upmc policy and procedure manual policy: …...c. reassessment for the presence of pain following...

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UPMC

POLICY AND PROCEDURE MANUAL

POLICY: HS-NA0408

INDEX TITLE: Nursing

SUBJECT: Pain Management Guidelines

DATE: May 31, 2013

I. POLICY

It is the policy of UPMC to provide excellence in patient care throughout the life span.

The relief of pain is inherent in patient care and includes relief of physical and

psychosocial symptoms associated with pain. Pain management is a vital part of patient

care and all patients have a right to pain relief. The prevention and relief of pain is

contingent upon pain assessment and reassessment, medication and non-medication

interventions, and the treatment of side effects that may be associated with analgesia.

The commitment of UPMC to prevent and treat pain is based on a body of scientific

knowledge derived from publications such as those of the World Health Organization

(WHO)11

, the American Pain Society (APS)2, Practice Guidelines for Acute pain

Management in the Perioperative Setting 3, and Guideline for the Management of Cancer

Pain in Adults and Children 4

. UPMC endorses the American Nurses Association Code of

Ethics for Nurses5, the American Hospital Association Patient’s Bill of Rights

6, and the

American Nurses Association Position Statement on Pain Management and Control of

Distressing Symptoms in Dying Patients7.

Links to policies referenced within this policy can be found in Section XII.

II. PURPOSE

The purpose of this policy is to provide direction to health care providers regarding the

assessment and management of pain across the lifespan and to:

Inform patients at the time of their initial evaluation that relief of pain is an important

part of their care and respond quickly to reports of pain to maximize comfort.

On initial evaluation and at regular intervals, assess for the presence, quality, and

intensity of pain and use patients’ self report as the primary indicator of pain.

Collaborate with the patient, responsible others, and healthcare providers to establish

a goal for pain relief and develop and implement a plan of care to achieve that goal.

Review and modify the plan of care for patients who have unrelieved pain, on a

regular basis.

Educate themselves and patient/family/caregiver about pain management.

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III. SCOPE

This policy applies to all United States based UPMC inpatient and outpatient facilities.

IV. DEFINITION (S)

PAIN:

“Pain is an unpleasant sensory and emotional experience associated with actual or

potential tissue damage, or described in terms of such damage. It is unquestionably a

sensation in a part or parts of the body but it is also always unpleasant and therefore an

emotional experience.”8

“Pain is whatever the experiencing person says it is, existing whenever he/she says it

does.”9

ACUTE PAIN:

“A complex constellation of unpleasant sensory, perceptual, and emotional experiences

associated with autonomic, psychological, emotional, and behavioral responses.”10

CHRONIC NONMALIGNANT PAIN:

“Pain that persists a month or more beyond the usual course of acute disease or a

reasonable time for an injury to heal or that is associated with a chronic pathologic

process that causes continuous pain or the pain recurs at intervals for months or years.”10

CANCER PAIN:

Cancer pain can be chronic or acute and typically is caused by one or more of the

following:

1. Tumor involvement: local, regional, and metastatic spread of the disease

2. Cancer-related procedures and treatment effects

3. Causes unrelated to cancer such as back pain, diabetic neuropathy, and

rheumatoid arthritis experienced by patients with cancer.11

V. ASSESSMENT

All patients will be screened for the presence of pain upon admission, at regular intervals

and prior to and following an invasive procedure. If present, pain shall be assessed. The

assessment will include a pain severity scale (see Appendix A), location, description, and

level of sedation, using an age appropriate sedation scale defined by your hospital. All

patients should be assessed related to the administration of opioids whether they are

opoid naïve or opiod tolerant.

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Adult Sedation Scale to assess unintentional sedation related to opioid medication

administration:

0 = none (alert)

1 = mild (occasionally drowsy, easy to arouse

2 = moderate (frequently drowsy, easy to arouse)

3 = severe (somnolent, difficult to arouse)

S = normal sleep

Children’s Hospital of Pittsburgh uses the University of Michigan Sedation Scale

(UMSS)

Additional detail such as alleviating and aggravating factors may be included when

warranted by the patient’s condition.

A. For the patients receiving care and treatment in an outpatient setting, pain

screening and assessment, if necessary, will occur on initial evaluation and then as

indicated by the patient’s condition. Consider referral to appropriate resources.

B. The pain rating scale used will be appropriate to the patient’s age and ability to

communicate. Pain rating scales recommended for use include but are not limited

to (see Appendix A):

(1) Zero to ten (0-10) Numeric Pain Intensity Scale (8 years and older,

approximately)*

(2) Wong-Baker FACES Pain Rating Scale (3 – 7 years and older,

approximately)*

(3) Word Descriptors (4 years and older)

Omitting PIPPS

(4) Cries CRIES Scale (birth – 6 months, approximately)

(5) FLACC Behavioral Pain Assessment Scale – 2 months and older,

approximately

(6) Neonatal Infant Pain Scale (NIPPS) - <37 weeks gestation and full term

infants until 6 weeks.

(7) N-PASS - Neonatal Pain, Agitation & Sedation Scale

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*Self-report pain assessment scales may also contain word descriptors

A hierarchy of assessment measures including (1) self-report, (2) pathological

condition (disease process), (3) behavior and (4) family/caregiver input shall be

considered as warranted by the patient’s condition.

If the patient is unable to verbally communicate the presence of pain, the

assessment will include observations: that may include (a) facial responses (i.e.:

grimace, frown, clenched teeth, etc); (b) verbal response (i.e.: moaning,

whimpering, crying); and (c) body movement (rigid, arching, withdrawing,

splinting, etc).

C. Reassessment for the presence of pain following pain-relieving interventions is

essential for effective pain management. Reassessment will include intensity,

using an appropriate pain scale or description of behaviors level of sedation (per

age appropriate sedation scale), and outcome. For those patients unable to

communicate verbally, the reassessment may include observations. Frequency of

reassessment will be determined by individual patient care needs and

environment.

VI. RECOMMENDATIONS CONCERNING CARE OF THE PATIENT WITH NON

OBSTETRICAL PAIN

Accept the patient’s report of pain and act on it, per physician order when required.

i.e. non-pharmacological interventions, medications, etc

Use the WHO1 analgesic ladder.

1

The American Pain Society endorses the WHO analgesic ladder. It focuses on

selecting analgesics on the basis of the intensity of pain using analgesics from

each of the analgesic groups (non-opioids, opioids for mild to moderate pain,

opioids for moderate to severe pain). Individualize the opioid dose for the very

young and the very old.

Oral route preferred; intramuscular injections discouraged (unpredictable absorption,

injections cause pain to relieve pain).

Around the clock analgesic administration is preferred over PRN administration for

persistent pain.

Provide rescue or “clinician bolus” doses as appropriate, and following physician

order (e.g. patients receiving pump-controlled analgesia therapy who experience

breakthrough pain.)

