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Nursing Best Practice Guideline
Shaping the future of Nursing
Revision Panel Members
Doris Howell, RN, PhD Team Leader Chair in Oncology, Nursing Research University Health Network – Princess Margaret Hospital Toronto, Ontario Maria Beadle, RN, CHPCN(c) Palliative Care Nurse Clinician St Joseph’s Health Care – Parkwood Hospital London, Ontario Ann Brignell, RN, CHPCN(c) Palliative Pain & Symptom Management Consultation Program Lambton & Kent Counties Sarnia, Ontario Marilyn Deachman, RN, BA, CHPCN(c) Consultant/Educator Oakville, Ontario Heike Lackenbauer, RN, BScN, CHPCN(c) Clinical Coordinator and Educator Lisaard House Cambridge, Ontario Salima Ladak, RN, BScN, MN, ACNP Acute Pain Service, TGH Coordinator, UHN Pain APN Network University Health Network – Toronto General Hospital Toronto, Ontario Andrea Martin, RN Network Director WWD Hospice Palliative Care Network Kitchener, Ontario Janice Muir, RN, BSc, BSN, MSc(N) Clinical Nurse Specialist, Pain Providence Health Care Vancouver, British Columbia Shirley Musclow, RN, MN, ACNP Chair: Canadian Pain Society Special Interest Group – Nursing Issues Nurse Practitioner, Acute Pain Service The Scarborough Hospital Scarborough, Ontario Lori Palozzi, RN, MScN, ACNP Anaesthesia Pain Service The Hospital for Sick Children Toronto, Ontario Sharon Preston, RN, CHPCN(c) Coordinator/Educator Palliative Care Integration Project Yarker, Ontario Suzanne Watt, RN, MSc(A), CON(c) Clinical Nurse Specialist – Pain Management McGill University Health Centre – Royal Victoria Hospital Site Montreal, Quebec Judy Watt-Watson, RN, PhD Professor and Associate Dean – Academic Programs University of Toronto, Faculty of Nursing Toronto, Ontario Karen Winter, RN, BscN, MN(cand) Pain Management Nurse Royal Victoria Hospital Barrie, Ontario Heather McConnell, RN, BScN, MA(Ed) Program Manager Nursing Best Practice Guidelines Program Registered Nurses’ Association of Ontario Toronto, Ontario
Assessment and Management of Pain supplement
This supplement to the nursing best practice guideline Assessment and Management of Pain is the result of a three year scheduled revision of the guideline. Additional material has been integrated in an attempt to provide the reader with current evidence to support practice. Similar to the original guideline publication, this document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. This supplement should be used in conjunction with the guideline as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
Pain continues to be a challenge to effectively manage, and remains a priority goal for patient care. A heightened awareness of pain management issues in nursing practice is evident. Initiatives that have contributed to this increased awareness include, but are not limited to: National Pain Awareness Week, the inclusion of pain indicators in the Canadian Council of Health Service Accreditation Standards, a revised nursing education curriculum from the International Association for the Study of Pain (www.iasp-pain.org), and standards of care from the Canadian Pain Society. A review of the most recent literature and pain guidelines published over the last 3-4 years does not suggest dramatic changes to our approach to pain management, but rather suggest some refinements and stronger evidence for our approach.
The Registered Nurses’ Association of Ontario (RNAO) has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a monitoring and revision process has been established for each guideline every 3 years. The revision panel members (experts from a variety of practice settings) are given a mandate to review the guideline focusing on the recommendations and the original scope of the guideline. Members of the panel critically appraised seven international guidelines on the topic of pain assessment and management, using the Appraisal of Guidelines for Research and Evaluation (AGREE, 2001) Instrument. From this review, two guidelines were identified to inform the revision process. These guidelines were: American Pain Society (2005). Guideline for the management of cancer pain in adults and children. Glenview (IL): American Pain Society (APS). Institute for Clinical Systems Improvement (2006). Assessment and management of acute pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI).
Review/Revision Process Flow Chart
Yield 1165 abstracts 118 studies met inclusion criteria Quality appraisal of studies Develop evidence summary tables
Revisions based on new evidence
Supplement published Dissemination
Refer to the additions to Appendix C (pg. Van Dijk et al. for example. throbbing). A systematic. other than PQRST. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize the need for screening to occur during other routine assessments. 2002 + 3 . 2005. 2001. + Practice Recommendations Part A: Assessment – Parameters of Pain Assessment 2. 2006. These include. Davis & Walsh. interference with usual activities. use behavioural indicators to identify the presence of pain.). 2002.adverse effects related to medication use and any pain related symptoms experienced by the individual. Grade of Recommendation = C Additional literature supports: Bird. Van Dijk et al. 2002. and timing (occasional.. and a number were re-worded for clarity or to reflect new knowledge. Additional literature supports: Bird. Additional literature supports: APS.Definitions Throughout this supplement. but there are various methods of approaching the assessment of the parameters of pain.. 2006. Kleiber et al... 2003. Brown. Voepel-Lewis et al. no recommendations were deleted. the numbering of the recommendations has been modified. 2001. quality of pain (what words does the person use to describe pain? . 2001. ache or discomfort. Van Dijk et al. by asking the person or family/care provider about the presence of pain. Brown. 2003. Additional parameters of pain assessment have been added to ensure that the recommendation is comprehensive.. the term “chronic pain” has been updated to “persistent pain” and “side effects” is now referred to as “adverse effects” in order to reflect current terminology. Summary of Evidence The following content reflects the evidence reviewed that either supports the original guideline recommendations. Bird. work. medication usage and adverse effects. 2003. unchanged changed + additional information Practice Recommendations Practice Recommendations Part A: Assessment – Screening for Pain 1. intermittent. 2001. 0-10 scale). etc. Malviya et al... several recommendations were combined. 2002. 21 of this supplement) for examples of additional mnemonics that can be used to approach a basic pain assessment. 2004. 2004.. 2003. effect of pain on function and activities of daily living (i.aching.e. In situations where the individual is non-verbal. Brown.. or during the provision of care. provoking or precipitating factors. or provides evidence for revision.. 2006. Basic parameters for pain assessment continue to be important and supported by the literature. 2002.. The wording of this recommendation has been changed. 2004. Kleiber et al. As a result. pain related symptoms.. 2004. Voepel-Lewis et al. Voepel-Lewis et al. validated pain assessment tool is selected to assess the following basic parameters of pain: ■ ■ ■ ■ ■ ■ ■ ■ Grade of Recommendation = C location of pain. 2002 + 3. Cavender et al. 2004.. cognitively intact persons. severity of pain (intensity. 2004) and screening all clients for pain supports this approach. radiation of pain (does the pain extend from the site?). ICSI. Kaasalainen & Crook... constant). for all clients. Through the review process. Van Dijk et al. Malviya et al. level of pain at rest and during activity. Cavender et al. However. Pain is endorsed nationally and internationally as the 5th vital sign (Davis & Walsh. 2004. Family/care provider reports of pain are included for children and adults unable to give self-report. A focus on screening through the use of behavioural indicators in the non-verbal client is also emphasized. Self-report is the primary source of assessment for verbal. Screen all persons at risk for pain at least once a day (when undertaking other routine assessments). Van Dijk et al.
