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Policies,Clinical,UW Health Clinical,Medical Records and Communication,Patient Assessment

Pain Management (3.5.5)

Pain Management (3.5.5) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Patient Assessment

3.5.5


UW HEALTH CLINICAL POLICY 1
Policy Title: Pain Management
Policy Number: 3.5.5
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 27, 2017

I. PURPOSE

To establish a safe and uniform method of pain screening, pain assessment, pain reassessment and pain
management documentation. This document is intended to define the basic level of care and does not
address all assessment standards. See specific policies for specialized analgesic techniques listed in the
reference section for additional information

II. DEFINITIONS

A. Pain Screening: interview to determine if the patient is experiencing pain.
B. Pain Assessment: in-depth evaluation when the patient reports the presence of pain including, quality,
onset, location, duration, aggravating and alleviating factors, impact on function and quality of life, an
acceptable level of pain, and intensity or patient’s rating of pain on a scale (e.g., 0 to 10, mild-moderate-
severe). Includes patient’s response to past/current drug and non-drug treatment. Evaluation may also
include attention to the underlying meaning of the pain to the patient, and associated spiritual and
psychological issues or distress.
C. Pain Reassessment: Following an intervention the patient should be reassessed for pain relief, side effects
and adverse events produced by the intervention, and the impact of pain and treatment effects on patient
function and quality of life.

III. POLICY ELEMENTS

UW Health recognizes that pain is a highly prevalent symptom, and that pain control is a high priority that
can be accomplished in the majority of patients. Establishing realistic expectations promotes understanding
of the degree of pain that can be controlled. We are committed to addressing all dimensions of pain safely
and effectively. The goal of pain management is to relieve the physical and psychosocial symptoms
associated with pain while maintaining or improving the patient's level of function. It is essential that patients
understand what a realistic goal is. At UW Health, patients and their families should expect appropriate
assessment and management of pain. The effective relief of pain requires professional expertise and
patient/family involvement. During routine patient care, pain management will be considered an element of
the plan of care for all patients.

This policy applies to all health care team members assessing or providing care to patients. This policy is to
be followed in the care of all inpatient and outpatient populations.

Health care team members consult with patients or family members to determine the appropriate pain scale
to use. Once the appropriate pain scale has been identified, it should be used throughout the hospital stay
unless a change in patient condition warrants a change in pain scale (for example, change in level of
consciousness). Care should be individualized based on specific patient needs, cultural considerations, and
professional judgment.

Health care team members include patients (and, if appropriate, family members) in the development of
goals for pain management. The goals may include:
ξ Patient will express adequate pain relief.
ξ Patient will have minimal side effects from the analgesic regimen.
ξ Patient will maintain or improve functional status.
ξ Patient will be satisfied with pain management.

IV. PROCEDURE

A. Screening
i. Patients will be regularly screened for the presence of pain as part of routine care.
a. Inpatient - Screening will minimally occur:
1. On admission



