Pain ManagementPain ManagementThe Legal SideThe Legal Side

References:References: Pain: Clinical Manual-M. McCaffery & C. Pasero &Pain: Clinical Manual-M. McCaffery & C. Pasero &

Core Curriculum For Pain Management Nursing-B. St.MarieCore Curriculum For Pain Management Nursing-B. St.MarieANA Pain Management Nursing: Scope and Standards of PracticeANA Pain Management Nursing: Scope and Standards of Practice

NANDA Nursing Diagnosis approved list.NANDA Nursing Diagnosis approved list.

Millions of dollars are awarded every year to Millions of dollars are awarded every year to patients who have suffered and endured pain patients who have suffered and endured pain

needlessly. Nurses, like doctors, have been needlessly. Nurses, like doctors, have been held accountable for failure to adequately treat held accountable for failure to adequately treat

pain and suffering. pain and suffering.

When we as professionals fail to treat pain, we When we as professionals fail to treat pain, we put ourselves at risk for licensure suspension, put ourselves at risk for licensure suspension,

disciplinary action, fines or having our disciplinary action, fines or having our privileges revoked. privileges revoked.

Every state has a nurse practice act and a board of nursing rules and regulations. This act defines the practice of APN, RN, and LPN’s.

The NPA is designed to help protect the public by broadly defining the legal scope of nursing practice.

Every nurse is expected to care for their patients within these defined practice limits.

If a nurse practices outside these limits or fails to provide care within these limits, they become vulnerable to charges of violating the law and losing his/her licensure.

For a copy of your State Nursing Practice For a copy of your State Nursing Practice Act or Board of Nursing rules and Act or Board of Nursing rules and regulations call:regulations call:

(312) 419-2900(312) 419-2900

Know your StandardsKnow your Standards

ANA-Nursing StandardsANA-Nursing Standards APS-American Pain SocietyAPS-American Pain Society ASPMN-American Society of Pain ASPMN-American Society of Pain

Management NursesManagement Nurses AANA-American Association of Nurse AANA-American Association of Nurse

AnesthetistsAnesthetists JCAHO-Joint Commission on Accreditation of JCAHO-Joint Commission on Accreditation of

Healthcare OrganizationsHealthcare Organizations

STANDARDS OF CARESTANDARDS OF CAREStandards of care: include safe Standards of care: include safe

and accepted nursing care and accepted nursing care practices. The standard of practices. The standard of care is assessed by policies care is assessed by policies and guidelines that are and guidelines that are written by nationally written by nationally recognized organizations or recognized organizations or specialty societies. specialty societies.

Standards include formal Standards include formal training, as outlined in training, as outlined in hospital policies or hospital policies or contained in authoritative contained in authoritative textbooks and articles.textbooks and articles.

Standards of Care are written by Standards of Care are written by nationally accredited organizations nationally accredited organizations such as the ANA, ASPAN and such as the ANA, ASPAN and JCAHO. These standards are often JCAHO. These standards are often used as guidelines for best practice used as guidelines for best practice and are evidence based.and are evidence based.

They are referred to and used as They are referred to and used as evidence in malpractice trials. evidence in malpractice trials.

Standards of care are the Standards of care are the goldgold standards used in healthcare. standards used in healthcare.

JCAHOJCAHO

1992-Standards manual now includes 1992-Standards manual now includes effective pain management as one of the rights effective pain management as one of the rights of a dying patient.of a dying patient.

1994-Previous statement was broadened to 1994-Previous statement was broadened to include all patients, not just the dying.include all patients, not just the dying.

1997-JCAHO begins working with institutions 1997-JCAHO begins working with institutions to create standards for pain assessment, to create standards for pain assessment, treatment and national quality improvement treatment and national quality improvement programs.programs.

JCAHO STANDARDS FOR PAIN JCAHO STANDARDS FOR PAIN MANAGEMENT.MANAGEMENT.

Patients are involved in all aspects of their care, Patients are involved in all aspects of their care, including effective pain managementincluding effective pain management

Patients have the right to adequate assessment and Patients have the right to adequate assessment and treatment of pain.treatment of pain.

