PNS Pain Management Guideline for Nursing

Competency (Adult & Pediatric)

Part I – General Information
1.Pain - An unpleasant sensory and emotional experience associated with actual or
potential tissue damage or described in terms of such damage (International Association for the
Study of Pain, (IASP). Pain is always subjective. Pain is whatever the person experiencing it says it
is, and it exists whenever he or she says it does.
2.Types of Pain
2.1. Acute Pain – New onset pain of a short duration (minutes to days) that usually subsides

as healing takes place. Intensity can range from mild to severe. Acute pain can be associated

with tissue damage, inflammation, surgical procedures, or disease process. Acute pain

episodes may be present in patients with chronic pain.

2.2. Chronic Pain – Prolonged pain that lasts longer than expected healing time (generally

longer than 3 months.). Pain etiology may not be apparent.

2.3. Cancer Pain – Pain that is associated with malignant tumors or its management, usually it

is a chronic pain with acute exacerbation.

2.4. Dental pain - Pain in the teeth or their supporting structures, caused by dental diseases or

pain referred to the teeth by non-dental diseases.

3. Pain Screening – Is a brief assessment or question that determines if the patient is

having pain.

4. Pain Assessment - If the patient is experiencing pain during admission, a comprehensive pain

assessment shall be conducted and documented on the Pain management flow sheet.

5. Pain Management – An interdisciplinary approach using the concept of 3 P’s (Physical,

Psychological, and Pharmacological) to effectively manage pain and provide patients with optimal
pain relief.
 PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)
6. Standardized Pain Assessment/Reassessment Scales shall be used as guide tool by PNS staff
nurses:
6.1. CRIES Scale – Preterm and full-term neonates (who are not on monitor).

6.2. Revised FLACC Pain Scale - > 2 months, non-verbal, and/or cognitively impaired children.

6.3. Revised FACES Pain Scale – for children 5-12 years

6.4. Numeric Rating Scale (NRS) for children over 7 years and adults

6.5. ABBEY Pain Scale – for patient with Dementia or who cannot verbalize.

6.6. Behavioral Pain Scale – for cognitively impaired – adults

Note: The PNS nurse shall conduct pain reassessment during each shift and document;

• Every four (4) hours in the pediatric population.

• Every four (4) hours in the adult population if with pain and every eight (8) hours if
no pain.
• Document in pain management flow sheet (or document in nurses’ notes if
applicable) manually if pain present:
• Every 15-30 minutes after parenteral drug therapy.
• One (1) hour after oral drug and non-pharmacological interventions.

7. Non-pharmacologic Strategies

7.1 - Physical Strategies such as repositioning, heat/cold, massage, and physiotherapy.

Examples of physical strategies include:

• Breathing exercises or blowing bubbles

• Repositioning
• Use of heat and/or cold
• Massage
• Pressure or vibration
• Activity out of bed as tolerated e.g. sitting up in a chair, going for short walks or rides in a
wheelchair.
• For complex and/or chronic pain issues, consultation with a Physiotherapist is recommended.
 PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)
7.2 - Psychological Strategies – Use of psychological strategies in conjunction with
pharmacological and physical strategies is an integral part of pain management.
Examples of psychological strategies include:
• Education- explanation of painful procedures to the adult or child as appropriate.
• Distraction – such as watching TV, playing and listening to favorite music/sound.
• Relaxation.
• Referral to child life specialist, clinical psychologist, psychiatrist as indicated for more
advanced strategies.
8. Pharmacological intervention shall be directed toward providing optimal pain relief. The specific
pain medications shall be at the discretion of the Consulting/Specialist Physician or their instructed
resident.
Example of common pain medications encountered in PNS:
• Paracetamol (Acetaminophen) - Ensure the maximum daily dose is not exceeded when
ordering Paracetamol either alone or
as a combination product.
• NSAIDs - Use the oral route when available.
• Adjuvants - Benzodiazepines/baclofen may be helpful for the treatment of painful muscle
spasms.
9. Education patients and their family / caregivers should be actively involved in pain assessment
and management. They have the right to be informed of all available and appropriate methods of pain
relief as well as the positive and negative consequences.
10. Documentation shall be completed in Nursing Pain Management Flowsheet, Nursing
Reassessment form, Nursing Progress Notes, Plan of Care and Patient/Family Education Record.
 PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)
Part II – Performance Process (Demonstration/Verbalization)
The standard for performing a complete pain management is:
• On admission
• On the day of discharge or transfer to another level of care
• Whenever a significant clinical change occurs
• With any self-report of pain or evidence of pain
• When identifying the level of pain
• When monitoring the effectiveness of pain interventions or treatment modalities
• During known painful procedures or activities.

Remember that pain is subjective and that the pain assessment is used to compare the patient's pain
intensity at different times. A pain assessment is not used to compare one patient's pain level with
another patient's pain level.