2000. 2000. Additional literature supports: Bird. 2001. Cavender et al. 2005. based on the research evidence that supports the use of a validated tool for the assessment of pain. Krulewitch et al. Brown. Malviya et al. history of pain. Voepel-Lewis et al. Verbal Scale. Jensen et al.. 2002. Behavioural Scale.. language. ICSI. 2004. 2004.. Kleiber et al. situational factors – culture.. Van Dijk et al. supplemented by physiological indicators when appropriate. 21) for a summary of additional assessment tools for the pediatric population. 2002. The selection of an appropriate pain assessment tool is based on its suitability of use with the patient population (Bird. The following parameters are part of a comprehensive pain assessment: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ physical examination. Pain assessment in patient populations who are unable to give self-report (non-communicative) may include behavioural indicators using standardized measures and physiological indicators where appropriate. psychological . person’s preferences and expectations/beliefs/myths about pain management methods.. Grade of Recommendation = A ■ ■ ■ ■ ■ Visual Analogue Scale (VAS). Brown. pain history and any resulting distress should be a component of a comprehensive pain assessment.. 2002. economic effects of pain and treatment.social variables (anxiety. Van Dijk et al.. 2002. 2001. Grade of Recommendation = C The wording of this recommendation has been changed to reflect a focus on the use of standardized behavioural indicators in the assessment of pain in non-communicative patients. psychosocial and spiritual effects. 2003. Voepel-Lewis et al.4. 2006.. 2003... 2001. 2004. effect and understanding of current illness. relevant laboratory and diagnostic data. The Grade of Recommendation has been changed to A from C. Bird. Van Dijk et al.. Van Dijk et al. Malviya et al. and person’s preferences and response to receiving information related to his/her condition and pain.. A standardized tool with established validity is used to assess the intensity of pain. 2004. 2005... Krulewitch. Additional literature supports: Alamo et al. 2004. Krulewitch et al.. Previous pain experience and pain history may impact on current pain status.. 22) for an example of a tool to support assessment of behavioural indicators in non-verbal adults. effects on activities of daily living. Refer to Appendix E in this supplement (pg. Brown. Additional literature supports: Bird. meaning of pain and distress caused by the pain (current and previous). As a result.. 2001. coping responses to stress and pain. Kaasalahen & Cook 2003.. Faces Scale. 2002 + 4 . depression). 2003. 2000. 2001.. Please note that there have been some revisions to the tools included in the appendices that support this recommendation – refer to Appendix B in this supplement (pg. Numeric Rating Scale (NRS). Van Dijk et al. APS. Cavender et al. Kleiber et al. Kleiber et al.. 2002 + 2003). Van Dijk et al. Feldt. 2002 + Practice Recommendations Part A: Assessment – Comprehensive Pain Assessment 6. ethnic factors. 2001. 2006. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize the person’s past pain experience as part of a comprehensive pain assessment. 2000. 5.
Additional literature supports: Bird. Van Dijk et al. with each new report of pain or instance of unexpected pain. 2002 + 8. for opioids: 15-30 minutes after parenteral opioid therapy. Effectiveness of intervention (both pharmacological and non-pharmacological) is reassessed after the intervention has reached peak effect (e.. or fever.. Pain is reassessed on a regular basis according to the type and intensity of pain and the treatment plan. constipation). Document on a standardized form that captures the person’s pain experience specific to the population and setting of care. extent of pain relief achieved – response (reduction on pain intensity scale). Van Dijk et al.. Brown. ■ ■ ■ Pain intensity and function (impact on activities) is reassessed at each new report of pain and new procedure.. Voepel-Lewis et al. Jensen & Chen. adverse effects of medications for pain treatment (e. Kaasalainen & Crook. Grade of Recommendation = C Additional literature supports: Bird. Documentation tools will include: ■ Initial assessment.. 2001. level of sedation. 2002 + 5 . quality and location. 2003. when intensity increases. tachycardia. 2002. 2004. barriers to implementing the treatment plan. at rest and on movement. sleep and mood. 2003. particularly if sudden or associated with altered vital signs such as hypotension.. Van Dijk et al. Brown.. Voepel-Lewis et al. intensity of pain at its worst in past 24 hours. 2002. Bird. 2001.g. Additional literature supports: APS. Voepel-Lewis et al. 2001. Unexpected intense pain. both pharmacological and non-pharmacological. Brown. 2003. 2002. 2005 + Practice Recommendations Part A: Assessment .Documentation of Pain Assessment 10. Acute post-operative pain should be regularly assessed as determined by the operation and severity of pain. comprehensive assessment and re-assessment.. 1 hour after immediate release analgesic).g. The following parameters should be monitored on an ongoing basis in persistent pain situations: ■ ■ ■ ■ ■ ■ ■ ■ current pain intensity.. Grade of Recommendation = C The wording of the recommendation has been changed to emphasize the need for the nurse to conduct a reassessment of pain intensity/severity following implementing a pain intervention (either pharmacological or non-pharmacological) to determine its efficacy. Van Dijk et al. 2002 + 9. 2004. Grade of Recommendation = C The wording of this recommendation has been changed to clarify that the parameters above are part of the ongoing reassessment of clients in persistent pain situations. nausea. should be immediately evaluated. according to peak effect time. and when pain is not relieved by previously effective strategies. and strategies used to relieve pain. Grade of Recommendation = C Additional literature supports: APS. 2003. effects of pain on ADL’s..Practice Recommendations Part A: Assessment – Reassessment and Ongoing Assessment of Pain 7. Van Dijk et al. 2005. 2004. ■ Monitoring tools that track efficacy of intervention (0-10 scale).. Van Dijk et al. 2002. and after each analgesic.
Grade of Recommendation = C Additional literature supports: Bird. 2004. ■ person’s goals for pain relief. 2002 + 6 . The nurse will engage in discussion with the interdisciplinary health care team regarding identified need for change in the treatment plan.. Validate with persons/care providers that the findings of the pain assessment (health care provider’s and person’s/care provider’s) reflect the individual’s experience of pain. 2003. Voepel-Lewis et al. 2002 + Practice Recommendations Part A: Assessment . providing a clear rationale for the need for change. 2002. Van Dijk et al. 2002.. ■ amount of regular and breakthrough pain medication taken in last 24 hours. Teach individuals and families (as proxy recorders) to document pain assessment on the appropriate tools when care is provided. 2004. 2002 + 12. ■ effect of unrelieved pain on the person. This will facilitate their contributions to the treatment plan and will promote continuity of effective pain management across all settings. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize the need to include the person’s experience of adverse effects related to treatment in the communication provided to team members.. Voepel-Lewis et al. Communicate to members of the interdisciplinary team pain assessment findings by describing parameters of pain obtained through the use of a structured assessment tool. Bird. 2001. 2002 + 15.. 2002. Grade of Recommendation = C Additional literature supports: Alamo et al.Communicating Findings of a Pain Assessment 13.. Brown. Advocate on behalf of the person for changes to the treatment plan if pain is not being relieved. 2002. ■ change in severity pain scores in last 24 hours. the relief or lack of relief obtained from treatment methods and related adverse effects. 2004.11. 2004. Voepel-Lewis et al. and ■ suggestions for specific changes to the treatment plan that are supported by evidence. The nurse supports his/her recommendations with appropriate evidence. Cavender et al. Voepel-Lewis et al.. ■ absence/presence of adverse effects or toxicity.. Van Dijk et al. 2004.. Brown. including: ■ intensity of pain using a validated scale.. Van Dijk et al. person’s goals for pain treatment and the effect of pain on the person.. Grade of Recommendation = C Additional literature supports: Brown. Grade of Recommendation = C Additional literature supports: Bird. Van Dijk et al. Van Dijk et al. ■ change in severity and quality of pain following administration of analgesic and length of time analgesic is effective. 2001.. 2002 + 14. 2003. Additional literature supports: Brown. Document pain assessment regularly and routinely on standardized forms that are accessible to all clinicians involved in care.
