Nipissing University BScN Learning Module
(RNAO, 2013)
Best Practice Guideline:
Assessment and Management of Pain
The Nipissing University BScN program is undergoing a pre-designation to become a Best Practice Spotlight Organization (BPSO). This project is funded by the RNAO in conjunction with the Ministry of Health and Long Term Care.
Disclosure: This presentation is based on the RNAO best practice guideline; Assessment and Management of Pain.
First Year
Knowledge of BPG, and assessment using BPG’s (Introduce BPG order sets).
Second Year
Clinical exposure to application of BPG’s
Third Year
Knowledge and use of BPG’s in complex settings.
Fourth/Fifth Year
Application of BPG’s in complex scenarios (critical thinking).
How to Use BPG's based on your Academic Year- A General Guideline
This guideline outlines EB practice, that addresses recommendations for health care providers assessing or managing those who have pain, are at a risk of developing pain. An overview of supports, and appropriate structures are discussed in order to provide the best possible evidence based (EB) care.
(RNAO, 2013)
(RNAO, 2013)
What is Pain?
(IASP, 2012; RNAO, 2013, p. 70)
Pain can also be classified based on location (somatic, visceral), a diagnosis, or duration.
It is important to understand that an individual may experience both nociceptive and neuropathic pain simulateneously.
Nationally, pain that is poorly managed places a burden on the person, society, and the health care system (Lynch, 2011).
(Canadian Pain Coalition’s Pain in Canada Fact Sheet 2012; Lynch, 2011; RNAO, 2013)
The Canadian Pain Coalition’s Pain in Canada Fact Sheet (2012) discusses how one in five Canadian's rate their pain from moderate to severe persistent chronic pain, and one third of those individuals are unable to work due to the impact that their pain has on their health along with their quality of life.
Effective Pain Management
Every individual has the right to effective pain management. It is a top priority for health care providers to assess, intervene, monitor, and prevent/minimize further pain whether their diagnosis or type of pain.
(IASP, 2012a; Jarzyna et al., 2011; Pompili et al., 2012; RNAO, 2017)
A physical, socioeconomic, and physical burden is placed on an individual who has persistent pain along with the family or caregiver. Pain is complex; it is highly subjective, and multidimensional with three components; cognitive, sensory, and affective. When caring for someone with pain, the process must be person-centred that allows for multidimensional approaches to enoucrgae the involvement of spiritual, cultural, and bio-psycho social factors that surround the individual. When caring for someone with pain, it should be an
interprofessioanl team effort.
Nurses often work directly with these individuals, and they have a resonsibility to intervene within their scope of practice, when an individual reports pain and to work with them in order to manage that pain. That being said means that nurses are obligated to asses and manage pain using competencies and EB care.
When should individuals seek assistance with pain management?
Pain that is uncontrolled is a common problem in society, and it can affect any age, including those are are unable to communicate. If pain is affecting these individuals in their activities of daily living, this can affect how they function, and their behaviour. This is because pain can cause individuals to feel distressed, especially if they are unable to communicate for themselves.
Pain is easier to manage in the early stages, before it becomes too intense to deal with. If an individual notices that someone they care for is unable to communicate their pain verbally, there are non- verbal cues to watch out for including crying, facial grimacing, irritbaility, or silence. If you suspect pain it is important to contact a health care professional.
(RNAO, 2013)
Purpose of Guideline:
This BPG is to assist health care providers to become more confident, competent, and comfortable when assisting with pain management
This guideline uses EB practice in order to assess, intervene, and manage an individuals pain using a client-centred method.
(RNAO, 2017)
(RNAO, 2013, p. 18)
Scope
Best practice recommendations are provided in three areas:
As nursing students, the focus will be on practice recommendations.
It is benefical to be aware of the educational, and system, organization, and policy recommendations.
Gap Analysis
The difference between current knowledge/practices (what we are doing) and current Evidence Based Practices (what we should be doing).
Gaps can occur in knowledge, skills or practice.
Performing a gap analysis on best
practice guidelines is an essential part
Reflect on the following questions, and be specific:
Where is our current practice?
Where do we wish we were/where should we be? Why has this gap occurred?
How are we going to close the gap?
(Anthony J. Jannetti, Inc. 2012)
of reflecting on practice. When reviewing the recommendations identify where there are gaps in current practice or knowledge, and take the time to reflect.
Steps to Conduct a Gap Analysis
(Anthony J. Jannetti, Inc. 2012)
Practice Recommendations
Assessment and Management of Pain
1.0 Assessment
(RNA0, 2013)
1.1 Screen for the presence, or risk of, any type of pain: On admission or visit with a health-care professional; After a change in medical status; and
Prior to, during and after a procedure.
1.2 Perform a comprehensive pain assessment on persons screened having the presence, or risk of, any type of pain using a systematic approach and appropriate, validated tools.
1.3 Perform a comprehensive pain assessment on persons unable to self-report using a validated tool.
1.4 Explore the person’s beliefs, knowledge and level of understanding about pain and pain management
1.5 Document the person’s pain characteristics.
(RNA0, 2013)
Pain Assessment Tool
(RNA0, 2013, p. 21)
Acronym:
O, P, Q, R, S, T, U, & V
How to Select a Pain Assessment Tool
(RNA0, 2013, p. 23)
Misbeliefs vs. Facts Regarding Pain Assessment
(RNA0, 2013, p. 28, 29)
2.0 Planning
(RNA0, 2013)
2.1 Collaborate with the person to identify their goals for pain management and suitable strategies to ensure a comprehensive approach to the plan of care.