UW HEALTH CLINICAL POLICY 2
Policy Title: Pain Management
Policy Number: 3.5.5

2. Every comprehensive health assessment.
a. Adult General Care – once every 24 hours
b. Critical and Intermediate Care – every 4 hours
c. All pediatric care once 8 hours while awake
b. Outpatient and Home Health - Routinely screen patients at outpatient clinic and home
health visits. Exceptions to this include:
1. Blood Pressure Check Visits by MA or RN.
2. Specific Education/counseling visits.
3. Blood draws or other diagnostic test visits, e.g., ultrasound in In Vitro
Fertilization.
4. Injection, Immunizations/skin tests and Travel Shot Visits.
5. Pacemaker and other device check type visits.
B. Assessment: Performed by health care team members within scope of practice, training or competency.
i. Review with the patient/family how to report and describe pain.
ii. A patient that can verbalize pain or answer questions independently, through an interpreter or by
other methods of communication should have a comprehensive pain assessment.
iii. Documentation of pain assessment,
a. When the pain screen is positive. Document pain systematically including:
1. To better understand the patient’s pain experience, the following elements are
available to assess: location(s), intensity, quality, onset, duration, aggravating
and relieving factors, and presence and severity of side effects to pain
medications as warranted by the patient's condition and the clinical setting. The
minimum documentation of a comprehensive pain assessment includes: location,
quality, frequency and severity.
2. If the patient cannot respond to these questions (for example due to
age/developmental stage or neurological status), a parent, other family member
or other caregiver can provide this information if they are available.
3. Document behaviors that may be indicative of pain including facial cues, increase
or decrease in movement (guarding, rubbing, etc.), restlessness and/or
vocalizations.
4. Pain assessment tools for cognitively impaired such as the Checklist of
Nonverbal Pain Indicators (CNPI) or the Neonatal Infant Pain Scale (NIPS) can
be used to assess patients who are unable to verbalize or otherwise
communicate about their pain level.
5. If no one is available to provide this information, the Health care team member
assessing the patient can answer these questions to the best of their ability by
using current and historical medical information.
iv. Selection of Pain Scale: Pain intensity is measured using a variety of scales depending on
population and individual patient preference. Health care team members consult with patients or
family members to determine the appropriate pain scale to use. Once the appropriate pain scale
has been identified, it should be used throughout the hospital stay unless a change in patient
condition warrants a change in pain scale. Examples of pain scales used at UW Health include:
a. Adult Scales
1. Numeric Rating Scale, 0-10 verbal or visual analog scale (0 = no pain to 10 =
worst pain possible)
2. Mild-moderate-severe
3. The Checklist of Nonverbal Pain Indicators (CNPI) for cognitively impaired adults.
4. Critical-Care Pain Observation tool (CPOT) typically used for intubated, sedated
adult ICU patients.
b. Pediatric Scales
1. Numeric Rating Scale also known as 0-10 verbal or visual analog scale (0 = no
pain to 10 = worst pain possible)
ξ Suggested for use in typically developing children greater than 8 years
of age
2. Mild-moderate-severe
ξ Suggested for use in typically developing children greater than 8 years
of age
3. The Faces Pain Scale – Revised (FPS-R) with no pain to “very much pain” from



UW HEALTH CLINICAL POLICY 3
Policy Title: Pain Management
Policy Number: 3.5.5

left to right
ξ Suggested use in children who can express their pain pictorially –
typically ages 4-8 years old
4. The Faces-Legs-Agitation-Cry-Consolability – Revised (FLACC-R). A behavior
based scale for children who cannot report pain either due to age or
developmental stage.
ξ Suggested for use in children developing normally from ages 1-4 years
or in children with developmental delays from ages 1 year to adult.
5. Neonatal/Infant Pain Scale (NIPS). A behavior based scale for children who
cannot report pain due to age less than one year.
c. Neonatal Pain, Agitation Sedation Scale
1. A pain scale specific to premature, neonatal population.
v. Investigate possible mechanical causes of pain such as immobilization, medical devices, full
bladder, cast too tight, etc. Investigate other psychosocial or spiritual aspects of pain when
appropriate.
C. Intervention: Provided by Health care team members as relevant and within scope of their individual
practice, licensure, privileges and/or job description.
i. Select pain control options most appropriate for the patient, family, caregiver and setting. Educate
the patient regarding the risks and benefits of options chosen and others, if appropriate.
ii. Administer prescribed analgesics and deliver interventions in a timely, logical and coordinated
manner. Educate the patient regarding potential side effects and medication regimen adherence.
iii. Explore patient/family concerns about use of opioids. Provide information, or refer to others who
can provide information to address these concerns.
iv. Facilitate use of nonpharmacological interventions such as massage, distraction, heat/cold,
positioning/immobilization, guided imagery, relaxation, focused breathing and others as clinically
appropriate. Educate the patient on the use of nonpharmacological approaches where feasible.
v. Include patients' psychosocial, spiritual, and cultural values and beliefs in pain management. Allow
patients and their families to express their spiritual beliefs and cultural practices
vi. Monitor ongoing effectiveness of the current pain management plan. Document medication
administration and effectiveness of analgesic and nonpharmacologic regimen
vii. Document plan which includes home care, interventions and outcomes. When response to routine
interventions is insufficient, assure access to the full range of interdisciplinary resources and
processes (e.g. Inpatient Pain Consult, Anesthesia Acute Pain Consult, Health Psychology consult,
etc.).
D. Reassessment: Reassessment of pain and documentation are two separate functions. Reassessment of
pain is ongoing and not simply a one-time event. Reassess after each intervention, and with each additional
report of pain, in a timely and comprehensive manner appropriate to the circumstances (i.e., patient
condition/risk factors, type of pain, level of intervention, combination therapy, and care setting) to ensure
safety and efficacy.
i. When patients are sleeping they do not need to be awakened to assess pain and sedation unless
there is concern by the RN that the patient may be oversedated rather than sleeping (for example
the patient stirs when the RN enters and examines pumps or other equipment in the room but does
not completely awaken as compared to a sedated patient who may not rouse with these activities).
However, a full respiratory assessment, rate, depth and regularity for a full minute, should be
conducted even when the patient is sleeping.
ii. A pain reassessment is completed and documented on Home Health revisits (or as specified in the
plan of care) if the patient reports unrelieved pain.
iii. In the inpatient setting, documentation of ongoing reassessments is performed by a RN for each
patient receiving pain treatment (pharmacological and non-pharmacological) at a minimum of three
times within 24 hours approximately 8 hours apart. This may occur at times such as shift handoff,
transfer to another unit, or a change in therapy.
iv. Ambulatory setting: reassess will be specific to plan of care (i.e., patient may stay in clinic to
determine the effectiveness of in clinic medication, may have telephonic communication, or may
have effectiveness accessed at next visit). Reassessment will be documented appropriately.
v. In the Emergency Department (ED), a documentation of ongoing reassessments is performed by a
RN for each patient receiving pain treatment of any kind at least once during the ED visit and
minimally once every 8 hours.
E. Response to pain interventions (pharmacological and nonpharmacological) is used to monitor effectiveness