Pain is assessed in all patientsPain is assessed in all patients Policies and procedures support safe medication Policies and procedures support safe medication

prescription or ordering, including scheduled prescription or ordering, including scheduled prescriptions and patient controlled analgesia. Spinal prescriptions and patient controlled analgesia. Spinal administration of pain management technologies used administration of pain management technologies used in patients with pain.in patients with pain.

JCAHO STANDARDS ( Continued )JCAHO STANDARDS ( Continued )

Their pain is monitored during the post procedure period for Their pain is monitored during the post procedure period for pain intensity, duration, location, character, and response for pain intensity, duration, location, character, and response for treatments, among other items.treatments, among other items.

Standards, intents, and examples for rehabilitative care and Standards, intents, and examples for rehabilitative care and services, includes pain interfering with function and mobility.services, includes pain interfering with function and mobility.

Patients are educated about pain and its management as part of Patients are educated about pain and its management as part of treatment, as appropriate.treatment, as appropriate.

The discharge planning process provides for continuing care The discharge planning process provides for continuing care based on the patient’s assessed needs at the time of discharge, based on the patient’s assessed needs at the time of discharge, including symptom management.including symptom management.

JACHO now closely monitors pain management and JACHO now closely monitors pain management and patient satisfaction related to pain management. patient satisfaction related to pain management.

Patients RightsPatients Rights

Patients have the right to Patients have the right to receive optimal pain relief and receive optimal pain relief and be involved in their pain be involved in their pain management treatments, management treatments, benefits and risks of benefits and risks of procedures, alternative pain procedures, alternative pain management modalities, and management modalities, and expected outcomes. expected outcomes.

PATIENT RIGHTSPATIENT RIGHTSFOR PAIN CONTROLFOR PAIN CONTROL

BILL of RIGHTS for people with painBILL of RIGHTS for people with pain I have the right to have my reports of pain accepted and I have the right to have my reports of pain accepted and

acted on by health care professionals.acted on by health care professionals.

I have the right to have my pain controlled, no matter what I have the right to have my pain controlled, no matter what its cause or how severe it may be.its cause or how severe it may be.

I have the right to be treated with respect at all times. I have the right to be treated with respect at all times. When I need medication for pain, I should not be treated When I need medication for pain, I should not be treated like a drug abuser.like a drug abuser.

……Remember, the single MOST RELIABLE indicator of Remember, the single MOST RELIABLE indicator of pain is the PATIENT’S SELF REPORT!!!pain is the PATIENT’S SELF REPORT!!!

Poor pain management and Poor pain management and substandard documentation can substandard documentation can

trigger:trigger: Survey citations for abuse, violation of patient rights Survey citations for abuse, violation of patient rights

and substandard care.and substandard care.

Litigation against hospitals, outpatient clinics, Litigation against hospitals, outpatient clinics, nursing homes, doctors, nurses, therapist and nursing homes, doctors, nurses, therapist and administrative personnel.administrative personnel.

Legal action against individual professionals who fail Legal action against individual professionals who fail to act in the patients best interest.to act in the patients best interest.

Nurses are held accountable for their individual Nurses are held accountable for their individual actions. Healthcare organizations are likely to hold actions. Healthcare organizations are likely to hold negligent employees accountable for their actions. negligent employees accountable for their actions. If you fail to follow your employer’s policies and If you fail to follow your employer’s policies and

procedures you may stand alone in a legal battle.procedures you may stand alone in a legal battle.

Patients ExpectPatients Expect

Knowledgeable and competent healthcare Knowledgeable and competent healthcare staffstaff

High quality careHigh quality care Safe environmentSafe environment Attentive and compassionate careAttentive and compassionate care Comfort care and management of painComfort care and management of pain Privacy and confidentiality Privacy and confidentiality

Why Suffer?Why Suffer?

Resources and Resources and knowledge exist to knowledge exist to provide satisfactory provide satisfactory and safe pain relief and safe pain relief in 90% of all people in 90% of all people who suffer pain.who suffer pain.