■ physical. Grade of Recommendation = C Additional literature supports: Brown.. 2002. 2002. 2001 + Practice Recommendations Part B: Management – Establishing a Plan for Pain Management 19. Refer persons with persistent pain whose pain is not relieved after following standard principles of pain management to: ■ a clinical team member skilled in dealing with the particular type of pain. 2003. Van Dijk et al. Provide individuals and families/care providers with a written copy of the treatment plan to promote their decision-making and active involvement in the management of pain. ■ etiology. 2004.. 2002. 2002 + 18. Van Dijk et al. ■ most effective pharmacological and non-pharmacological strategies. spiritual and concomitant medical factors involved. psychological.. Grade of Recommendation = A Additional literature supports: Alamo et al. Report situations of unrelieved pain as an ethical responsibility using all appropriate channels of communication in the organization. and communicating unrelieved pain to the appropriate clinician and supporting them in advocating on their own behalf. and sociocultural factors shaping the experience of pain. Additional literature supports: Cavender et al. Brown. Establish a plan for management in collaboration with interdisciplinary team members that is consistent with individual and family goals for pain relief. Voepel-Lewis et al.. Grade of Recommendation = C The wording of this recommendation has been changed to reflect that the communication related to unrelieved pain should be directed to the appropriate clinician. Voepel-Lewis et al. not exclusively the physician. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize that the referral for persons with unrelieved persistent pain may be to any member of the clinical team skilled in pain assessment and management. Changes to the treatment plan will be documented and communicated to everyone involved in the implementation of the plan. 2002 + 20. and there has been no change in the intent of the recommendation. Voepel-Lewis et al.16. Kleiber et al. 2004. Provide instruction to the person/care provider on: ■ ■ the use of a pain log or diary (provide a tool).. Additional literature supports: Bird. ■ baseline characteristics of pain. The plan will be adjusted according to the results of assessment and reassessment.. 2004. and ■ current and future primary treatment plans. Van Dijk et al. Van Dijk et al. 2004. 2002 + 17.. ■ a multidisciplinary team to address the complex emotional.. including individual/care provider documentation. psycho/social.. ■ management interventions. Grade of Recommendation = C Additional literature supports: Brown. 2002 + 7 . Brown. The change in the wording is for clarification only. taking into consideration the following factors: ■ assessment findings. 2002. 2004.
2005. general condition of the person. nociceptive. 2005.... Block et al. 2005. intensity of pain. 2003. usually via bolus and continuous infusion.. the indicators provided are identified as examples only. Maltoni et al. cost to the person and family. 2005. Grade of Recommendation = A ■ ■ The wording of this recommendation has been changed in order to include additional pain management modalities. Devulder et al. Pharmacological Management of Pain – Selecting Appropriate Analgesics Please Note: The recommendations in this section have been reordered to reflect more closely the process of care. neuropathic). Additional literature supports: Akrofi et al. 21. 2004 + 22.. catheter placement (location). Rogers & Ostrow. Additional literature supports: APS. taking into account: ■ ■ ■ ■ ■ ■ ■ ■ the type of pain (acute.Practice Recommendations Part B: Management.. Murat et al. thrombocytopenia). concurrent medical conditions. Advocating for referral (now Recommendation 27) is appropriate after all other aspects of analgesic selection have been considered. (2003) reviewed 100 studies that compared epidural therapy versus parenteral opioids post-operatively. regardless of analgesic type. Murat et al. The oral route is the preferred route for persistent pain and for acute pain as healing occurs. They found that the epidural route provided better pain relief for up to three post-operative days.. persistent. With regards to potential for analgesic toxicity. Regional analgesia provides site-specific relief and is an effective pain management modality in certain populations and should be considered. Grade of Recommendation = A The wording of this recommendation has been changed to clarify the various pain types that need to be considered in selecting an analgesic. potential for analgesic toxicity (e. and type and time of pain assessment. (2006) assessed the benefits and harms of postoperative epidural analgesia compared with systemic opioid-based pain relief for adults undergoing abdominal aortic surgery. They concluded that epidural analgesia. Advocate for use of the most effective analgesic dosage schedules and least invasive pain management modalities: ■ ■ ■ ■ ■ Tailor the route to the individual pain requirements and the care setting. and there has been no change in the intent of the recommendation. Nishimori et al. Cepeda et al. Intravenous administration is the parenteral route of choice after major surgery.. renal impairment. 2007 + 8 . 2003. 2003. Grade of Recommendation = C The intramuscular route is not recommended because it is painful and not reliable. age. Consider using a butterfly injection system to administer intermittent subcutaneous analgesics. peptic ulcer disease. The change in the wording is for clarification only. 2003. to emphasize that these are NOT the only situations where analgesic toxicity is a concern. 2005... A Cochrane review by Nishimori et al. provided better pain control compared with parenteral opioids. and the setting of care.g. Ensure that the selection of analgesics is individualized to the person. Block et al. response to prior or present medications. Grade of Recommendation = B Epidural patient controlled analgesia is more effective than intravenous patient controlled analgesia in certain surgical procedures and should be considered for eligible patients. A meta-analysis conducted by Block et al.. Cepeda et al. 2005.
that there is no clear evidence to support one NSAID over another. Consider the following pharmacological principles in the use of opioids for the treatment of severe pain: ■ ■ ■ Mixed agonist-antagonists (e. Initial doses should not exceed maximum recommended amounts.. 2005. Wiffen et al. Use a step-wise approach in making recommendations for the selection of analgesics for pharmacological management to match the intensity of pain unless contraindicated due to age. ICSI. (2007) explored the use of NSAIDS. Devulder et al. There is strong evidence to support the use of NSAIDS in combination with opioid analgesics for the management of post-operative pain (Cepeda et al. NSAIDS and anti-depressants are important adjuncts as they provide independent analgesia for specific types of pain. Grade of Recommendation = A The wording of this recommendation has been changed to emphasize that meperidine is not recommended in the treatment of pain + 9 . 2006. taking into consideration previous opioid use/dose/preparation and strategies to prevent adverse effects. such as neuropathic pain. 2005. Recognize that meperidine is not recommended for the treatment of pain. which can cause seizures and dysphoria. should be calculated carefully based on the current or most appropriate weight of the neonate. for cancer pain. The use of anticonvulsants is also supported in a systematic review by Wiffen et al. ■ Adjuvant medications such as anticonvulsants. Special precautions are needed in the use of opioids with neonates and infants under the age of six months.. pentazocine) are not administered with opioids because the combination may precipitate a withdrawal syndrome and increase pain. Drug doses. unless contraindicated. McNichol et al.. 2005. 2003. ■ Caution and starting with low doses are needed in administering adjuvant medications in the elderly who may experience significant anticholinergic and sedative adverse effects. ■ ■ Meperidine is contraindicated in persistent pain due to the build-up of the toxic metabolite normeperidene. Maltoni et al. Grade of Recommendation = B 26.g. renal impairment or other issues related to the drug: ■ Mild to moderate pain should be treated with acetaminophen or NSAIDS unless the person has a history of ulcers or a bleeding disorder. Maltoni et al. Recognize that a multi-modal analgesic approach is most effective for the treatment of pain and includes the use of adjuvant medications as part of treatment for mild pain and for specific types of pain. Grade of Recommendation = B The wording of this recommendation has been changed. Meperidine toxicity is not reversible by naloxone. Additional literature supports: Block et al. Grade of Recommendation = A The wording of this recommendation has been changed.. alone or combined with opioids. a statistically insignificant trend towards superiority (1/14 papers) or a slight but statistically significant advantage (9/14 papers). including those for local anaesthetics. Cepeda et al. 2007. A systematic review by McNicol et al. and that trials of combinations of NSAIDs with an opioid have disclosed either no difference (4/14 papers).. 2007 + 25. as the original recommendations 24 and 25 have been combined to emphasize the importance of a multi-modal analgesic approach. Additional literature supports: Cepeda et al. They concluded that NSAIDS appear to be more effective than placebo for cancer pain.. The elderly generally receive greater peak and longer duration of action from analgesics than younger individuals. Devulder et al. ■ Moderate to severe pain should be treated with an opioid analgesic.23. 2005 + 24. as it has been combined with the original Recommendation 26. 2005.. to emphasize the use of a step-wise approach in selecting analgesics. compared with either single analgesic on its own. 2005. (2007) in those experiencing persistent neuropathic pain – this review found no evidence for the effectiveness of anticonvulsants in acute pain situations. thus dosing should be initiated at lower doses and increased more slowly (“careful titration”). Meperidine has limited use in acute pain due to a lack of drug efficacy and a build-up of toxic metabolites. which could occur within 72 hours.. 2005)....