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Consider the KISS principle – Keep It Simple and the Same:

i.e. sustained release morphine and immediate release morphine

Consider adjuvant medications such as non-steroidal anti-inflammatory medications

(NSAIDs), tricyclic antidepressants, anticonvulsants

Titrate to effect.

All analgesic doses must be titrated to optimize the balance between analgesia and

negative or undesirable side effects. For IV opioids, titration may occur as often as

every 5 minutes, whereas titration of a tricyclic antidepressant may occur only every 4

to 5 days. Generally, the goal is to use the smallest dose that relieves the maximum

amount of pain with the fewest negative or undesirable side effects. The prescriber

must indicate the specific titration parameters, if used. Orders such as “titrate to

comfort” are not acceptable. The prescriber must also indicate specific doses and

frequency of dosing.

Use equianalgesic doses when changing route of administration and opioid.

(Appendix B) Refer to the Pediatric Drug Therapy Handbook & Formulary,

Department of Pharmacy, and Children’s Hospital of Pittsburgh of UPMC for

pediatric dosing. Refer to Neofax for neonatal dosing.

Recognize and treat side effects vigorously (i.e. sedation, nausea, vomiting,

constipation, itching and respiratory depression).

Incorporate non-pharmacological modalities as indicated to supplement treatment

regimens (i.e. heat, cold, back rubs with change in position, TENS unit, oral sucrose with

non-nutritive sucking (pacifier) for infants).

Consider using complementary modalities. (Appendix C)

Use pain prevention techniques to facilitate activity such as turning, deep breathing,

coughing and ambulation.

Consider that opioid doses are individualized to the patient; therefore the dosing range

can be wide. A ceiling effect is reached when increasing the dose does not provide

additional analgesia. The analgesic effects of mu agonist opioids have no ceiling effect.

The maximum dose of opioids analgesics is related to patient tolerance of the medication

and patient tolerance of side effects. NSAIDs and acetaminophen have a ceiling effect.

The ceiling effect is reached when increasing the dose does not provide additional

analgesia.

Do not use placebos to assess the nature of pain or treat pain. (see UPMC Policy HS-

HD-CP-02, Placebo)

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Monitor for the development of tolerance and treat appropriately.

Tolerance to the analgesic effects of an opioid is a state of adaptation in which

exposure to a drug induces changes that result in a diminution of the drug’s

effectiveness over time. Opioid tolerance is defined as a decrease in the

effectiveness of a medication, particularly opioids, and the need for escalating

doses to achieve pain relief.

Opioid tolerant may be defined as: patients who are taking, for 1 week or longer, at least:

60 mg oral morphine/day;

25 mcg transdermal fentanyl/hour;

30 mg oral oxycodone/day;

8 mg oral hydromorphone/day;

25 mg oral oxymorphone/day; or

An equianalgesic dose of any other opioid.

Expect physical dependence and prevent withdrawal.

Physical dependence is not the disease of addiction. It is a state of adaptation that

is manifested by a drug-class specific withdrawal syndrome produced by abrupt

cessation, rapid dose reduction, decreasing level of medication in the blood,

and/or administration of an antagonist. This syndrome is characterized by

anxiety, irritability, chills alternating with hot flashes, salivation, lacrimation,

rhinorrhea, diaphoresis, piloerection, nausea, vomiting, abdominal cramps, and

insomnia.

Do not label a patient with the disease of addiction if you mean physically dependent

on, or tolerant to, opioids.

Addiction is defined as a primary, chronic, neurobiologic 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. The exact prevalence of iatrogenic addiction in acute and

cancer pain in not known.

Be alert to the psychological state of the patient. The presence of anxiety intensifies

the pain experience.

Multimodal therapies may be used to optimize analgesic efficacy while minimizing

the risk of adverse events. Multimodal analgesia is achieved by combining different

analgesics that act by different mechanisms (e.g., opioids, NSAIDs, and local

anesthetics), resulting in additive or synergistic analgesia, lower total doses of

analgesics, and fewer side effects.

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It is the standard of care to administer a topical local anesthetic for children who must undergo

the following invasive procedures:

1. Venipuncture (blood draw)

2. Percutaneous intravenous cannulation (IV)

3. Totally implantable central venous port access

4. Subcutaneous catheter insertion

5. Percutaneous inserted central catheter (PICC) placement

The following clinical effectiveness guideline and policy should guide nursing practice.

http://intranet.chp.edu/04policies/04gce/04gce_misc/603-00.pdf

http://intranet.chp.edu/04policies/04ptcare/04ptcare_5/860.doc

Examples of Multimodal Therapy

Combination of Agents Example

Systemic NSAIDa plus systemic opioid PO Ibuprofen plus PO Hydromorphone

Systemic NSAID plus epidural opioid and

local anesthetic

IV ketorolac plus epidural fentaNYL and

bupivacaine

Systemic NSAID plus local infiltration of

anesthetic plus systemic opioid

IV ketorolac plus lidocaine infiltration of surgical

site plus IV PCA morphine

Regional block plus systemic NSAID plus

epidural opioid and local anesthetic

Intraoperative anesthetic plus IV ketorolac plus

postoperative fentaNYL and bupivacaine epidural

Continuous regional local anesthetic

infusion plus systemic opioid

Post-operative ropivacaine nerve plexus infusion

plus IV PCA morphine

Source: Reference 6 (adapted). McCaffery M, Portenoy RK. Overview of three groups of

analgesics. In: McCaffery M, Pasero C, eds. Pain Clinical Manual. 2nd ed. St. Louis, MO: Mosby

Inc; 1999a:103-128.

a NSAIDs need to be used with care in surgical patients due to the risk of bleeding (“anti-

platelet” effect).

IV: intravenous; NSAID: nonsteroidal anti-inflammatory drugs; PCA: patient-controlled

analgesia; PO: per os (oral).

http://intranet.chp.edu/04policies/04gce/04gce_misc/603-00.pdf

http://intranet.chp.edu/04policies/04ptcare/04ptcare_5/860.doc

POLICY HS-NA0408

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VII. PATIENT AND FAMILY EDUCATION

A. Essential to effective pain management is involvement and education of the

patient and/or family.

1. The health care provider will communicate that pain management is an

important part of the patient’s care while taking into consideration

personal, cultural, spiritual, and/or ethical beliefs of the patient/family.

2. Education will include (as appropriate):

a. Understanding pain and its risks

b. The importance of effective pain management

c. The pain assessment process

d. Methods for pain management, including pharmacological and non-

pharmacological methods

e. The patient’s/family’s roles in managing pain

f. Potential side effects of pain medication

g. Patient-specific goal-setting

3. Instructions provided to the patient and/or family shall be recorded in the

patient’s medical record.