……HoweverHowever

50% of conscious patients who die in the hospital 50% of conscious patients who die in the hospital setting will experience moderate to severe pain.setting will experience moderate to severe pain.

61% of acute pain sufferers reported pain ratings of 61% of acute pain sufferers reported pain ratings of 7-10 on the pain scale.7-10 on the pain scale.

67% of metastatic cancer patients reported pain and 67% of metastatic cancer patients reported pain and 62% of those had pain severe enough to impair their 62% of those had pain severe enough to impair their ability to function. 42% of those patients were not ability to function. 42% of those patients were not prescribed analgesic capable of relieving their pain.prescribed analgesic capable of relieving their pain.

LEGAL IMPLICATIONS AND LEGAL IMPLICATIONS AND JOINT COMMISSION ASIDE…JOINT COMMISSION ASIDE…

we want to provide the we want to provide the best care for THE PATIENTbest care for THE PATIENT!!

There are There are significant harmful significant harmful effects of effects of UNRELIEVED painUNRELIEVED pain

The stress responses activate the The stress responses activate the sympathetic nervous systemsympathetic nervous system and and cause effects involving cause effects involving multiple multiple systems.systems.

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE

ENDOCRINE SystemENDOCRINE System Increased adrenocorticotrophic hormone (ATCH)Increased adrenocorticotrophic hormone (ATCH) Increased cortisol & antidiuretic hormone (ADH)Increased cortisol & antidiuretic hormone (ADH) Increased epinephrine & norepinephrineIncreased epinephrine & norepinephrine Increased growth hormone (GH), catacholamines & reninIncreased growth hormone (GH), catacholamines & renin Increased angiotensin II & aldosteroneIncreased angiotensin II & aldosterone Increased glucagon & interleukin-1Increased glucagon & interleukin-1 Decreased insulinDecreased insulin Decreased testosterone Decreased testosterone

All totaling All totaling The STRESS RESPONSE!The STRESS RESPONSE!

HOLY COW!HOLY COW!

Who would have thought that so many Who would have thought that so many changes could occur in the body with pain? changes could occur in the body with pain?

But, that was just the But, that was just the

ENDOCRINE SYSTEM!ENDOCRINE SYSTEM!

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE

METABOLIC SystemMETABOLIC System Gluconeogenesis – breakdown into glycogen of amino Gluconeogenesis – breakdown into glycogen of amino

acids & fat acids & fat as though the body is in starvationas though the body is in starvation Hepatic glycogenolysis – Conversion of glycogen to Hepatic glycogenolysis – Conversion of glycogen to

glucose in the liverglucose in the liver HyperglycemiaHyperglycemia Glucose intolerance – poor use of available glucoseGlucose intolerance – poor use of available glucose Insulin resistanceInsulin resistance Muscle protein catabolism (destruction) as well as Muscle protein catabolism (destruction) as well as

destruction of carbohydrates and fatdestruction of carbohydrates and fat Increased lipolysis – destruction of fat cellsIncreased lipolysis – destruction of fat cells

……Imagine the implicationsImagine the implications for the diabetic or if the patient for the diabetic or if the patient is on steroids!is on steroids!

IMPLICATIONS FOR THEIMPLICATIONS FOR THE ENDOCRINE & METABOLIC ENDOCRINE & METABOLIC

SYSTEMSSYSTEMS

Overall, the endocrine & nervous systems, regulate the Overall, the endocrine & nervous systems, regulate the metabolic system to maintain normal body growth and metabolic system to maintain normal body growth and function. Multiple cascading events occur when pain is function. Multiple cascading events occur when pain is not controlled:not controlled: Protein, fat & CHO catabolism/destructionProtein, fat & CHO catabolism/destruction Poor glucose conversion and use of available glucosePoor glucose conversion and use of available glucose INFLAMMATION + ENDOCRINE/METABOLIC changes INFLAMMATION + ENDOCRINE/METABOLIC changes

= weight loss, tachycardia, increased respiratory rate, fever, = weight loss, tachycardia, increased respiratory rate, fever, shock and eventually deathshock and eventually death

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE CARDIOVASCULAR SystemCARDIOVASCULAR System