. and advocating for their use in practice. but are not limited to: ■ pain unresponsive to standard treatment. Recognize that opioids should be administered on a regular time schedule according to the duration of action and depending on the expectation regarding the duration of severe pain. according to: ■ cause of the pain. Cepeda et al. ■ age. Maltoni et al. Additional literature supports: Devulder et al. Pharmacological Management of Pain – Optimizing Pain Relief with Opioids 28. Doses are usually increased every 24 hours for persons with persistent pain on immediate release preparations. The exception to this is transdermal fentanyl. Grade of Recommendation = A Additional literature supports: Devulder et al. peak-effect and half-life) and route of the drug. duration of action. and ■ history of substance abuse. ■ If severe pain is expected for 48 hours post-operatively.. 2005. 2005 + 10 . Grade of Recommendation = C Devulder et al.. Grade of Recommendation = B Additional literature supports: Devulder et al. ■ mix of neuropathic and nociceptive pain.e. Lam et al. Grade of Recommendation = B Additional literature supports: Akrofi et al... ■ In persistent cancer pain. and every 48 hours for persons on controlled release opioids...27. analgesics may be effective given on an “as needed” basis. Advocate for consultation with a pain management expert for complex pain situations which include. ■ onset and peak effect. ■ multiple sources of pain. Late in the post-operative course. (2005) supports the need for pain guidelines that are specific to a type of pain in order to support evidence-based practice and decision-making. ■ duration of the analgesic effect. according to their duration of action. which can be adjusted every 3 days. 2005 + 29. ■ clinical condition. 2005. Use principles of dose titration specific to the type of pain to reach the analgesic dose that relieves pain with a minimum of adverse effects. ■ Long-acting opioids are more appropriate when dose requirements are stable. 2005 + Practice Recommendations Part B: Management. Ensure that the timing of analgesics is appropriate according to personal characteristics of the individual.. 2001 + 30. ■ individual’s response to therapy. and ■ known pharmacokinetics and pharmacodynamics of the drugs administered. Practitioners should consider referring to guidelines specific to pain type. routine administration may be needed for that period of time. opioids are administered on an “around-the-clock” basis. 2005. ■ concomitant drug use. pharmacology (i.
2003 + 32. Grade of Recommendation = A The wording of this recommendation has been changed for clarification. should be reduced by 25-50%. Use an equianalgesic table to ensure equivalency between analgesics when switching analgesics. • Adjustment to the “around-the-clock” dose is necessary if more than 2-3 doses of breakthrough analgesic are required in a 24-hour period. Murat et al. or if refractory nausea and vomiting. rather than by one-half as previously recommended. Breakthrough doses of analgesic should be administered to the person on an “as needed” basis according to the peak effect of the drug (po/pr = q1h. and the type of surgery. Ensure that alternate routes of administration are prescribed when medications cannot be taken orally. Grade of Recommendation = C This recommendation has been changed to reflect that the dose of the new analgesic. ■ Transdermal preparations for persons with persistent pain. • Breakthrough analgesic doses should be adjusted when the regular “around-the-clock” medication is increased. when switching from one analgesic to another. Grade of Recommendation = A 11 . Additional literature supports: Block et al. care setting. Grade of Recommendation = C The wording of this recommendation has been changed to include the use of the epidural route as an option for breakthrough medication in certain clinical situations. tolerance and dependency to prevent these from becoming barriers to optimal pain relief. Rogers & Ostrow.. Additional literature supports: National Comprehensive Cancer Network. and are usually administered as bolus medications through PCA pumps or epidural route. IV = q 10-15 min). Recognize the difference between drug addiction. It is most effective to use the same opioid for breakthrough pain as that being given for “around-the-clock” dosing. cost and resources.. Recognize that the safest method when switching from one analgesic to another is to reduce the dose of the new analgesic by 25-50% in a stable pain situation. SC = q 30 min. Promptly treat pain that occurs between regular doses of analgesic (breakthrough pain) using the following principles: ■ ■ ■ ■ Breakthrough doses of analgesic in the post-operative situation are dependent on the routine dose of analgesic. 2004 + 34. 2003. • Breakthrough doses of analgesic for continuous cancer pain should be calculated as 10-15 per cent of the total 24-hour dose of the routine “around-the-clock” analgesic. Additional literature supports: Block et al. taking into consideration the most efficacious and least invasive route. ■ Continuous subcutaneous opioid infusions for persistent cancer pain. individual preferences.. 2003. 2005 + 33. the individual’s respiratory rate. the intent of the recommendation remains unchanged. Individuals with persistent pain should have: • An immediate release opioid available for pain (breakthrough pain) that occurs between the regular administration times of the “around the-clock” medication.31. and pain is not controlled.
route or timing of administration. It was the consensus of the revision panel that there was a need to emphasis that naloxone (an opioid antagonist) should be used with caution in order to reduce the effects of opioid induced respiratory depression without completely reversing analgesia. Additional literature supports: Cepeda et al. confusion. Recommend changes in analgesics when inadequate pain relief is observed. 2005 + 36. Grade of Recommendation = C ■ The wording of this recommendation has been changed for clarification. Grade of Recommendation = A The wording of this recommendation has been changed to focus on the need to monitor all persons taking opioids. Grade of Recommendation = C The wording of this recommendation has been changed to focus on the active role nurses have in identifying the need for. Counsel patients that adverse effects to opioids can be controlled to ensure adherence with the medication regime. ■ In the presence of inadequate pain relief following appropriate dose titration. Monitor persons taking opioids. delirium refractory to prophylactic treatment. Evaluate the efficacy of pain relief with analgesics at regular intervals and following a change in dose. Evaluation should include assessment for residual pathology and other pain causes. constipation and drowsiness. but not limited to. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize the need to refer to a pain specialist in the situations described. and to emphasize the need for monitoring for toxicity as a safety issue. and institute prophylactic treatment as appropriate. however the grade of recommendation has been changed to “A” as the need for prophylactic treatment of adverse effects such as constipation have been recommended in recent randomized controlled trials. 2005 + 40. Maltoni et al. Additional literature supports: Cepeda et al. 2005 + 37. can slow or stop breathing. Refer to a pain specialist for individuals who require increasing doses of opioids that are ineffective in controlling pain. and recommending. Monitor persons taking opioids for potential toxicity when the person exhibits: Unacceptable adverse effects such as. Grade of Recommendation = A The wording of this recommendation remains unchanged. + Anticipate and Prevent Common Adverse Effects of Opioids 39.. or in doses larger than necessary to control the pain. such as neuropathic pain. or when they have not been titrated appropriately. 2005. a change in analgesic. Advocate for a change in treatment plan. Additional literature supports: APS. recognizing that opioids used for people not in pain.Monitoring for Safety and Efficacy 35. Grade of Recommendation = C 12 . + 38. myoclonus.. Anticipate and monitor individuals taking opioids for common adverse effects such as nausea and vomiting.. as required.
