (usually more than 3-6 months). Pain may or may not be associated with a diagnosable disease process and autonomic activity is usually absent. Persistent pain is often associated with functional loss, mood and behavior changes and reduced quality of life.

• Nociceptive pain – is caused by stimulation of specific peripheral or visceral pain receptors from disease processes like osteoarthritis, soft tissue damage like falls, medical treatments like surgery or venipuncture. Pain is usually localized and responsive to treatment.

• Neuropathic pain – is caused by damage to the peripheral or central nervous system and is usually associated with diabetic neuropathies, stroke, chemotherapy treatments for cancer, or post-herpetic and trigeminal neuralgias. It is usually more diffuse and less responsive to analgesic medications.

Significance:

Pain has major implications for health, functioning and quality of life. Unrelieved pain is associated with depression, sleep disturbances, withdrawal and decreased socialization, functional loss and increased dependency, exacerbations of cognitive impairment and increased health care utilization and costs.

Assumptions:

1) Pain assessment must be regular, systematic, and documented to accurately evaluate the effectiveness of treatment.

2) Self-report is the gold standard for pain assessment.

BEST PRACTICE STANDARD:

All patients will assessed for pain on a regular basis and will either be pain free, or their pain will be controlled to a level that is acceptable to the patient and allows the patient to maintain the highest level of function possible.

POLICY:

All patients will be assessed for pain on admission, and subsequently, as appropriate, using a standardized assessment scale. An individualized plan of care (POC) will incorporate 1) the patient’s personal goals for pain control, 2) medication and non-medication pain reduction strategies, 3) effects of pain on patient’s physiologic, functional, cognitive, and emotional health, and 4) self-management education and support strategies.

PROCEDURE:

1. On admission/start of care (SOC) and at appropriate intervals determined by the plan of care, assess the patient for pain as follows:

a. Review medical history, physical exam, laboratory and/or diagnostic tests to understand events contributing to pain.

b. Assess/reassess pain levels including:

• Location and duration

• Intensity

• Character

• Frequency and pattern

• Precipitating and relieving factors

• Patient’s acceptable level of pain

• Nursing/therapy interventions and patient response to interventions

c. Review medications including OTC drugs and home remedies. Determine which pain control measures have been effective previously for the patient. Assess patient/caregiver attitudes and beliefs about analgesics, other drugs that support pain relief and non-pharmacologic treatments.

d. Use one of the following standardized pain assessment tools to assess/reassess pain taking care to consistently use the same rating scale for each assessment:

• Numerical Rating Scale (NRS)

• Verbal Descriptor Scale (VDS)

• Faces Pain Rating Scale

e. Observe the patient for nonverbal and behavioral signs of pain like facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalizations, crying or change in behavior from usual patterns. Gather information from family members about the patient’s pain experiences.

f. Assess pain regularly, at least at Start of Care (SOC), Resumption of Care (ROC), at the 60-day reassessment, and at Discharge. If pain is at an unacceptable level per patient rating scale, pain will be reassessed at least every 24 hours until an acceptable level for the patient is reached.

g. If an acceptable level of pain control is not reached with 48-72 hours of ongoing intervention, refer to the patient’s primary/managing physician, medical director or designee and document such communication.

h. Educate patients and families about pain medications and side effects, adverse effects and issues of addiction, dependencies and tolerance.

i. Educate patients and families to use analgesic medications prophylactically prior to and after painful procedures/treatments.

j. Educate patients to take pain medications on a regular basis to avoid allowing pain to escalate; and educate patients/families to use non-pharmacological strategies to manage pain such as relaxation, massage and heat/cold.

k. Document pain assessments including which standardized tool was used, patient-specific pain management/teaching interventions, and patient response to interventions in the patient’s clinical record according to agency policy.

ATTACHMENTS:

1. Review of Pain Intensity Scales, Collaboration for Home Care Advances in Management and Practice (CHAMP), champ-

• Numerical Rating Scale (NRS)

• Verbal Descriptor Scale (VDS)

• Faces Pain Rating Scale

2. WILDA Pain Assessment Guide

3. Using a Pain Diary

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