4. The effectiveness of education will be evaluated on an on-going basis.

VIII. DOCUMENTATION

A. Inpatient Population

1. The initial screening and assessment of pain, if indicated, will be

documented on admission.

2. Reassessment will be recorded with the intensity documented using the

pain scale, sedation scale, quality descriptors and outcome parameters

defined per the scale(s) defined for specific patient populations.

Observations and further assessment details are to be documented in the

Medical Record.

3. The plan for patient care will be developed and/or revised based on

specific patient needs.

B. Procedural and Outpatient Departments

1. Assessment and reassessment for presence of pain will occur in procedural

and outpatient departments and documented on the appropriate

departmental record. Patients being seen in ambulatory clinics will be

assessed for the presence of pain appropriate to the context of their visit.

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When pain is present, the assessment will include intensity, location, and

onset.

2. Based on the patient’s response to the assessment, the provider will

conduct a further assessment and determine appropriate intervention or the

need for referral.

3. The plan for patient care will be developed and/or revised based on

specific patient needs.

IX. STAFF EDUCATION

A. Education in pain assessment and management will be provided for appropriate

clinical staff during orientation and on an ongoing basis.

B. Many clinical departments have specially educated staff (Pain Management

Resource Nurses/Clinicians) who serve as on-site resources and educators for the

clinical staff.

C. A variety of pain management resources are available throughout the UPMC.

These include advanced practice nurses, pain management resource nurses and

clinicians, pharmacists, and physicians.

X. OVERSIGHT AND EVALUATION

A. An interdisciplinary pain committee/team serves as a resource for clinical issues

surrounding pain management. The team reviews current clinical practice and

makes recommendations for change based on evidence and research.

B. Patient interviews and surveys are used to evaluate the appropriateness and

effectiveness of pain management.

C. Some organizations may benchmark pain assessment data (e.g., National Database

for Nursing Quality Indicators).

XI. ASSOCIATED POLICIES/PROCEDURES

Individual UPMC facilities may have institution specific policies related to pain

management techniques.

XII. POLICIES REFERENCED WITHIN THIS POLICY

HS-HD-CP-02 Placebo

http://infonet2.upmc.com/Policies/systemwide/Documents/HSHDCP02.pdf

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SIGNED: Holly Lorenz

Chief Nursing Executive

ORIGINAL: January 6, 2003

APPROVALS:

Policy Review Subcommittee: May 9, 2013

Executive Staff: May 31, 2013

PRECEDE: June 1, 2012

SPONSOR: Chief Nursing Executive

Attachments

Appendixes:

Appendix A Pain Rating Scale (Adult and Children’s)

Appendix B Analgesic Reference Guide

Appendix C Complementary Modalities for Pain Management

References:

1Cancer Pain Relief, 2

nd Ed. Geneva, World Health Organization, 1996.

2 American Pain Society (APS): Principles of analgesic use in the treatment of acute pain and

cancer pain, Ed 4, Glenview, Ill, 2008.

American Pain Society (APS): (2003) Principles of analgesic use in the treatment of acute and

cancer pain (5th

ed.). Glenview, IL: APS.

American Pain Society (APS): Guideline for the Management of Acute and Chronic Pain in

Sickle Cell Disease), Glenview, Ill, 1999.

3 American Society of Anesthesiologists (ASA): Practice Guidelines for Acute Pain

Management in the Perioperative Setting, Anesthesiology (2004;100:1573-81).

4

American Pain Society (APS): Guideline for the Management of Cancer Pain in Adults and

Children, Glenview, Ill, 2005.

5American Nurses’ Association (ANA) Code for Nurses published by American Nurses

Publishing, 600 Maryland Ave., SW, Suite 100W, Washington, D.C. 20024-2571. Copyright ©

1976, 1985 by the American Nurses Association. All rights reserved. G-56 7.5M 10/96.

6American Hospital Association (AHA) A Patient’s Bill of Rights copyrighted material 1992 by

the American Hospital Association, 840 North Lake Shore Drive, Chicago, Illinois 60611.

Printed in the USA. All rights reserved. Catalog number 157759.

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7American Nurses Association (ANA) Position Statement on Promotion of Comfort and Relief

of Pain in Dying Patients, American Nurses Association, 600 Maryland Ave., SW, Washington,

D.C. 20024. September 5, 1991, rev. 1995.

8 International Association for the Study of Pain. Subcommittee on Taxonomy. Pain Terms: a

list with definitions and notes on usage. Pain. 1979;6:250.

9 McCaffery, M. Nursing practice theories related to cognition, bodily pain, and man

environment interactions, Los Angeles, 1968, UCLA Students Store.

10 Bonica, JJ, Definitions and taxonomy of pain, in: Bonica, JJ, Ed. The Management of Pain.

2nd

ed. Philadelphia, PA: Lea & Febiger; 1990:18-27.

11

Pasero, C., & McCaffery, M., (2010) Management of Opioid-Induced Adverse Effects. In Pain

Assessment and Pharmacologic Management. Elsivier-Mosby: St.Louis. pp. 520-521.

12

Foster, R.L., Varni, J.W. Preliminary validation of instruments to measure child and parent

satisfaction with post-operative pain management. A poster presented at the 9th

World Congress

of Pain, Vienna, Austria, 1999.

13

Anand KJS. 2001. Consensus statement for the prevention and management of pain in the

newborn. Archives of Pediatric Adolescent Medicine, 155(2): 173-180.

14

Stevens, B, Yamada, J, Ohlsson, A. Sucrose for analgesia in newborn infants undergoing

painful procedures. Cochrane Database Syst Rev.

2010;(1):CD001069.doi:10.1002/14651858.CD001069.pub3. (more recent systematic review)

15

Pasek, TA, Huber, JM. Hospitalized infants who hurt: A sweet solution with oral sucrose.

Critical Care Nurse, 2012;32(1):1-9 (in press).

16

Thompson, DG. 2004. Utilizing an oral sucrose solution to minimize neonatal pain. Journal for

the Society of Pediatric Nurses, 10(1): 3-10.

17

Gray L, Watt L, Blass EM. 2000. Skin-to-skin contact is analgesic in healthy newborns.

Pediatrics. 105(1): e14.

18

Johnston CC, Stevens B, Pinelli J et al. 2003. Kangaroo care is effective in diminishing pain

response in preterm neonates. Archives of Pediatrics & Adolescent Medicine 157(11):1084-8.

19

Ludington-Hoe SM, Hosseini R, Torowizc DL. 2005. Skin-to-skin contact (Kangaroo Care)

analgesia for preterm infant heelstick. AACN Clinical Issues. 16(3):373-387.

20

O’Malley-Dafner, L., & Davies, P., (2000). Naloxone-induced pulmonary edema The American

Journal of Nursing, 100(11), 24AA-24JJ.