and monitor constantly for this adverse effect. + Practice Recommendations Part B: Management Pharmacological Management of Pain – Anticipate and prevent common adverse effects of opioids – Constipation 46. ■ Laxatives should be prescribed and increased as needed to achieve the desired effect as a preventative measure for individuals receiving routine administration of opioids. Grade of Recommendation = C The wording of this recommendation has been changed. for example. 2003. Recognize and treat all potential causes of adverse effects taking into consideration medications that potentiate opioid adverse effects: ■ Sedation – sedatives. Grade of Recommendation = B ■ Osmotic laxatives soften stool and promote peristalsis and may be an effective alternative for individuals who find it difficult to manage an increasing volume of pills. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize that the nurse should consult with the prescribing clinician (not exclusively the physician) regarding switching antiemetics. antiemetics.41. Assess all persons taking opioids for the presence of nausea and/or vomiting. Institute prophylactic measures for the treatment of constipation unless contraindicated.. 2005 + 43. Recognize that antiemetics have different mechanisms of action and selection of the right antiemetic is based on this understanding and etiology of the symptom. This change has been made to acknowledge the role that nurse practitioners and others play in initiating orders for treatment. antihistamines and other anticholinergics. tricyclics. Grade of Recommendation = B Stimulant laxatives may be contraindicated if there is impaction of stool. Additional literature supports: Block et al. Enemas and suppositories may be needed to clear the impaction before resuming oral stimulants. tricyclics. tranquilizers. ■ Confusion – phenothiazines. Consult with the prescribing clinician regarding switching to a different antiemetic if nausea/vomiting is determined to be related to the opioid. paying particular attention to the relationship of the symptom to the timing of analgesic administration.. ■ Postural hypotension – antihypertensives. Grade of Recommendation = C Bulk forming agents should be avoided when bowel motility is compromised. Grade of Recommendation = C ■ ■ 13 . Ensure that these persons are prescribed an antiemetic for use on an “as needed” basis with routine administration if nausea/vomiting persists. and does not improve with adequate doses of antiemetic. Grade of Recommendation = C 45. with opioids. Cepeda et al. Pharmacological Management of Pain – Anticipate and prevent common side effects of opioids – Nausea and vomiting 42. and it is now combined with the original Recommendation 45 for clarity and conciseness. Assess the effect of the antiemetic on a regular basis to determine relief of nausea/vomiting and advocate for further evaluation if the symptom persists in spite of adequate treatment. Grade of Recommendation = A Practice Recommendations Part B: Management. Grade of Recommendation = C 44.
Grade of Recommendation = C 48.. chest tube removal. Pharmacological Management of Pain – Anticipate and prevent common adverse effects of opioids – Drowsiness/sedation 50. Additional Literature Supports: Herdon et al.g. Counsel individuals on dietary adjustments that enhance bowel peristalsis recognizing personal circumstances (seriously ill individuals may not tolerate) and preferences. Cavendar et al.. that there is insufficient data to assess the efficacy of other psychological interventions.. ■ Combine pharmacologic (e. Pharmacological Management of Pain – Anticipate and prevent procedural pain 51. medical tests.g. Grade of Recommendation = A The wording of this recommendation has been changed to reflect an increased focus on prevention of pain in infants. 2001 + 47. adequate fluid intake is required to avoid dry. Recognize that transitory sedation is common and counsel the person and family/care provider that drowsiness is common upon initiation of opioid analgesics and with subsequent dosage increases. ■ Anticipate and prevent pain when performing procedures on infants to prevent sensitization for pain in the future. Murat et al. 2001). based on recent strong evidence in relation to prevention of procedural pain in children. combined cognitivebehavioural interventions and hypnosis) can be used with children and adolescents to manage or reduce pain and distress associated with needle-related procedures. Notify the appropriate clinician of confusion or hallucinations in order to evaluate drowsiness which continues beyond 72 hours. These agents should be reserved for those who are not receiving long-term opioid therapy and are able to maintain adequate hydration. 2002. Pappagallo.. Urgently refer persons with refractory constipation accompanied by abdominal pain and/or vomiting to the appropriate clinician. + Practice Recommendations Part B: Management. This change has been made to reflect the scope of nursing practice. 2003). topical anaesthetic) with non-pharmacologic options for prevention. Uman et al. not exclusively the physician. such as cognitive-behavioural therapies. Anticipate pain that may occur during procedures e.. caution should be taken to avoid their use in those on fluid restriction. Additional literature supports: Akrofi et al. They noted. dressing changes. This change has been made to reflect the scope of nursing practice. 2005. 2004. The use of non-pharmacological interventions. Kleiber et al. along with pharmacological approaches is a valuable approach to procedure-related distress (Murat et al. those confined to bed or in those with strictures or partial obstruction (Herndon.. There is strong evidence from RCTs that supports the prevention of procedural pain. 2007 + 14 . Rogers & Ostrow. Bulk-forming laxatives are effective at providing a mechanical distenation that promotes bowel function. A systematic review conducted by Uman et al. hardened stool (Pappagallo. 2001. however.The wording of this recommendation has been changed to include a statement regarding avoiding the use of bulk forming agents in the presence of decreased bowel motility. (2007) concluded that there is preliminary evidence that a variety of cognitive-behavioural interventions (distraction. 2004.. line insertion/removal etc. However. to determine the underlying cause. Grade of Recommendation = C Practice Recommendations Part B: Management. 2001) and potential bowel obstruction. 2003.. when confusion or hallucinations are present with drowsiness. Pappagallp. + 49. Grade of Recommendation = C The wording of this recommendation has been changed to reflect that referral should be to the appropriate clinician. Grade of Recommendation = C The wording of this recommendation has been changed to reflect that referral should be to the appropriate clinician. 2002. not exclusively the physician. The grade of recommendation has been changed to grade “A”.
