Pain Assessment, the Key to Treating Pain in the Inpatient Setting

1. C A S S I A Y I , A P R N , M S N , C N S , C C R N
Pain Assessment, the Key to
Treating Pain in the Inpatient
Setting
Considerations in The Aging And Palliative Populations

2. Objectives
 Apply the Pain Assessment Hierarchy to pain
assessment and reassessment in all patient
populations
 Review importance of sedation assessment
 Make the connection between good assessment and
good management

3. Hierarchy Of Pain Assessment
Self
Report
Behavioral
assessment
Assume or Anticipate
pain (APP)

4. The Numeric Pain Scale
 Ask your patient to rate his or her pain on a scale of
0-10, 0 being no pain, and 10 being the worst pain

5. Some elderly patients may prefer to describe their pain as
mild, moderate, or severe

6. A Reminder About the FACES Tool:
 DO NOT choose a face for the patient based on how
he/she looks!

7. Behavioral Assessment Pain Tools
CPOT
CNPI
BPS
NVPS
NPAT

8. Behavioral Score Does Not Equal Intensity!!!!
 Example= Two people may have the same cut on
their finger…
Person #1 may be crying,
squeezing his finger, and grimacing.
Person #2 may be just grimacing
This does not mean that Person #1 is experiencing more
pain….he just displaying behaviors of pain differently.

9. Pain and the Dying patient
 Pain is not automatic!
 Pain must be assessed, just like with any other
patient population!
• Don’t misinterpret other signs/symptoms of dying
with pain!
• Restlessness, agitation, moaning, and groaning may
accompany terminal delirium
• If the diagnosis is unclear, a trial of opioid may be
necessary to judge whether pain is driving the
observed behaviors

10. Respiratory Variations in the Dying patient- NOT
indicator of pain
 Patterns:
 Tachypnea, Apnea
 Chin-lift, jaw-jerk*
 Diminishing tidal volume
 Oropharyngeal secretions*
 Symptoms: generally
comfortable
 Distressing to family, not to
patient
 Management
 Family support
 Oxygen variably effective
 Opioids (rarely)

11. Palliative Patients are at Increased Risk of Pain
 Disease Process
 Immobility (who’s driving this??)
 Skin break down
 Dyspnea

12. Pain Reassessment
 Reassessment times should coincide with peak
medication effectiveness, when the patient will
feel the greatest effects of analgesia and will also
experience the peak of side effects.
 5-45 minutes for IV opioids
 45-75 min for PO opioids

13. PlasmaConcentration
0
Time
IV Peak
30 min
PO / PR/ IM
60 minutes
60 min
SQ Peak
A little longer than IV
30 min 60 min
When should
you assess??

14. Assessing for sedation
RASS
Ramsey
POSS
GCS

15. Why is the Sedation Assessment
So Important?
 Remember sedation ALWAYS precedes respiratory
depression!! If we can catch the patient while they
are sedate, we should be able to prevent all opioid
related respiratory depression!
If left untreated,
can lead to
This
This

16. Sleep and Assessing Pain
 If your patient is asleep when you need to
reassess for pain, this could mean 2 things:
 Your patient is finally able to sleep! Assess the respiratory status
and review previous sedation assessment. If normal, do not wake
the patient up!
-OR-
 The pain medication you gave made your patient sedate. If the
respiratory assessment is abnormal, wake the patient up! Further
evaluation is required.

17. What is a Good Respiratory Assessment?
 Respiratory Assessment Includes:
 Observe for a full minute!
 Assess the rate
 Assess the rhythm
 Assess the depth
 Assess respiratory effort. Are they snoring?

18. Do our Current Assessment Tools
work????
 Self-report= gold standard
 Problem with self-report using a uni-dimensional
scale
 Pain is a multi-dimensional complex experience- Dynamic!
 Numeric scale difficult for some to use
 Requires linguistic and social skills
 Patients modulate pain behaviors and self-report based on
their perception of what’s in their best interest
 Providers see verbal and non-verbal signs of pain, but
can only respond to reported number
Schiavenato, M & Craig KD. (2010) Clin J Pain. 26(8);667-676

19. Patients Modulate Pain

20. Is There Something Better?
University of Utah – 2012 Pilot Project
 CAPA© developed to replace conventional numeric
rating scale (NRS; 0-10 scale)
 Press Ganey© scores increased from 18th to 95th
percentile
 55% patients preferred CAPA ©
 Nurses preferred CAPA © 3:1 over NRS

21. Clinically Aligned Pain Assessment (CAPA)
“Pain is More Than Just a Number” ©
 Evaluates
 intensity of pain
 effect of pain on
functionality
 effect of pain on sleep
 efficacy of therapy
 progress toward comfort
 Engages patient and
clinician in a brief
conversation about pain
resulting in coded
evaluation
From, Donaldson & Chapman, 2013.

