Pain Scales
This self-report pain scale is validated for children 8 years and older
What is the 0-10 numeric scale?
These patients should be screened for the presence of pain in the ED
Who is EVERY patient?
Morphine is not recommended for patients with failure of this organ
What is renal/kidney failure?
This location is where policy information on pain assessment and practice area specific guidelines can be found
What is PolicyTech?
The ED nurse starts a ketamine drip for a patient with pancreatitis who ends up boarding in the ED until an OR is open. The RN should reassess pain at a frequency of ______ for continuous IV infusions.
What is every 4 hours?
This functional pain scale should be used for all adult patients who can self-report pain
What is the DVPRS?
(Defense and Veterans Pain Rating Scale)
An adult patient's level of alertness and unintended sedation with opioid administration should be measured with this
What is the Richmond Agitation and Sedation Scale (RASS)?
Combination of meds from these two classes increases a patient's risk for respiratory depression
What are benzodiazepines and opioids?
The initial patient pain screening occurs in triage. For all positive screens the RN is responsible to complete this
What is a full pain assessment?
- using the most appropriate tool for patient age and cognitive ability
John received 5 mg PO oxycodone in the ED at 1300, the RN should reassess pain by this time
When is within 60 minutes or by 1400?
CPOT, FLACC, N-PASS, & COMFORT B are examples of this type of assessment scale
What is an observational assessment scale?
*not a self-report or functional assessment
Pain should be reassessed at this interval after admin of a med via IV/IM/SL/SQ or rectal route
When is within 30 min?
The process of multiple PRN medications being ordered for the same indication without clear distinction on when to use each can lead to this if multiple medications are used together
What is therapeutic duplication?
System expectations indicate that functional pain assessments should be completed at this interval
When is,
-“at first positive pain score screening” and then
-“per calendar day at minimum”?
This pain scale would be most appropriate to use for Billy (6y.o. w/cognitive impairment) who can not self-report pain with a 0-10 scale
What is rFLACC pain scale?
*rFLACC – FLACC revised for use with pediatric patients >3 y.o. with a cognitive impairment where a self-report scale is not appropriate.
Validated functional assessment scale for use in pediatrics
What is none?
*Pediatric functional impact of pain is based on observation of ADLs, there is not validated scale.
Severe pain is indicated by these self-reported DVPRS number ranges
What is 7-10 pain?
These medication pharmacokinetic properties influence when pain reassessments should be performed
What is the medication’s onset and peak time?
Per policy, for adult patients a RASS, should be documented at these times (2)
What is at baseline before any sedative medications are administered and with each pain reassessment thereafter?
A 6month infant presents to the ED with occasional facial grimace, is squirming and draws up her legs, and frequently cries out but is reassured by her mother. Using the FLACC scale, pain level is scored ______.
What is 7 (severe pain)?
FLACC scale is used in infants and children up to age 3, which include these 5 components
Face, Legs, Activity, Cry, & Consolability (FLACC)
Pediatric monitoring for analgesia side effects of unintended sedation include these 3 components
What are?:
1. Respiratory Quality
(regular/irregular/labored/snoring/ventilator)
2. Respiratory Depth (normal/shallow/apnea/ventilator)
3. Sedation Level
3 patient risk factors that can contribute to unintended oversedation and respiratory depression with opioids include
What is?:
-Obesity
- Opioid naive
-> 60 y.o.
-Renal or liver insufficiency
-PMH: CHF, COPD, OSA, smoker
-Coadmin w/ benzos or antihistamines
For observation or boarding admitted patients, a pain assessment must be documented at these times (3)
When is?:
-Within 2 hours of admission
-At least once per 8 hours
-With PRN pain medication admin and post-admin reassessments
Gloria (74yF) was ordered an IV med for pain r/t a fractured femur as she was becoming agitated with cares.
1a. Her RASS score prior to administration would be -
30 min after 0.5 mg IV dilaudid, Gloria arouses to voice but is drowsy and does not make eye contact.
1b. Her RASS reassessment score would be -
What is?:
1a- RASS of +2, agitated
1b- RASS of -3, mod sedation