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21Malviya, S, Voepel-Lewis, T, Tait, AR, Merkel, S, Tremper, K, Naughton, N, Depth of

sedation in children undergoing computed tomography: validity and reliability of the University

of Michigan Sedation Scale (UMSS). British Journal of Anesthesia, 2002;88(2):241-245.

22

Shields, CH, Styadi-Park, G, McCown, MY, Creamer, KM, Clinical utility of the bispectral

index score when compared to the University of Michigan Sedation Scale in assessing the depth

of outpatient pediatric sedation. Clinical Pediatrics, 2005;44:229-236.

23

Malviya, S, Voepel-Lewis, T, Tait, AR, A comparison of observational and objective measures

to differentiate the depth of sedation in children from birth to 18 years of age. Anesthesia

Analgesia, 2006;102:389-394.

24

Malviya, S, Voepel-Lewis, T, Ludomirsky, A, Marshall, J, Tait, AR, Can we improve the

assessment of discharge readiness? Anesthesiology, 2004;100:218-224.


APPENDIX A.1.

UPMC

PAIN RATING SCALES

“The single most reliable indicator of the existence and

intensity of pain is the patient’s self-report”….McCaffery and

Pasero in Pain: Clinical Manual, Mosby: 1999, p. 40.

The types of pain rating scales that are recommended for patients

5 years and older include:

Numeric Pain Intensity Scale

Word Descriptors

Wong-Baker FACES Pain Rating

Scale©

Zero to 10 Numeric Pain Intensity Scale:

The zero (0) to 10 scale is the easiest to use for patients

who are able to verbalize their subjective pain rating. Ask

the patient to rate their pain with zero (0) being “no pain”

and ten (10) being the “worst pain imaginable”. Document

the number as a fraction, e.g. 6/10.

Word Descriptors:

Ask the patient to describe their pain using one of the five

descriptors:

None Mild Moderate Severe Excruciating

(0) (2.5) (5) (7.5) (10)

Document the number as a fraction, e.g. 6/10.

Wong-Baker FACES Pain Rating Scale©

Explain to the patient that each face is for a person who feels

happy because he has no pain (hurt) or sad because he has some or

a lot of pain. Face 2 hurts just a little bit, face 4 hurts a

little bit more, face 6 hurts even more. Face 8 hurts a whole

lot. Face 10 hurts as much as you can imagine, although you don’t

have to be crying to feel this bad. Ask the person to choose the

face that best describes how he is feeling. This scale is

recommended for persons age 3 and older. Document the number as

a fraction, e.g. 6/10.


Appendix A.2

The N-PASS is a valid and reliable clinical pain/agitation and

sedation tool for neonates. Nurses find the N-PASS easy to use

clinically, facilitating documentation and management of pain and

sedation.

Information for the N-PASS scale may be obtained at:

http://www.n-pass.com/assesment_table.html

Appendix A.3.

Coding Tips for CRIES

Crying The characteristic cry of pain is high-pitched.

If there is no crying or it is not high-pitched. Score 0

If crying is high-pitched but the baby is easily consoled Score 1

If crying is high-pitched and the baby is inconsolable Score 2

Requires O2 for Oxygen

saturation >95%

(Consider other causes

of changes in

oxygenation: atelectasis,

pneumothorax,

oversedation, etc.)

Look for changes in oxygenation. Babies experiencing pain manifest decreases

in oxygenation as measure by TCO2 or oxygen saturation.

If no oxygen is required Score 0

If < 30% O2 is required Score 1

If > 30% O2 is required Score 2

Increased vital signs Note: Take blood pressure last, as this may wake the baby, making other

assessments difficult.

Use baseline preoperative parameters from a period free of stress.

Multiply baseline HR x 0.2, then, add this total to the baseline value to determine

whether the HR is 20% faster.

Do likewise for BP, using the same mean value.

If HR and BP are both either unchanged or less than at baseline Score 0

If either HR or BP is increased less than 20% of baseline Score 1

If either one is increased more than 20% from baseline Score 2

Expression The facial expression most often associated with pain is a grimace characterized

by a lowered brow, the eyes squeezed shut, a deepening of the nasolabial furrow,

and open lips and mouth.

If no grimace is present Score 0

If grimace alone is present Score 1

If grimace and a vocalization without crying (grunt) are present Score 2

Sleeplessness This parameter is scored according to the infant’s state during the preceding

hour.

If the baby has been continuously asleep Score 0

If the baby has awaken at frequent intervals Score 1

If the baby has been awake continuously Score 2

http://www.n-pass.com/assesment_table.html

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HR=Heart Rate; BP=Blood Pressure; ↑=Increase; TCO2=Transcutaneous CO2

Source: Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial

testing of validity and reliability. Paediatric Anaesth; 1995; 5(1):53-61. This neonatal pain assessment

tool was developed at the University of Missouri-Columbia.

Copyright 1995 S. W. Krechel and J. Bildner. Adopted with permission.

AJN. August 2002.Vol. 102.NO. 8. p.63


Appendix A.4.

The FLACC Behavioral Pain Assessment Scale Each of the five categories is scored from 0-2, resulting in a total score between 0 and 10

Reprinted with permission: Merkel SL, et al. The FLACC: a behavioral scale for scoring postoperative pain in young

children. Pediatr. Nur 1997;23(3):293-7. The FLACC scale was developed by Sandra Merkel, MS RN, Terri

Voepel-Lewis, MS RN and Shobha Malviya, MD at C. S. Mott Children’s Hospital, University of Michigan Health

System, Ann Arbor, MI.

How to use the FLACC In patients who are awake: observe for 1 to 5 minutes or longer. Observe legs and body uncovered. Reposition

patient or observe activity. Assess body for tenseness and tone. Initiate consoling interventions if needed.

In patients who are asleep: observe for 5 minutes or longer. Observe body and legs uncovered. If possible,

reposition the patient. Touch the body and assess for tenseness and tone.

Face

Score 0 if the patient has a relaxed face, makes eye contact, shows interest in surroundings

Score 1 if the patient has a worried facial expression, with eyebrows lowered, eyes partially closed, cheeks

raised, mouth pursed.

Score 2 if the patient has deep furrows in the forehead, closed eyes, an open mouth, deep lines around the

nose and lips.

Legs

Score 0 if the muscle tone and motion in the limbs are normal

Score 1 if patient has increased tone, rigidity, or tension; if there is intermittent flexion or extension of the

limbs

Score 2 if patient has hypertonicity, the legs are pulled tight, there is exaggerated flexion or extension of the

limbs, tremors

Activity

Score 0 if the patient moves easily and freely, normal activity or restrictions

Score 1 if the patients shifts positions, appears hesitant to move, demonstrates guarding, a tense torso,

pressure on a body part

Score 2 is the patient is in a fixed position, rocking; demonstrates side-to-side head movement or rubbing of

a body part.