22. CAPA© Tool (modified; original in blue)
The conversation leads to documentation- not the other way around.
Question Response
Comfort •Intolerable
•Tolerable with discomfort
•Comfortably manageable
•Negligible pain
Change in Pain •Getting worse
•About the same
•Getting better
Pain Control •Inadequate pain control Inadequate pain control
•Partially effective Effective, just about right
•Fully effective Would like to reduce medication
(why?)
Functioning •Can’t do anything because of pain
•Pain keeps me from doing most of what I need to do
•Can do most things, but pain gets in the way of some
•Can do everything I need to
Sleep •Awake with pain most of night
•Awake with occasional pain
•Normal Sleep
From, Donaldson & Chapman, 2013.

23. Good Assessment is what Makes Good
Management Possible!

24. PlasmaConcentration
0
Time
IV Peak
20 min
PO / PR/ IM
60 minutes
60 min
SQ Peak
A little longer than IV
30 min 60 min
Morphine IV
Peak effect: 20 minutes
Half-life: 2-4 hours
Continuous morphine infusion :
Time to steady state: 10-20
hours

25. PlasmaConcentration
0
Time to Drip Steady State
164 8 12
Time ( hours )
20 24
50%
75%
87.5%
93.75%
97%
100%
Pain Control
Change GTT
Steady State

26. Pain Management with Geriatric Patients
Analgesic therapy issues
 Physiologic changes
 Absorption
 Distribution
 Metabolism
 Elimination
 Opioids
 Recommend reducing initial opioid dosing
by 25-50% in elderly patient

27. • Retrospective study at UC San Diego
• Patients who died while receiving Continuous
Morphine Infusion (CMI) from 2012-2013
N=190
• Mean age was 66.4 years (range: 19-99 years)
• 109 males and 81 females
• At initiation of CMI, 25.8% (n=49) had an oncologic
diagnosis and 73.2% (n=139) were in the ICU.
Morphine Study at UCSDH
Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at End
of Life. Submitted to Journal of Palliative Medicine January 2015

28. • Prior to CMI initiation, 40.5% (n=77) were opioid naïve
• 85% (n=160) had documented indication for CMI (e.g.
compassionate extubation or comfort care with pain/dyspnea)
• 60% (n=120) did not receive any bolus doses prior to CMI
initiation and of these 23% were opioid naïve (n=44)
• Between start and end of CMI
+130% in rate of CMI
+442% morphine IV dose
Patients on CMI:
24.2% (n=46) had a GFR < 30 mL/min
73.1% (n=139) a GFR >30 mL/min
2% (n=5) were not recorded
A Few Key Findings from Morphine Study
Internal data: Lin KJ, Chang A, Edmonds KP, Roeland EJ, Revta C, Ma JD, Atayee RS. Variable Patterns of Continuous Morphine Infusions at
End of Life. Submitted to Journal of Palliative Medicine January 2015

29. What is the Goal?
Continuous Infusion Bolus
• Achieve continuous pain/agitation
control by administering a
continuous infusion (at the lowest
possible dose to minimize
accumulation)
• Assess the effect of the continuous
drip rate when steady state is
reached
(5-72 hours with pain meds)
• Should not be used for patients
with anuria or oliguria
There are 2 goals of IV boluses for
patients who are already on a
continuous drip:
1. To treat a pain score or agitation
level that is above/beyond the
patient’s consistent level.
2. Indicates if the continuous IV
infusion needs to be increased

30. Continuous Infusions- Back to Basics! Bolus 1st!
Bolus
Re-Assess
Still have pain? Re-
Bolus!
No more pain? If
painful stimuli is
constant, titrate up!
Assess
Start Here!

31. In Conclusion….
 Assess, Assess, Assess before you treat!
 Assess for sedation, not just pain!
 Pain and sedation assessment will help you decide
HOW to treat.
 Pain assessment is still important in the palliative
population! Don’t make assumptions!
 Consider lower doses in the aging population
 Bolus before you titrate!

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