Increased heart rateIncreased heart rate Increased cardiac outputIncreased cardiac output Increased Peripheral vascular resistanceIncreased Peripheral vascular resistance Increased Systemic vascular resistanceIncreased Systemic vascular resistance HYPERTENSIONHYPERTENSION Increased coronary vascular resistanceIncreased coronary vascular resistance Increased myocardial oxygen consumptionIncreased myocardial oxygen consumption HypercoagulationHypercoagulation Deep vein thrombosisDeep vein thrombosis

ULTIMATELY…PAINULTIMATELY…PAIN actually actually CONTRIBUTESCONTRIBUTES TO TO Heart Attacks, Strokes and DVTs!Heart Attacks, Strokes and DVTs!

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE RESPIRATORY SystemRESPIRATORY System Decreased flows and volumesDecreased flows and volumes AtelectasisAtelectasis ShuntingShunting HypoxemiaHypoxemia Decreased coughDecreased cough Sputum retentionSputum retention InfectionInfection

CAUSING…CAUSING… Decreased oxygen carrying capacityDecreased oxygen carrying capacity……and even and even PneumoniaPneumonia

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE GU SystemGU System

Decreased urinary outputDecreased urinary output Urinary retentionUrinary retention Fluid overloadFluid overload HypokalemiaHypokalemia ……Causing increased cardiac workload & HTN, Causing increased cardiac workload & HTN,

dysrhythmias…dysrhythmias…

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE GI SystemGI System

- Decreased gastric & bowel motilityDecreased gastric & bowel motility- … … Potential constipation & ileus (GI paralysis)Potential constipation & ileus (GI paralysis)

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE MUSCULOSKELETAL SystemMUSCULOSKELETAL System

Muscle spasmMuscle spasm Impaired muscle functionImpaired muscle function FatigueFatigue ImmobilityImmobility ……More risk for DVT, pneumonia, increased staysMore risk for DVT, pneumonia, increased stays

-- Reduction in cognitive functioning-- Reduction in cognitive functioning-- Mental confusion-- Mental confusion

UNRELIEVED PAIN AND UNRELIEVED PAIN AND

COGNITIVE FUNCTIONCOGNITIVE FUNCTION

UNRELIEVED PAIN ANDUNRELIEVED PAIN AND

DEVELOPMENTAL IssuesDEVELOPMENTAL Issues Increased behavioral and physiologic responses to painIncreased behavioral and physiologic responses to pain Altered temperamentsAltered temperaments Higher somatization – Higher somatization – to convert anxiety into physical symptomsto convert anxiety into physical symptoms Infant distress behaviorInfant distress behavior Possible altered development of the pain systemPossible altered development of the pain system Increased vulnerability to stress disordersIncreased vulnerability to stress disorders Addictive behaviorAddictive behavior Anxiety statesAnxiety states

UNRELIEVED PAIN AND THEUNRELIEVED PAIN AND THE IMMUNE SYSTEMIMMUNE SYSTEM

-- Depression of the immune system-- Depression of the immune system

UNRELIEVED PAIN AND RELATIONSHIP TO UNRELIEVED PAIN AND RELATIONSHIP TO FUTURE PAINFUTURE PAIN

Predisposed to debilitating chronic pain syndromesPredisposed to debilitating chronic pain syndromes Postmastectomy pain increased Postmastectomy pain increased Postthoracotomy pain increasedPostthoracotomy pain increased Increased episodes of Phantom pain if pain not controlled Increased episodes of Phantom pain if pain not controlled

adequately pre-operativelyadequately pre-operatively Posttherpetic neuralgia – pain following an attack of Posttherpetic neuralgia – pain following an attack of

herpes zoster/shingles herpes zoster/shingles

……Yes, Yes, pain your patients have todaypain your patients have today will affect will affect their pain thresholds and their ability to cope their pain thresholds and their ability to cope with pain later in life!with pain later in life!