Cry

Score 0 if the patient has no cry or moan, awake or asleep

Score 1 if the patient has occasional moans, cries, whimpers or sighs

Score 2 if the patient has frequent or continuous moans, cries, grunts

Consolability

Score 0 if the patient is calm and does not require consoling

Score 1 if the patient responds to comfort by touching or talking in 30 seconds to 1 minute

Score 2 if the patient requires constant comforting or is inconsolable. Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-report

is not possible, interpretation of pain behaviors and decisions regarding treatment of pain require careful

consideration of the context in which the pain behaviors are observed.

Each category is scored on the 0-2 scale, which results in a total score of 0-10.

Interpreting the Behavioral Score

0= Relaxed and comfortable

1-3= Mild discomfort

4-6= Moderate pain

7-10= Severe discomfort or pain or both

AJN.October 2002.Vol.102.NO.10.p.55

POLICY HS-NA0408

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Appendix A5.

NIPS assessment includes five behavioral items (facial expression, crying, arms, legs, and state of

arousal) and one physiological indicator (breathing pattern).

Scored at 1-minute intervals before, during, and after a procedure.

Total score ranges from 0 to 7. NIPS was researched in preterm and full-term infants who required capillary, venous, or arterial

punctures and is ideal for newborns not on cardiorespiratory monitoring. Pain scores must be interpreted in light

of the pattern of how total scores change between pain and non pain situations and whether risk factors for pain

are present.

References:

(Lawrence, Alcock, McGrath, Kay, MacMurray, & Dulberg, 1993. The development of a tool to assess neonatal

pain. Neonatal Network. 12(6).59-66. Figure 1. page 60.

Reprinted with permission from The Children’s Hospital of Eastern Ontario (CHEO) from Lawrence, J., Alcock.D.,

McGrath, P., Kay, J., MacMurray.S., & Dulberg, C. (1993)

1 2 1 2 3 4 5 1 2

Facial expression

0-Relaxed; 1-Grimace

Cry

0-No cry; 1-Whimper;

2-Vigorous

Breathing patterns

0-Relaxed

1-Change in breathing

Arms

0-Relaxed/restrained

1-Flexed/extended

Legs

0-Relaxed/restrained

1-Flexed/extended

State of Arousal

0-Sleeping/awake

1-Fussy

Total

Before During After

Neonatal Infant Pain Scale (NIPS)

Before During After


Appendix B: Analgesic Reference Guide (Refer to the Pediatric Drug Therapy Handbook & Formulary, Department of

Pharmacy, Children’s Hospital of Pittsburgh of UPMC for pediatric dosing. Refer to Neofax for neonatal dosing.)

Nonopioid Analgesics Maximum Starting Dose *Starting doses are can often be given less frequently than cited below.

Commentsa,b,c

(MDD) = Maximum Daily Dose

Acetaminophenc

650 mg PO/PR Q4hr Lacks anti-inflammatory effect of NSAIDs

MDD for healthy patients = 3,000mg

MDD for alcoholics, or G6PD deficiency and & elderly = 2,000 mg

CrCL 10-50 ml/min: dose Q6hr; CrCL <10 ml/min: dose Q8hr

Avoid chronic use in Hepatic Impairment (See Warnings – Footnotes)

Avoid use in acute liver disease

Acetaminophen Injection

(Ofirmev®)

1000mg IV Q6hr MDD for healthy patients = 3000mg (higher doses in hospitalized patients)

For pts unable to take PO/NG with post-op pain, mild/mod pain, or critically

ill pt with fever

Automatic interchange to oral therapy by pharmacy after 24hrs (4doses)

For additional comments see above

Aspirinb

650 mg PO Q4hr MDD for healthy patients = 3.9g

Do Not Use in patients (especially in children <16 y/o) with suspected viral

illness due to risk of Reye’s Syndrome

Inhibits platelet function for life of platelet ( 7 days)

CrCL <10 ml/min: avoid use (See Warnings –Footnotes)

Avoid use in patients with severe liver disease

Ibuprofen (Motrin®)b

400 mg PO Q8hr MDD for healthy patients = 3,200mg

Avoid use in patients with severe hepatic impairment

Avoid use in patients with renal impairment

Naproxen Sodium (Anaprox®)b

275 - 550 mg PO initially, then

275 mg PO Q6hr MDD for healthy patients = 1,375 mg

MDD (geriatric) = 400mg/day (200mg q12h)

CrCL <30 ml/min: use is not recommended

Use lowest possible dose in patients with advanced liver disease

Nabumetone (Relafen®)b

500mg -– 1000 mg PO daily in

one or two divided doses

(max 2000mg daily)

Limit use to 7 – 14 days

MDD for healthy patients = 2000 mg

CrCL 30-50 mL/min: 750 mg daily; max 1500 mg /day

CrCL < 30 mL/min: 500 mg daily; max 750-1000mg/day

Not for use perioperatively post CABG (true for all NSAIDs)

Meloxicam (Mobic®)b

Non-formulary

7.5 mg PO daily MDD = 15 mg; CrCL ≤ 20 ml/min: use is not recommended

Celecoxib (CeleBREX®)2

400 mg PO in one dose on day

one; 200 mg BID MDD in otherwise healthy patients = 400 mg

Use is not recommended in patients with severe renal or hepatic dysfunction

For patients with moderate hepatic impairment decrease the dose by 50%

Ideal for patients on anticoagulation therapy or antiplatelet therapy and

patients with GI ulcers or irritation due to the COX-2 selective nature

Indomethacin (Indocin®)b

25-50 mg PO Q8hr MDD for otherwise healthy patient = 200 mg

Generally not first line agent due to high incidence of CNS & GI side effects,

except in pain associated with gout Generally not recommended in elderly

patients due to safety issues

Not for use in patients with advanced renal disease

Ketorolac (Toradol®)b

15-30 mg IM / IV Q6hr

Pt age 17-64: 20mg PO once,

then 10mg q4-6H prn

Elderly, renally impaired, and/or weight <50kg dose = 10-15 mg PO/IM/ IV

Q4-6 hr

MDD (normal, healthy) = 120 mg IM / IV, 40mg/day PO

MDD ( age > 65 years or < 50kg) = 60mg IM/IV, 40mg/day PO

Limit duration to maximum of 5 days; automatic stop of 3 days of therapy

Can precipitate renal failure in dehydrated / renally compromised patients.