there is no change to the intent of the recommendation. Tolerance is usually not a problem and people can be on the same dose for years. Clarify the difference between addiction. ■ Persons using opioids on a long-term basis for pain control may be on the same dose for years. Ensure that individuals understand the importance of promptly reporting unrelieved pain. Anxiolytics and sedatives are specifically for the reduction of associated anxiety. 2004. Lam et al.. In a systematic review conducted by Devulder et al. Additional literature supports: Cheung et al. had significant clinical benefit in the care of women having elective hysterectomy.. Cheung et al. Pharmacological Management of Pain – Patient and family education 54. and the correction of myths. which are known to arise from long-term opioid use. Additional literature supports: Murat et al.. They noted. If used alone. Devulder et al. The wording of this recommendation has been changed to update the term « conscious sedation » to « moderate sedation ». Grade of Recommendation = A The wording of this recommendation has been changed to emphasize the importance of an individualized approach to patient education. Grade of Recommendation = C Additional literature supports: Akrofi et al. They found significant improvements in functional outcomes. 2003 + Practice Recommendations Part B: Management. Ensure that skilled supervision and appropriate monitoring procedures are instituted when moderate sedation is used. coupled with these strategies. Murat et al. tolerance and physical dependence to alleviate misbeliefs that can prevent optimal use of pharmacological methods for pain management. (2005). Rogers & Ostrow. it was identified that opioids are the preferred therapy for the long-term management of persistent pain. with particular attention focused on strategies for the prevention and treatment of adverse effects. 2004 + Grade of Recommendation = C 53. however. 2004. Additional literature supports: Brown. new sources or types of pain and adverse effects from analgesics. Grade of Recommendation = C 56. as well as confirming that this treatment approach is associated with positive safety and efficacy. (2004) in an RCT explored the effect of psycho-educational interventions (specifically cognitive interventions of distraction and reappraisal) with information given prior to surgery on post-operative outcomes of Chinese women. See Appendix A (pg.. anxiolytics and sedatives blunt behavioural responses without relieving pain. ■ Persons who no longer need an opioid after long-term use need to reduce their dose slowly over several weeks to prevent withdrawal symptoms because of physical dependence. 2001 + 55. 2005. They concluded that pre-operative information. on the functional status of patients. Recognize that analgesics and/or local anaesthetics are the foundation for pharmacological management of painful procedures. including quality of life. The wording of this recommendation has been changed for clarity only. Provide the person and their family/care providers with information about their pain and the measures used to treat it. a need to establish the impact of physical tolerance and other outcomes. using an individualized approach. 20) for a definition of moderate sedation.52. 2003.. 2005 + 15 . but may require upward adjustments of dosage with signs of tolerance. changes in their pain. Grade of Recommendation = A ■ Addiction is a psychological dependence and is rare with persons taking opioids for persistent pain.
Non-pharmacological methods of treatment should not substitute for adequate pharmacological management. Taylor et al. 2004. 2003 + 16 . 2005 + 58.. Brown. APS. Document all pharmacological interventions on a systematic pain record that clearly identifies the effect of analgesic on pain relief. 2005.. Cheung et al. Grade of Recommendation = A The original guideline Recommendations 62 and 63 have been combined in this modified recommendation... Additional literature supports: Antall & Krevesic. 2004. Voss et al. 2004. ■ Imagery. 2003. Utilize this record to communicate with interdisciplinary colleagues in the titration of analgesic.. Roykulcharoen & Good. 2003. Refer to Appendix H (pg. Any potential contraindications to non-pharmacological methods should be considered prior to application. Grade of Recommendation = C Additional literature supports: Akrofi et al. Several randomized studies of various sizes support the grade of recommendation “A” for the use of massage (Poitrowski et al. ■ Massage. ■ Pressure/vibration. 2002. Good et al. relaxation (Roykulcharoen & Good.. Implement educational and psychosocial interventions that facilitate coping of the individual and family early in the course of treatment... in a controlled trial. 2005 + 60. Eccleston et al. severity. Grade of Recommendation = A The recommendation has been changed to include the use of both educational and psychosocial interventions to facilitate coping. There is evidence from randomized studies on the efficacy of these interventions.Practice Recommendations Part B: Management. pain and satisfaction). 2003). Additional literature supports: Antall & Krevesic. 2002. found that psychosocial interventions. Wirth et al. 2005 + Practice Recommendations Part B: Management. 2005. Grade of Recommendation = C Additional literature supports: Devulder et al. location and type of pain should all be documented.. Selection of non-pharmacological methods should be based on individual preference. The use of music as a strategy is an addition to the original recommendation. 2003). Voss et al. Mehling et al. ■ Relaxtion. 2004). Poitrowski et al. 2005. including randomized studies.. Combine pharmacological methods with non-pharmacological methods to achieve effective pain management. (2003). 22) for a listing of behavioural/cognitive interventions for acute pain. The date. Laurion & Fetzer. and may include strategies such as: ■ Superficial heat and cold. Non Pharmacological Management of Pain 59. 2004. There is strong evidence. 2003. to support the use of a combination of pharmacological and non-pharmacological approaches to pain management.. imagery (Laurion & Fetzer. 2002. Provide the individual and family in the home setting with a simple strategy for documenting the effect of analgesics. along with education pre-operatively resulted in significant positive clinical outcomes (anxiety. Hatton. time. 2004. ICSI. and therefore the grade of recommendation has been changed to an “A”. 2006. Cheung et al. Hatton.. 2006. 2004). and music (Laurion & Fetzer. and ■ Music. Pharmacological Management of Pain – Effective Documentation 57.
removal of barriers... Roykulcharoen & Good. non-malignant pain. They found that although the intervention group did not have better pain management overall.2005. Recognize that cognitive-behavioural strategies combined with other approaches...) across populations and settings.. including multidisciplinary rehabilitation. Nurses prepared at the entry to practice level must have knowledge of the principles of pain assessment Grade of Recommendation = C and management. 2004 + 66. Educational programs should be designed to facilitate change in nurses’ knowledge.. and the needs of specific patient populations and settings. Grade of Recommendation = A This recommendation has been changed to include educational interventions. corporate standards. practice modifications. 2004. Additional literature supports: Bogduk et al. Cheung et al.61. Chiu et al. 2004. Good et al. 2004 + 64. (2006).. Eccleston et al. can be helpful strategies for treatment of persistent. 2004 + 65. multi-faceted access to resources. LeFort et al. (2004) evaluated a preadmission education intervention to reduce pain and related activity interference after coronary artery bypass surgery. The + 17 . etc. 2004 + 62. 2004. Additional literature supports: Brown. Institute educational and psycho-educational interventions as part of the overall plan of treatment for pain management. time for research activities and provision of education. Barlow & Ellard. reminder systems. Butter et al. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize that there should be a specific focus on different patient populations in nursing education to support individualized patient care. 2006 + Education Recommendations 63. 2002. Additional literature supports: Ravaud et al.. 2002. 1998. Additional literature supports: Antall & Krevesic. Voss et al. attitudes and beliefs about pain assessment and management in order to support practice across populations and settings. Schofield. Watt-Watson et al. Grade of Recommendation = C The wording of this recommendation has been changed to emphasize the need for an approach to education that recognizes the resources required for successful implementation. along with psycho-educational interventions. 2004. and must address the resources necessary to support practice (e. 2004. examined the relationship between contextual factors and research utilization in nursing and identified six factors that were statistically significant: role of the nurse. 2002. The principles of pain assessment and management should be included in orientation programs and be made available through professional development opportunities in the organization. Meijers et al. 2005. as part of a comprehensive approach to pain management. 2004. they had some reduction in painrelated interference with activities and fewer concerns about taking analgesics.. The literature continues to support the use of psycho-educational interventions as part of the plan of care. Grade of Recommendation = C Additional literature supports: Ravaud et al. McGillion et al. skills.. Watt-Watson et al. multi-faceted support.g. Educational programs must support translation of knowledge into practice. Cheung et al.. Watt-Watson et al. Grade of Recommendation = A The wording of this recommendation has been changed to emphasize that cognitive-behavioural strategies are not sufficient to manage all types of pain.. 2005. organizational climate (culture). 2004. 2002.. Ravaud.