UW HEALTH CLINICAL POLICY 4
Policy Title: Pain Management
Policy Number: 3.5.5

and if pain management plan requires modification. Report and document communication to appropriate
provider:
i. if pain is unrelieved
ii. if interventions are insufficient to reduce pain to an acceptable level
iii. if side effects are not managed by initial planned interventions
iv. if new or unexplained pain develops.
F. With provider, review assessment of pain, current analgesic effectiveness, prior analgesic history, and
present medical situation. Determine need for adjustment in treatment plan.

V. COORDINATION

Author: Clinical Nurse Specialist, Pain Management
Senior Management Sponsor: SVP, Patient Care Services and CNO
Reviewers: Pain Clinical Nurse Specialist and Pain Patient Care Team
Approval committees: Nursing Practice Council; Nursing Executive Council; Pediatric Practice Committee;
Nursing Patient Care Policy and Procedure Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: December 19, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
UW Health Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UW Health clinical policy #3.5.2, Screening, Assessment and Reassessment of Patients
Nursing Patient Care departmental policy #13.16P, Basic Care – Inpatient Pediatrics (Birth – 18 years of
age) (Pediatric)
UW Health clinical policy #6.1.2, Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric
Patients
UWHC policy #8.92, Epidural and Intrathecal (Neuraxial) Analgesia
Nursing Patient Care departmental policy #1.41, Care of Patient Receiving a Continuous Peripheral Nerve
Block (Perineural) Infusion
Nursing Patient Care departmental policy #10.18AP, Parenteral (Intravenous or Subcutaneous) Lidocaine
for Neuropathic Pain (Adult and Pediatric)
Nursing Patient Care departmental policy #13.14, Documentation in the Inpatient’s Clinical Record
UW Health clinical policy #3.2.6, Inpatient Health Link Downtime and Recovery
UW Health clinical policy #3.2.5, Ambulatory Health Link Downtime and Recovery
UWHC policy #8.16, Patient Care Orders
American Pain Society, www.americanpainsociety.org
Agency for Healthcare Research and Quality, www.ahrq.gov
World Health Organization, www.who.int/

VIII. REVIEW DETAILS

Version: Revision
Next Revision Due: January 2020
Formerly Known as: Hospital Administrative policy #8.76