If creatinine elevated, use ½ of the recommended dose (MDD = 60 mg/day)

Use cautiously in patients with hepatic impairment as use can result in

elevation of liver enzymes

May be considered first-line in cases of bone pain due to metastasis

The Intramuscular route is not a preferred route of administration


a (MDD) = Maximum Daily Dose

b ASPIRIN / NSAIDS: Chronic use is associated with dose-related increases in gastric mucosa damage/erosions/peptic ulcer disease;

bleeding from inhibition of platelet function typical of most NSAIDs (irreversible for life of platelet with Aspirin), fluid retention and impairments

to renal function. Hypersensitivity reaction triad symptomatology includes rhinitis, asthma, and nasal polyps. Other signs of hypersensitivity

include hypotension, shock, and syncope within minutes. To reduce the risks associated with NSAIDs, avoid alcohol and administration while

fasting and always use lowest effective dose. COX-2 selective NSAIDs (CeleBREX) may be more appropriate for patients who may be at

greatest risk for bleeding or GI problems, but haves been associated with an increase risk of MI, stroke, and hypertension.

c ACETAMINOPHEN: Chronic alcohol use, liver disease, and a fasting state can predispose patients to hepatic toxicity, even at therapeutic

doses. Doses > 4000 mg /daily (max) can lead to hepatic necrosis. Use caution not to exceed maximum daily doses of acetaminophen,

especially when combining acetaminophen tablets with combination products that contain acetaminophen, such as Percocet®, / Ultracet® or

Vicodin.®. Doses > 1500 mg daily can enhance anticoagulant effects of warfarin.

Appendix B: Analgesic Reference Guide (Refer to the Pediatric Drug Therapy Handbook & Formulary, Department of

Pharmacy, Children’s Hospital of Pittsburgh of UPMC for pediatric dosing; Refer to Neofax for Neonatal dosing)

Nonopioid Analgesics (continued) Maximum Starting Dose *Starting doses are can often be given less frequently than cited below.

Commentsa,b,c

(MDD) = Maximum Daily Dose

Duloxetine (Cymbalta®)

60 mg PO once daily MDD for healthy patients = 60 mg daily

Patients with renal impairment: initiate lower dose and increase

gradually

CrCl < 30 ml/min: not recommended for use

Do not use in patients with hepatic insufficiency

Pregabalin (Lyrica®) 150 mg/day PO in divided doses MDD for healthy patients = 600mg/day. Doses must be increased by

no more than 150 mg/day every 7 days.

CrCl 30-60 ml/min: MDD 300mg/day CrCl 15-30 ml/min: MDD

150mg/day CrCl < 15 ml/min: MDD 75mg/day HD: 25-150mg

supplement

Gabapentin (Neurontin®)

300 mg/day PO DO NOT interchange with once-daily formulation

MDD for healthy patients = 3600 mg/day

CrCl 30-59 ml/min: MDD 1400 mg/day in 2 divided doses; CrCl 15-

29 ml/min 700mg/day once daily; CrCl 15ml/min: 300mg/day once

daily; CrCl < 15 ml/min: ↓ dose in proportion to CrCl HD: give 125-

350mg supplement

Gabapentin – Extended Release

(Gralise®) Non-Formulary

300 mg/day PO NOT interchangeable with other gabapentin products

MDD for healthy patients = 1800 mg/day

CrCl < 30 ml/min and HD: avoid use

Ketamine

Starting dose:

Low-dose analgesia (AIPPS:

PUH/SHY/Pass/Mercy):

4-10mg/hr (general units);

patients must be in ICU to receive

doses >10mg/hr; 48-hour

automatic stop on infusion

duration;

Chronic pain: doses up to

30mg/hr

Palliative care: doses up to

42mg/hr

Consider dose reduction in patients with liver impairment

AIPPS low-dose analgesia, chronic pain, or palliative care protocol

must be approved by institution P&T Committee prior to

implementation

o AIPPS: No IV push or bolus doses should be given

Must be infused via a locked device as a continuous infusion, on the

non-ICU unit

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Medication Opioid agonistsd Starting dose *Starting doses can often be given less

frequently than cited below

Equi-analgesic dosee Commentsd Opiate Agents (See Warnings – Footnotes)

Morphine – Immediate Release

15-30 mg PO Q3hr or 2.5-10 mg IV/IM/SQ Q2-6hr

30 mg PO 10 mg IV/IM/SQ

M-6G (active metabolite) enhances sedative effects of morphine; especially in renal dysfunction; If CrCL 10-50 ml/min: use 75% of normal dose; If CrCL <10

ml/min: use 50% of normal dose; dose 25-50% for age > 70

(Loading Dose) Morphine IV 0.03 mg/kg Q 10 mins

- repeat until 50% in pain score or patient is satisfied (Maintenance Dose) Est. Hourly Maintenance Dose = Loading Dose T1/2 (hrs) x 2

Morphine – Extended Release

MS Contin® -15mg PO Q8hr Kadian® - 10-20mg PO Q12-24hr

Avinza® - 30mg PO Q24hr

Oramorph SR® - 15-30mg PO Q8-12hr

Roxanol® - 10-30mg PO Q4hr

Do not crush/chew/dissolve caps or content

Kadian and Avinza may sprinkle on applesauce immediately prior to use

Renal Dosing: CrCl 10-50 ml/min: use 75% of the normal dose, CrCl <10 ml/min: use 50% of the normal dose

Oramorph®, Avinza®, Kadian® and MS Contin® Black Box Warning: swallow tabs whole due to risk of rapid release and absorption of potentially fatal morphine dose

Kadian® tablet strength restriciton: 100/200mg ER for opioid tolerant pts only

Codeine

15-30mg PO Q3hr or 30 mg IM/SQ Q4hr

120 mg IM/SQ (parenteral) 200mg PO (Not recommended at this dose.)

Greater risk of nausea and constipation than other opioids narcotics

If CrCL 10-50 ml/min: use 75% of the normal dose

If CrCL <10 ml/min: use 50% of the normal dose

10% of Caucasians lack enzyme to metabolically activate Codeine

FentaNYL (Sublimaze®)

20 – 75 mcg IV Q1hr 0.1 mg IV ** Note typical doses are in micrograms (not milligrams !).

Maximum dose on monitored unit (non-ICU): 25mcg (Mercy: 50 mcg) IV no greater than q2hr

FentaNYL (Transdermal - Duragesic®)

Opiate Opioid naïve: Start with 25 mcg/hr patch Q72h

100 mcg/hr IV/SQ or transdermally = 4 mg/hr of IV/SQ Morphine Sulfate 1mcg/hr transdermally = 2 mg/day of Morphine Sulfate PO

Start w/ no more than 25 mcg/hr of Duragesic transdermal system patches (opiate opioid naïve)

Not for acute pain – delay in onset of analgesia from patch is approx 12 –18 hrs. Opioid effects persist > 18 hrs after patch removal.