Policies must clearly support or direct expectations of staff that satisfactory pain relief is a priority. to nursing practice. Rycroft-Malone. Grade of Recommendation =C 68. 2004. Nursing regulatory bodies should ensure that Standards of Nursing Practice include the adoption of standards for accountability for pain management. Additional literature supports: Alley. Grade of Recommendation = C Additional literature supports: Meijers et al. Health care organizations need to demonstrate support for an interdisciplinary approach to pain care. such as access to experts in pain management. More research needs to be conducted to identify the contextual factors that consistently enhance research utilization. In order to be successful in implementing evidence based pain care. Grade of Recommendation =C Additional literature supports: Alley et al. family/care providers and staff to provide effective pain assessment and management. correlational study conducted by Alley (2001) examined the influence of a formal organizational pain management policy on nurses’ pain management practices in a tertiary-care medical centre. Meijers et al. 2003 + 69. 2006 + 70... Additional literature supports: Brown. 2004. or the most important. 2006 + Grade of Recommendation = C 72. Health care organizations must demonstrate their commitment to recognizing pain as a priority problem. Health care organizations must have educational resources available to individuals and families/care providers regarding their participation in achieving adequate pain relief. 2002) as part of the overall organizational culture. 2006 Organization and Policy Recommendations 67. Grade of Recommendation = C Additional literature supports: Meijers et al. Dahl et al. 2001.. Health care organizations must have documentation systems in place to support and reinforce standardized pain assessment and management approaches.authors concluded that overall.. the results of the study were mixed and that these factors are not necessarily the only. 2001 + 71. Grade of Recommendation = C A descriptive. Health care organizations must ensure that resources are available to individuals. The implications for nursing practice include an increased understanding of the influence an organizational policy could have on improvements in pain management. She found that nurses’ knowledge of pain management and their sense of accountability for pain management were significantly related to knowledge of the organization’s chronic pain management policy.. Additional literature supports: Brown. organizations need to consider approaches for implementation that support an interdisciplinary approach to care (Rycroft-Malone. 2002 + 18 .
Additional Literature Supports: Wallin. patient experiences with their care and patient clinical outcomes (Wallin. but are not limited to: ■ the use of a model of behaviour change to guide the development of strategies for implementation. their adherence to the recommendations. The Toolkit is recommended for guiding the implementation of the RNAO nursing best practice guideline Assessment and Management of Pain. Health care organizations must have quality improvement systems in place to monitor the quality of pain management across the continuum of care. Nursing best practice guidelines can be successfully implemented only where there are adequate planning. theoretical perspectives and consensus. ■ Dedication of a qualified individual to provide the support needed for the education and implementation process. consider the most effective methods for dissemination and implementation of guideline recommendations. researchers and administrators) has developed the Toolkit: Implementation of clinical practice guidelines based on available evidence. Ongoing evaluation should occur on many levels. 2002 + 75. organizational and administrative support. 2002. Refer to the guideline (pg. 2002. Brouwers. Davies & Dunn. Danseco. 2005. Edwards & Virani. Rycroft-Malone et al. Grade of Recommendation =C Additional literature supports Dobbins. In this regard.73. Additional literature supports: Davies.. Grade of Recommendation = C A key component of successful implementation of best practices in pain care is that of evaluation and monitoring. It has been found through a systematic review of randomized trials that although there are many strategies to influence practice change.. 1995). 87) for a summary of suggested structure. Graham. ■ Ongoing opportunities for discussion and education to reinforce the importance of best practices. Organizations may wish to develop a plan for implementation that includes: ■ An assessment of organizational readiness and barriers to education. resources. In planning educational strategies. 2005). ■ the use of a combination of strategies to influence practice change. 1995.. 2005 + 74. as well as the appropriate facilitation. Oxman et al. process and outcome indicators for organizations to consider in their quality improvement monitoring approaches. Meijers et al. Davies. ProfettoMcGrath & Levers. the most effective approach is achieved when a combination of strategies are utilized (Oxman et al. and include the nurses’ experience with the guideline. Harrison. ■ Opportunities for reflection on personal and organizational experience in implementing guidelines. RNAO (through a panel of nurses. ■ designing implementation strategies that take into consideration the influence of the organizational environment. Grade of Recommendation = A There are numerous models that promote a structured approach to moving research evidence into practice.. Rycroft-Malone et al. 2006 + 19 . (2002) discuss the importance of the organizational environment (or culture) as a key element in a framework for implementing evidence into practice. Profetto-McGrath & Levers. ■ Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. These methods include. and change models that can be used to guide the development of strategies for implementation.
open your eyes either alone or accompanied by light tactile stimulation. ■ Conduct an organizational needs assessment related to pain assessment and management in order to identify current knowledge and further educational requirements. ■ Provide organizational support such as having the structures in place to facilitate best practices in pain care.. facilitation and project management skills. ■ Identify and support designated best practice champions on each unit to promote and support implementation. 2007). 2007). ■ Pain initiatives within organizations should leverage on the standards of the Canadian Pain Society (CPS) and the Canadian Council of Health Services Accreditation (CCHSA) in order to support implementation and sustainability of practice change. however updates to the following appendices are noted. A summary of these strategies follows: ■ Have at least one dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support. 2006). behavioural and cognitive strategies. such as a light tap on the shoulder or face. including medications. Identify short-term and long-term goals. which is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal command (e. acknowledging work well done (Davies & Edwards. a drug) introduced into a living system to be eliminated or disintegrated by natural processes (Medline Plus. 2004). having. or utilizing more than one mode or modality (Medline Plus. Celebrate milestones and achievements. 2007). ■ Create a vision to help direct the change effort and develop strategies for achieving and sustaining the vision. Research Gaps and Implications In order to support nurses in the provision of optimal pain care. withdrawal and addiction with long-term use of opioids. 20 . ■ Research related to physical tolerance. For example. Develop new assessment and documentation tools (Davies & Edwards. For example. multi-modal pain management involves a variety of approaches. having an organizational philosophy that reflects the value of best practices through policies and procedures.Implementation Strategies The Registered Nurses’ Association of Ontario and the guideline panel have compiled a list of implementation strategies to assist health care organizations or health care disciplines who are interested in implementing this guideline. ■ Coping and relationship to pain ■ Administration of opioids via subcutaneous injection/infusion – efficacy of approach.g. Appendix A: Glossary of Clinical Terms The following terms have been added to the glossary: Multi-modal: Relating to. written or technology supported means. ■ Establish a steering committee comprised of key stakeholders and interdisciplinary members committed to leading the change initiative. 98): Conscious sedation: This term has been replaced with the term “moderate sedation”. 2006). The following term has been revised as found in the guideline (pg. Wilson & Work Group on Sedation. The individual should have good interpersonal. Non-communicative: An individual who is unable to communicate through verbal. 2004). additional research in the following areas would benefit practice: ■ Long-term effects of opioids in specific pain populations – clinical population over 20 years (non-cancer) to support evolving practices in these areas re. not a sternal rub). Cardiovascular function is usually maintained (Cote. Half-life: The time required for half the amount of a substance (e.. clinical expertise and leadership. No intervention is required to maintain a patent airway and spontaneous ventilation is adequate. non-addiction. Mixed pain: Mixed pain etiology contains both inflammatory and neuropathic components (Medscape. Appendices The review/revision process did not identify a need for additional appendices.g. Peak effect: The amount of medication in the blood that represents the highest level during a drug administration cycle (Mosby.