UNRELIEVED PAIN ANDUNRELIEVED PAIN AND QUALITY OF LIFE (QOL) QUALITY OF LIFE (QOL)

ISSUESISSUES

Increased sleeplessnessIncreased sleeplessness Problems with anxiety & fearsProblems with anxiety & fears Hopelessness, depression and thoughts of suicideHopelessness, depression and thoughts of suicide

-- certainly not to be seen as “benign,” but on the contrary, -- certainly not to be seen as “benign,” but on the contrary, can be life threateningcan be life threatening

Increased stress within familiesIncreased stress within families

MISCONCEPTIONMISCONCEPTION““PAIN NEVER KILLED ANYONE”PAIN NEVER KILLED ANYONE” Unrelieved pain may be dangerous and is, therefore, Unrelieved pain may be dangerous and is, therefore,

unacceptable. Research now shows that past attitudes unacceptable. Research now shows that past attitudes of expecting surgery to hurt and believing that “pain of expecting surgery to hurt and believing that “pain never killed anyone” are no longer justified. never killed anyone” are no longer justified.

Post-op pain Post-op pain can killcan kill by delaying healing and by delaying healing and contributing to complications that are life-threatening.contributing to complications that are life-threatening.

Unrelieved post-op pain must now be viewed and Unrelieved post-op pain must now be viewed and treated as a complication or risk, not as an acceptable treated as a complication or risk, not as an acceptable consequence of surgery.consequence of surgery.

Chronic pain also has many serious adverse effects Chronic pain also has many serious adverse effects such as suppressing immune function.such as suppressing immune function.

-OVERALL – OVERALL – Poor pain management Poor pain management

Increases patient lengths Increases patient lengths of stayof stay

Causes unnecessary Causes unnecessary stress on the heart & stress on the heart & HTNHTN

Causes DVT, Causes DVT, pneumonia or other pneumonia or other serious complicationsserious complications

Decreases the ability to Decreases the ability to heal efficientlyheal efficiently

Increases relationship Increases relationship stresses between the stresses between the patient, family & staffpatient, family & staff

Can seriously affect the Can seriously affect the patient’s long-term patient’s long-term health and welfarehealth and welfare

Increases the risk of Increases the risk of liability for the hospital liability for the hospital AND the individual AND the individual staff member – YOU!staff member – YOU!

PAIN IS THE #1 REASONPAIN IS THE #1 REASONpatients seek medical carepatients seek medical care

Document as though a Document as though a jury/attorney will be jury/attorney will be reviewing it – they may!reviewing it – they may!

Know the Know the organizational policies organizational policies and procedures for pain and procedures for pain management and management and documentationdocumentation

Follow those guidelinesFollow those guidelines Question if the policies Question if the policies

need updating or need updating or improvementsimprovements

Pain management Pain management should always be a should always be a priority in your priority in your continuing educationcontinuing education

Always provide care Always provide care which is conscientious which is conscientious and compassionate, and and compassionate, and document accordinglydocument accordingly

Your patients depend on Your patients depend on YOU to be an advocate YOU to be an advocate for them in their time of for them in their time of need need

Thorough Assessment tools are more Thorough Assessment tools are more than just a convenience…than just a convenience…

……Pain assessment should be Pain assessment should be at least at least as often as vital signs:as often as vital signs:

PAIN IS THE 5PAIN IS THE 5THTH VITAL SIGN VITAL SIGN Pain assessment is required to be completed on Pain assessment is required to be completed on

ALL patients a MINIMUM of every shift ALL patients a MINIMUM of every shift Even if the patient appears asleep, the FLACC Even if the patient appears asleep, the FLACC

scale can and should be used scale can and should be used Remember, sleep does not guarantee that the patient is pain-free – Remember, sleep does not guarantee that the patient is pain-free –

Sleep can be a coping mechanismSleep can be a coping mechanism Always reassess pain level when the patient wakes up!Always reassess pain level when the patient wakes up!