Do not cut, chew or alter patch; Rotate placement site

FentaNYL (Transmucosal – Actiq®)

200mcg x 1-2, 30 minutes apart for breakthrough pain; no more than 6/day initially

Dissolve in mouth / cheek

Do not chew or swallow

FentaNYL (Buccal Tablet – Fentora®)

100 mcg x 1; re-dosing of same amount may occur 30 minutes after initial dose

Indicated for cancer patients who experience breakthrough pain on their current opioidate regimen (i.e.,; opioidate-tolerant)

Dissolve in mouth / cheek; Do not chew or swallow.

More than 4 tablets simultaneously has not been studied.

HYDROmorphone (Dilaudid®)

2-4 mg PO Q3hr or 0.2-0.6 mg IV/SQ Q3hr

7.5 mg PO 1.5 mg IV/SQ

Shorter duration of action than Morphine

Safe medication practice: Use brand name in order to avoid mix-ups with other opioid analgesics.

Dilaudid® IV is approximately 7 times more potent than morphine IV per mg!

OxyCODONE

5-15mg PO Q4hr

20 mg PO

Percocet® & Tylox® contain acetaminophen

Percodan® (w/ aspirin); Combinox® (w/ ibuprofen)

If CrCL 10-50 ml/min: use 75% of the normal dose

If CrCL <10 ml/min: use 50% of the normal dose

Hepatic impairment use 50% of usual dose

Methadone

5-10 mg PO Q6hr or 2.5-5 mg IV/IM/SQ Q8hr

Acute: 20 mg PO; 10 mg IV/IM/SQ Chronic: 2-4 mg PO; 2-4 mg IV/IMSQ

Effect accumulates over 2-5 days leading to need for reduction in dose size and frequency

Use caution in the elderly

CrCl <10 ml/min: decrease dose by 25-50%

Oxymorphone – Immediate Release (Opana® injection and tablets)

0.5mg initially Q2-4hr. Up to 1.5mg may be required Opioid naïve(usual dose): 10 mg PO Q6H

1 mg IV/SQ 10 mg rectal (cant find rectal formulation)

CrCL < 50 mL/min – decrease start dose. Titrate slowly.

Mild Hepatic dysfunction– Start 5mg Q 4-6 hr PRN

Contraindicated in Moderate to – Severe Hepatic Dysfunction.

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Opioid agonistsdMedication Starting Dose Equi-analgesic dose Commentd

Oxymorphone - Extended Release (Opana ER® tablets)

Opioid naïve: 5 mg PO Q12hr Conversion to ER: Use ½ the dose of immediate release oxymorphone Q12hr (i.e. oxymorphone 40mg/day = Opana ER 20 mg Q12hr)

10 mg PO Indicated for management of moderate to severe pain when continuous, around the clock opioid analgesia is needed for an extended period of time (several days).

Concurrent alcohol can cause increased levels and a potentially fatal overdose due to dose dumping.

Administer 1 hour before or 2 hours after meal.

Use 1/3 to 1/2 of normal dose if on other CNS depressants due to risk of respiratory depression, hypotension, and profound sedation

Contraindicated in pts w/ moderate to- severe hepatic dysfunction

CrCL < 50 mL/min – decrease start dose. Titrate slowly.

Do not crush or chew; only swallow whole

Meperidine (Demerol®) (Use of meperidine Demerol is restricted at UPMC)

Adults: 100 mg IV/ Q3hr *Oral administration not recommended due to high risk of GI side effects *IM painful

300 mg PO 75 mg IV/

Toxic metabolite (normeperidine) accumulates with chronic dosing in elderly and/or renal impairment - leading to excessive CNS excitation and seizures.

Risk of serotonin syndrome increases when used with MAOIs & other serotonergic agonists.

Meperidine may be less likely to promote histamine release and should be reserved for patients who may experience allergic-like reactions to other narcotics.

HYDROcodone Combination

Adults: 5-10 mg PO Q3hr 30 mg PO

Norco®, Vicodin® products & Lortab® contain acetaminophen

Opioid/APAP- combination products should have < 325mg of acetaminophen per dosage unit. Products will be automatically switched to the <325mg APAP-containing product by the inpatient pharmacist.

Vicoprofen® (contains w/ ibuprofen)

TraMADol (Ultram®)

Adults: 25 mg/day ORALLY every morning, titrated in 25 mg increments as separate doses every 3 days to reach 25 mg four times daily; then, may increase total daily dose by 50 mg as tolerated to reach 50 mg four times daily; after titration, 50 to 100 mg ORALLY every 4hr as needed can be used

120 mg PO

MDD = 400 mg (healthy) ; for patients <75 y/o = 300 mg; for pts w/ renal impairment = 200 mg

TraMADol lowers seizure threshold

Immediate Release: If CrCL is <30 ml/min, use dose no higher than 50-100 mg Q12hr (maximum of 200 mg/day)

Extended Release: avoid use if CrCL <30 ml/min; max 300mg daily

Useful adjunct to NSAIDs when treating pain associated with osteoarthritis

Cirrhosis: recommended dose is 50mg PO q12h (immediate-release); extended-release should be avoided.

TraMADol (TraMADol Ultracet® 25 mg/ Acetaminophen 325 g)

2 tablets Q4hr prn for pain relief (maximum of 8 tablets/day)

Combination accounts for synergistic analgesic effects

CrCL <30 ml/min: max 2 tab Q12hr; no more than 5days

Hepatic impairment: use not recommended

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dOPIOIDS:

When assessing acute pain, consider the following symptoms:

1) Sympathetic stimulation invokes hypertension, tachycardia, tachypnea, mydriasis, diaphoresis and pallor.

2) Other symptoms include decreased activity, fearful expression, grimacing, teeth grinding, crying, striking out,

bracing, guarding, rubbing, wincing with movement, irritability, restlessness, abnormal gait, unwillingness to

move, and apathy.

In selecting an initial opioid dose, attention should be given to the following factors:

1) The total daily dose, potency and specific characteristics of the opioid the patient has been taking previously

2) The relative potency estimate used to calculate the equivalent dose needed

3) The patient’s degree of opioid tolerance

4) The age, general condition, and medical status of the patient

5) Concurrent non-opioid analgesic and other medications

6) The type and severity of the patient’s pain

7) The balance between pain control and adverse experiences

Opioid agonistsdMedication Starting Dose Equi-analgesic dose Commentd

Mixed opioid agonist-antagonists – all mixed agonist-antagonists can precipitate withdrawal in opiate-tolerant patients. For this reason, the drugs in this class should only be used

in patients without a history of recent or concomitant opioid use.