Anesthesiology... 6. P. McGrath.e. 101) as a sample assessment tool for pediatric pain assessment. 10 (Wong –Baker uses a 0-5 point scale) which has a strong positive correlation to the numeric 0-to-10 scale. C. & Finley. Spafford. 99(1-2).. based on the needs of the practice setting: SAMPLE 1: PAINED Place – Location of the pain (could be multiple sites). throbbing. 93(2). walking. turning. included in the original guideline (pg. Policies and Pamphlets... van Korlaar. pressure. Appendix C – Sample Questions for Baseline Assessment of Pain There are several mnemonics noted in the literature that can be used to structure a baseline assessment of pain.painsourcebook. In addition to the PQRST approach. Amount – Refers to pain intensity (10 point scale). Relieving Factors – What makes your pain better? Ask about any non-pharmacological approaches. C. McGrath. facial.e. (2002). social interactions). References: ■ Hicks. The revised scale has six faces. C. During the observation. Pain. moving.g. A. Treatment – What medications work for you? Do you have side effects from your medications? 21 . (2001). and details of this tool have been included in this supplement by panel consensus. P.. 349-357. stress. burning.. aching. which reduces the potential for confusion based on facial expression. B. etc? Aggravating Factors – What makes your pain worse (e. 2. clinicians may want to consider using one of the following mnemonics. The faces on this scale don’t illustrate smiles or tears (as does the Wong-Baker scale).e. Pain. social. pattern of pain. onset. 4.e. Intensifiers – What makes the pain worse? (i. sleep. physiologic signs) and measures 27 variables during a 10 minute observation. Sample 1: Non-communicating Children’s Pain Checklist (NCCPC): This tool has demonstrated preliminary validity and reliability for measuring pain in children with severe cognitive impairments. & Camfield. duration. the observer rates each variable on a 3 point scale (not at all – 1 to very often – 3)... L. French and twenty-four other languages. vonBaeyer. Sample 2: Faces Pain Scale – Revised (FPS-R) The Wong-Baker Faces Scale. The Faces Pain Scale – Revised: Toward a common metric in pediatric pain measurement. or with children in long-term care or at home (NCCPC-R). G. Psychometric properties of the non-communicating children’s pain checklist – revised. which are then added to provide a total score. L. 96(3). non-pharmacological methods). breathing. Effects – Effect of pain on quality of life (i. C. & Goodenough. 173-183. It is available in English. Descriptors – Description of the quality of the pain (i. www. etc. activity. shooting. Camfield.. etc. chewing). has been replaced with the Faces Pain Scale – Revised. SAMPLE 2: OLDCART Onset – When did the pain start? Location – Where is your pain? (Could be multiple sites). P. G. (2002). Nullifiers – What makes the pain better? (i. ■ The Faces Pain Scale – Revised is available online at: Pediatric Pain Sourcebook of Protocols. It may be used with children experiencing post-operative pain (NCCPC-PV). functional status. The NCCPC-PV contains six subscales (vocal. References: ■ Breau. A.Appendix B – Pain Assessment Tools for Neonates. numbered 0. appetite. The neutral anchors used in the Faces Pain Scale – Revised are considered to be more appropriate for children. I.). type and amount of medication.. time of day.). stabbing.ca. Infants and Children The following tools have been added as examples of validated tools that clinicians may which to use in order to meet the assessment needs of specific pediatric populations.. Finley. adverse effects of analgesics. throbbing. ■ Breau. 8. Duration – How long does your pain last? Is it persistent or periodic? Characteristics – What does it feel like? Is it burning. Validation of the non-communicating children’s pain checklist – postoperative version. sharp. 528-535. body and limbs. activity. position.
vision. facial grimaces/winces (furrowed brow. 22 . cries. the panel reached consensus on providing an example protocol for each of the two approaches. 124 of the guideline) provides a sample of a subcutaneous injection protocol to support clinical practice in the administration of medications by injection. cursing during movement. K. consideration should be given to the impact of pain on the individual’s function (functional ability and functional status). and to recognize that policy development related to this care must consider legislation. etc.Appendix E – Tools for Assessment of Pain in Adults Checklist of Non-verbal Pain Indicators (CNPI) The Checklist of Nonverbal Pain Indicators was designed to measure pain behaviours in cognitively impaired older adults post-operatively. Refer to the Brief Pain Inventory. It is an observational tool that includes six behaviours that are scored at rest and on activity – the presence of a pain indicator is scored as 1. as well as a total score. 2006). while the absence of the indicator is scored as 0. however the presence of any of the behavioural indicators may be indicative of pain. gasps).). clenched teeth). inability to keep still). or affected area during movement).org/publications/trythis/assessingPain. and determining the most appropriate choice can be challenging (ICSI. The panel reviewed the literature related to the “single-site” versus “multi-site” approach. bed. 1(1). however there was no evidence to recommend one particular protocol. rubbing (massaging affected area). There is no specific cut-off score to indicate pain severity. Appendix H – Non-pharmacological Methods of Pain Control Copyright 2006 by ICSI. Organizations are advised to consider these protocols as examples only. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). values and unique features of each organization. References: ■ Feldt. The six indicators are: verbal complaints (non-verbal: moans. recognizing that neither has been validated. The two sample protocols are available for download on the RNAO website at www. vocal complaints (words expressing discomfort or pain – “that hurts”.rnao.pdf When conducting a comprehensive pain assessment. intervention and monitoring by the clinician. 126). Pain Management Nursing. http://www. 13-21. Various strategies can enhance or complement pharmacological interventions. bracing (clutching or holding onto side rails. groans. The checklist of non-verbal pain indicators (CNPI).org/bestpractices. (2000). which may include behavioural/cognitive interventions or physical modalities. ■ The Checklist of Non-verbal Pain Indicators (CNPI) is available online at: John Hartford Institute for Geriatric Nursing and the Alzheimer’s Association – Assessing Pain in Persons with Dementia. Appendix G – Sample Subcutaneous Injection Protocol Appendix G (pg. Institute for Clinical Systems Improvement (2006). The subscores (at rest and on activity are summed). restlessness (shifting of position [constant or intermittent]. and requires further assessment. which has a subscale that incorporates the key components of a functional assessment. mission. “ouch”. Assessment and management of acute pain. The following summary is intended to supplement the interventions identified in the guideline (pg.hartfordign. Reproduced with permission. Therefore. Not all interventions are effective for all persons with pain.
procedural distress. Description Goal Positive reinforcement Transform meaning of pain from a punative to challenging event. using imaginatvie stories or “pain switches” or “anesthetic gloves” ■ Physical strategies: application of heat or cold. Decrease anxiety and pain. rest or exercise ■ Music. children can then practice procedure using coping techniques. the use of pacifiers. During times of anxiety. massage. Decrease anxiety. Relaxation Preparation Help child to develp a realistic expectation about a procedure. art and play therapies 23 . Techniques include counting. blowing bubbles.Behavioural/Cognitive Interventions for Acute Pain Type of Treatment Behavioural/Cognitive Interventions Desensitization Systematic gradual exposure to feared situations or objects. Memory change To reduce anticipatory distress and. swaddling. and repeats a set of positive thoughts. Hypnosis Thought stopping and positive self-statements Distraction Shift attention away from the procedure and pain onto more enjoyable things. Positive statements and tangible rewards after a painful procedure. Demonstration of a mock procedure by another child or adult who demonstrates positive coping behaviours. Take focus away from procedure and enhance sense of mastery through metaphor in imagined experience. through realistic memories. the child repeats “stop” when anxious thoughts occur. Modeling and rehearsal Other approaches that may be successful include: ■ Verbal preparation and communication with health care providers ■ Sensorimotor strategies: especially with infants. or talking about topics unrelated to the procedure. Helping child to more positively reframe any negative memories about previous procedures. Dissociate from painful experience through involvement in imagined fantasy that is fun and safe. over time. Provide information about the procedure and suggest helpful strategies that can be used during procedure to cope with pain and anxiety. rocking and holding ■ Imaginative involvement: especially with children. Explaining the steps of the procedure and providing sensory information about the procedure. Progressive relaxation of muscle groups combined with controlled breathing. Replace catastrophic thinking and reduce anxiety. immobilization.
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