Equipment

• Facility-approved pain assessment tool

• Vital signs monitoring equipment
Implementation
• Review the patient's pain history and previous pain level, when available, to serve as a basis
for comparison.
• Review the patient's medical diagnosis and history of painful events or tissue trauma.
Remember that the patient may have pain from causes other than his primary diagnosis or
complaint.
• Determine whether the patient is taking any medications that may affect the perception of
pain or the ability to communicate pain. Some medications (such as benzodiazepines,
phenothiazine, and barbiturates) sedate the patient or reduce anxiety but don't provide
analgesia.
• Perform hand hygiene.
• Confirm the patient's identity using at least two patient identifiers.
• Provide privacy.
• Raise the patient's bed to waist level when performing patient care to prevent back strain.
• Ask the patient whether he has any pain. If he does, ask about the pain's character, quality,
onset, location (and whether it radiates), duration, and frequency. Determine what
exacerbates the pain and what relieves it. Determine whether the patient has a current pain
PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)
regimen and, if he does, how it relates to his current level of pain. Findings from these
assessments provide information about the patient's current pain level and provide a baseline
for future assessments.
• Assess the patient's level of functioning, including his ability to participate in activities of daily
living. Evaluating the patient's level of function is important because pain affects the degree of
independence, level of need for caregivers, and overall quality of life.
• Assess what coping techniques have previously been successful to establish a guideline for
future interventions.
• Assess for the presence of pain indicators, taking into consideration the patient's age and
sleep patterns. Acute pain indicators include statements of pain, increased respiratory or heart
rate, shallow respirations, decreased oxygen saturation level, crying, moaning, restlessness,
anxiety, and grimacing. Chronic pain indicators include disrupted sleep, changes in eating
patterns, withdrawal from activities, and symptoms of depression.
• Assess the patient's pain level using a validated, appropriate, facility-approved pain
assessment tool. After you identify a tool that works well for the individual patient, use the
same tool each time (unless the patient's condition changes; for example, he becomes
disoriented or unresponsive) to compare adequacy of pain management. A valid and reliable
tool increases confidence that the tool is accurately measuring pain.
• Perform a thorough physical examination that includes the painful area to obtain additional
assessment data.
• Implement appropriate interventions, taking into consideration the patient's verbal and
cognitive level, coping style, environment, medication history, and type and intensity of pain.
• Reassess the patient's pain level if clinical indicators of pain are present; after implementation
of pain interventions (according to the medication's onset of action); after analgesic, and after
any other type of pain management intervention to ensure adequacy of pain management and
to detect unmanaged pain.
• Reassess the patient's pain level and quality approximately 15 to 30 minutes after parenteral
pain medication or approximately 60 minutes after oral pain medication. If the patient is still in
pain, notify the practitioner and alter the treatment plan as appropriate.
• Reassessment should include not only pain relief, but also adverse reactions or events
produced by treatment and the impact of pain and treatment on patient function and quality
of life.
• Work with the patient to develop a care plan using intervention appropriate to the patient's
lifestyle.
• Be aware that a patient receiving opioid analgesics may be at risk for addiction, physical
dependence, or tolerance.
• If the patient has dementia or another cognitive impairment, don't assume that he can't
understand a pain scale or communicate his pain. Experiment with several pain scales to find
one that works.
 PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)
• Provide the appropriate interventions. Re-enforce pain management education.
• Return the bed to the lowest position to prevent falls and maintain patient safety.
• Perform hand hygiene.
• Document the procedure.
Part III – Pain Scales (as guide tools)
1. FACES Pain Scale – Revised (FPS-R)
Instructions:
In the following instruction, say “hurt” or “pain,” whichever seems right for a particular child. “These
faces show how much something can hurt. This face [point to left- most face] shows no pain.
The faces show more and more pain [point to each from left to fit] up to this one [point to
right-most face] – it shows very much pain. Point to the face that show how much you hurt
[right now.]
Score the chosen face 0, 2, 4, 6, 8, 10, counting left to right, so ‘0’ = ‘no pain’ and ‘10’ = ‘very much
pin.’ Do not use words like ‘happy’ and ‘sad.’ This scale is intended to measure how much children
feel inside.

2. Behavioral Pain Scale for Cognitively Impaired

Instructions: Observe the patient for 3-5 minutes at rest and with activity and then score each
of the 5 categories from 0 – 2 which results in a total score between 0 – 10.
EMOTION MOVEMENT VERBAL CUES FACIAL CUES POSITION /
0 - Smiling 0 - None 0 - Quiet 0 - Relaxed, calm GUARDING
1 - Anxious, irritable 1 - Restless, slow, 1 - Noisy breathing, expression 0 - Relaxed body
2 - Almost in tears decreased movement whining, whimpering 1 - Drawn around 1 - Guarding / tense
2 - Immobile, afraid to 2 - Immobile, afraid mouth and eyes 2 - Fetal position,
move to move 2 - Screaming, jumps when touched
crying out
PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)

3. Numeric Rating Scale (NRS)

4. CRIES Scale
PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)

5. Revised FLACC Pain Scale

 PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)

6. ABBEY Pain Scale

PNS Pain Management Guideline for Nursing
Competency (Adult & Pediatric)