2.2 Establish a comprehensive plan of care that incorporates the goals of the person and the interprofessional team and addresses:
Assessment findings;
The person’s beliefs and knowledge and level of understanding; and The person’s attributesG and pain characteristics.
(RNA0, 2013)
3.0 Implementation
(RNA0, 2013)
3.1 Implement the pain management plan using principles that maximize
efficacy and minimize the adverse effects of pharmacological interventions including:
Multi-modal analgesic approach;
Changing of opioids (dose or routes) when necessary;
Prevention, assessment and management of adverse effects during the administration of opioid analgesics; and
Prevention, assessment and management of opioid risk.
3.2 Evaluate any non-pharmacological (physical and psychological) interventions for effectiveness and the potential for interactions with pharmacological interventions.
3.3 Teach the person, their family and caregivers about the pain management strategies in their plan of care and address known concerns and misbeliefs.
(RNA0, 2013)
Interventions Regarding Pain Management
(RNA0, 2013. p. 87)
Adverse Effects of Opiods
Nurses should be aware of the adverse effects of opioids and should work to prevent and manage when needed. Sedation is an adverse effect and can come about when increasing opioid doses, this can be dangerous as sedation can lead to respiatory depression.
(RNA0, 2013. p. 87)
Adverse Effects of Opiods
(Pasero, 2009; Jarzyna et al., 2011 RNA0, 2013)
Considerations when administering opioids: When a dose is increased
The titration of opiods too quickly People who have never used opioids
Change in opioid medication, route or delivery
Recent or rapid change in the function of a vital organ Concurrent use of medications that can depress the CNS
Pre-existing factors for resiratory depression
Nurses and the interprofesional team are accountable to frequently monitor individuals using opioids and their response, in order to ensure their safety and avoid adverse effects. This is specifically important for those who have never used opioids before.
4.0 Evaluation
(RNA0, 2017)
4.1 Reassess the person’s response to the pain management interventions consistently using the same re-evaluation tool. The frequency of reassessments will be determined by:
Presence of pain; Pain intensity;
Stability of the person’s medical condition; Type of pain e.g. acute versus persistent; and Practice setting
4.2 Communicate and document the person’s responses to the pain management plan.
(RNA0, 2013)
Listed below are the education and system, organization and policy recommendations related to this BPG for your reference
5.0 Education Recommendations
(RNA0, 2013)
5.1 Educational institutions should incorporate this guideline, Assessment and Management of Pain (3rd ed.), into basic and interprofessional curricula for registered nurses, registered practical nurses and doctor
of medicine programs to promote evidence-based practice.
5.2 Incorporate content on knowledge translation strategies into education programs for health-care providers to move evidence related to the assessment and management of pain into practice.
5.3 Promote interprofessional education and collaboration related to the assessment and management of pain in academic institutions.
5.4 Health-care professionals should participate in continuing education opportunities to enhance specific knowledge and skills to competently assess and manage pain, based on this guideline, Assessment and Management of Pain (3rd ed.).
(RNA0, 2013)
6.0 Organizational and Policy
Recommendations
(RNA0, 2013)
6.1 Establish pain assessment and management as a strategic clinical priority.
6.2 Establish a model of care to support interprofessional collaboration for the effective assessment and management of pain.
6.3 Use the knowledge translation process and multifaceted strategies within organizations to assist health-care providers to use the best evidence on assessing and managing pain in practice.
6.4 Use a systematic organization-wide approach to implement Assessment and Management of Pain (3rd ed.) best practice guideline and provide resources and organizational and administrative supports to facilitate uptake.
(RNA0, 2013)
Research Gaps and Future Limitations
(RNA0, 2013)
References
Anthony J. Jannetti, Inc. (2012). A representation: Incorporating a needs assessment and gap analysis into the educational design. Pitman, NJ: Author.
Canadian Pain Coalition. (2012). Pain in Canada Fact Sheet. Canadian Pain Society. Retrieved from http://www.canadianpainsociety.ca / pdf/pain_fact_sheet_en.pdf
International Association for the Study of Pain (IASP). (2012a). IASP Curriculum Outline on Pain for Nursing. Retrieved from http://www.iasp-pain.org
/AMTemplate.cfm?Section=Nursing
Lynch, M. (2011). The need for a Canadian pain strategy. Pain Research & Management, 16(2), 77-80.
Jarzyna, D., Jungquist, C., R., Pasero, C., Willens, J. S. Nisbet, A., Oakes, L.,...Polomano, R. (2011). American Society for Pain Management Nursing Guideline on Monitoring for Opioid-Induced Sedation and Respiratory Depression. Pain Management Nursing 12(3), 118-145.
Pasero, C. (2009). Assessment of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 24(3), 186-190.
Pompili, M., Innamorati, M., Serafini, G., Gonda, X., Campi, S., Rapinesi, C.,…Girardi, P. (2012). How does subjective experience of pain relate to psychopathology among psychiatric patients? General Hospital Psychiatry, Epub ahead of print. Retrieved from http://www.ncbi.nlm.nih.gov
/pubmed/22595339
Registered Nurses’ Association of Ontario. (2013). Assessment and Management of Pain (Rev. ed.). Retrieved from http://rnao.ca/ Registered Nurses’ Association of Ontario. (2013). Health Education Fact Sheet. Helping People Manage Their Pain (Rev. ed.) Retrieved from