Butorphanol (Stadol®)

1mg spray in one nostril Q3hr OR

1-2 mg IV Q3hr

2 mg IV/SQ

If renal or hepatic dysfunction, use ½ typical IV dose & space doses 6 hours apart

In renal or hepatic dysfunction: initial dose of nasal spray should not exceed 1 mg. 2nd dose should be given no less than 90-120 minutes after

Effective for pain associated with migraines; pain associated with labor; pain assoc w/ gallstones

Nasal spray convenient for patients unable to swallow

Buprenorphine (Buprenex®)

300 mcg/dose IV/IM q6hr 300mcg IV/IM ↓ dose by 50% if respiratory disease or elderly/debilitated patient

Dose of IM may be increased to 600mg/dose (IM ONLY)

Caution in advised in patients with moderate/severe hepatic impairment

Long-term use is not recommended

Buprenorphine – Transdermal (Butrans®)

5 mcg/hr patch Q7days See Comments Do not alter/cut patch

MDD = 20mcg/hr patch

Replace patch every 7 days

Dose may be changed after a minimum of 72 hr

TTD of PO morphine dose or equivalent of < 30mg, start with 5mcg/hr patch

TTD of PO morphine between 30-80mg, start with 10mcg/patch

TTD of PO morphine or equivalent of > 80mg, 20mcg/hr patch may not provide adequate pain control

Not studies in severe hepatic impairment

Nalbuphine (Nubain®)

10 mg/ 70 kg IV/SQ Q3hr 10 mg/ 70 kg IV/SQ Similar to butorphanol; Less psychomimetic effects than Pentazocine

Use reduced dose and monitor patients with renal or hepatic impairment

Maximum: 20mg as single dose & 160mg/day

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8) Risk factors for abuse, addiction or diversion, including a prior history of abuse, addiction or diversion

9) Allergies and drug to drug interactions based on the patient’s medication profile.

Reduce opioid doses and monitor more closely in patients with the following conditions: frail (< 50 kg),

elderly (age > 70: reduce dose by 25 to 50%), sleep apnea, pulmonary fibrosis, O2 dependency, obesity, asthma,

COPD or other types of respiratory dysfunction. Caution in patients with increased intracranial pressure, pregnancy,

liver or renal insufficiency. Use can lead to orthostatic hypotension due to histamine release and peripheral

vasodilation.

Drug Interactions: Opioid analgesics should be started at 25 to 33 percent (1/3 to ½) of the usual dose in patients

who are concurrently receiving other central CNS depressants including sedatives or hypnotics, general anesthetics,

phenothiazines, tranquilizers, or alcohol because respiratory depression, hypotension, and profound sedation or

coma may result.

Treatment of opioid overdose: Usual initial adult naloxone dose = 0.04 mg IV every minute until a change in

alertness is observed.

Cessation of opioid therapy: When the patient no longer requires opioid therapy, doses should be tapered

gradually to prevent signs and symptoms of withdrawal.

e Approximate equivalent dose of opioid for moderate to severe pain.

References:

1) American Pain Society. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain. (5th eEd.). Glenview, IL:

American Pain Society, Glenview, IL; 2003.

2) McEvoy GK (ed). AHFS Drug information.; McEvoy GK (ed); American Society of Health-System Pharmacists; Bethesda MD:

American Society of Health-System Pharmacists. 2007.

3) Cohen M, et al. An omnipresent risk of morphine HYDROmorphone mix-ups. ISMP Newsletter 2004, July 1.

http://www.ismp.org/Newsletters/acutecare/articles/20040701.asp?ptr=y (Accessed 2007, July)

http://www.ismp.org/Newsletters/acutecare/articles/20040701.asp?ptr=y

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Appendix C

Non-pharmacological/Complementary Modalities for Pain Management

Complementary modalities are used to treat pain, anxiety, fear, ineffective coping, restlessness,

and sleep disturbances. Independent modalities do not require formal training, while dependent

or formal modalities require specialty training, while dependent or formal modalities require

specialty training.

Independent Non-pharmacological and Complementary Modalities

A. Presence

The single most important aspect of promoting comfort is the underlying relationship

between the patient and his or her care provider.

Refers to both physically “being there” and psychologically “being with” the patient.

B. Progressive Relaxation and Deep Breathing

Assess pain level. If pain is present, consider intervening accordingly with pain

medication. Pain relief improves the ability to follow directions and participate in the

relaxation process.

Relaxation is a method of behavioral control in which a person performs techniques

that will reduce or eliminate pain. This modality can interrupt the cycle of pain,

anxiety, and muscle tension that often develops with unrelieved pain.

Several forms of relaxation techniques have been suggested for use in pain

management. (e.g. deep-breathing exercises, muscle relaxation, Lamaze therapy and

visual imagery.)

As patient begins to exhale, the healthcare provider may instruct the patient to

progressively begin relaxing groups of muscles in a head to toe approach. (e.g. begin

with facial muscles to neck and shoulder muscles, etc.) The body tends to relax

naturally on exhalation.

Practice with the patient during non-stressful periods to augment efficacy.

C. Prayer / Meditation

Can be used as a way to connect to the spiritual core of healing and foster hope.

Prayer or meditation can evoke deep states of relaxation.

Offer Pastoral Care support to the patient and family.

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D. Distraction Techniques

Distraction produces analgesic effects by sending intense stimuli through the brain

that can increase the release of endorphins.

The brain can process only a limited amount of signals at any given time.

Forms of distraction include; music, conversation, reading, poetry, crafts, television

viewing, laughter and deep breathing for relaxation.

Techniques should be appropriate to patient’s energy level and are most effective

when the activities interest the patient or when they involved multiple senses such as

hearing, vision, touch and movement.

E. Imagery

Alters the perception of pain stimuli within the brain, helps promote relaxation and

can increase the production of endorphins.

This technique has been found to be helpful when used with planned invasive

procedures.

Patients can use imagery independently or with the assistance of another person. A

care provider or friend can help guide the patient in “painting” an imaginary picture.

The more details that can be pictured with the image the more effective the technique.

Using multiple sensations during the imagery can be helpful, similar to distraction

techniques.

Strategies to help guide the patient include using details to describe the imaginary

scene. (e.g. “Smell the fresh scent of the ocean air; listen to the seagulls overhead.)

F. Sucrose

A 24% oral sucrose solution (Sweet-Ease®

) may decrease crying episodes and cry

duration in response to pain. It provides safe, effective non-pharmacologic analgesia

to infants before and during painful procedures. It may reduce crying-related energy

expenditure and soothe infants. 24% oral sucrose solution (Sweet-Ease®) may be used

in conjunction with opioids and non-pharmacologic interventions such as non-

nutritive sucking (pacifier), positioning, swaddling and kangaroo care, thereby

mimicking endogenous non-opioid & opioid systems. Age dependency of oral sucrose

analgesia may be the result of developmental changes in the interaction between

gustatory and pain pathways.

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G. Infant and Child Massage by Parent

Kangaroo Care

Kangaroo care provides a method of patient care in which a term or pre-term infant is

placed in direct skin-to-skin contact with a primary family caregiver such as mother or

father. This contact is to support parental attachment, infant development and pain

management.