Tolerable levels of pain should be assessed & Tolerable levels of pain should be assessed & documented regularly, as this is the objective/ documented regularly, as this is the objective/ goal to be achievedgoal to be achieved

As a patient advocateAs a patient advocateYOUR care determines outcomesYOUR care determines outcomes

If the pain goal is not achievable with the If the pain goal is not achievable with the current medications/interventionscurrent medications/interventions Call the physician for additional ordersCall the physician for additional orders Seek a referral for further pain treatmentSeek a referral for further pain treatment Ask for order allowing alternative therapiesAsk for order allowing alternative therapies

If pain control is still inadequate, continue up If pain control is still inadequate, continue up the chain of command until adequate the chain of command until adequate management is achieved…remember, this is a management is achieved…remember, this is a VITAL SIGN and essential for basic careVITAL SIGN and essential for basic care

NANDA - Nursing Diagnoses & PainNANDA - Nursing Diagnoses & Pain

The most OBVIOUS Nursing Diagnosis is “Pain related The most OBVIOUS Nursing Diagnosis is “Pain related to…” (chronic vs. acute) …and then the apparent to…” (chronic vs. acute) …and then the apparent cause.cause.

But, there are MANY different possible But, there are MANY different possible affectsaffects of of uncontrolled pain, we must consider the possibilities uncontrolled pain, we must consider the possibilities of other issues CAUSED BY PAINof other issues CAUSED BY PAIN

Consider… “Activity intolerance R/T (acute or Consider… “Activity intolerance R/T (acute or chronic) pain”chronic) pain”

Which of the following Nursing Diagnoses could you Which of the following Nursing Diagnoses could you have found useful for some of your patients?... have found useful for some of your patients?...

NANDA - Nursing Diagnoses & PainNANDA - Nursing Diagnoses & Pain- Other Possible Diagnoses -- Other Possible Diagnoses -

Activity IntoleranceActivity Intolerance R/T pain R/T pain Sleep pattern disturbanceSleep pattern disturbance R/T R/T

painpain Ineffective individual copingIneffective individual coping

R/T painR/T pain ConstipationConstipation R/T pain R/T pain Urinary retentionUrinary retention R/T pain R/T pain Hopelessness Hopelessness R/T painR/T pain PowerlessnessPowerlessness R/T pain R/T pain Spiritual distressSpiritual distress R/T pain R/T pain Acute confusionAcute confusion R/T pain R/T pain Altered thought processesAltered thought processes R/T R/T

painpain Ineffective family copingIneffective family coping R/T R/T

painpain NoncomplianceNoncompliance R/T pain R/T pain

Impaired home maintenanceImpaired home maintenance managementmanagement R/T pain R/T pain

Violence, actual/risk for: Violence, actual/risk for: directed at self/othersdirected at self/others R/T pain R/T pain

Altered family processesAltered family processes R/T R/T painpain

Impaired Social InteractionImpaired Social Interaction R/T R/T painpain

Altered growth and Altered growth and development (behavioral)development (behavioral) R/T R/T painpain

Knowledge deficitKnowledge deficit (specify: pain (specify: pain management, coping skills, meds, management, coping skills, meds, education for other pain related education for other pain related diagnoses…) R/T paindiagnoses…) R/T pain

……Others, actually numerous, can be Others, actually numerous, can be affected by different levels of affected by different levels of painpain

……A final note about A final note about

CHRONIC PAINCHRONIC PAIN Decreased Quality of Life (QOL) in patients Decreased Quality of Life (QOL) in patients

with chronic pain represents the greatest harm with chronic pain represents the greatest harm of all…it is the most unforgivable.of all…it is the most unforgivable.

Chronic pain is so easily treated, but if not Chronic pain is so easily treated, but if not treated, is completely dehumanizing to the treated, is completely dehumanizing to the patient and the family.patient and the family.

KNOWLEDGE is POWERKNOWLEDGE is POWER Patients and Staff are empowered to determine Patients and Staff are empowered to determine

outcomes with effective careoutcomes with effective care

We are coming out of the dark ages with pain We are coming out of the dark ages with pain management and moving forward with truly effective management and moving forward with truly effective assessment & treatments for pain: the reason patients assessment & treatments for pain: the reason patients came here in the first placecame here in the first place

GRASP ONTO GRASP ONTO THE KNOWLEDGE!THE KNOWLEDGE!