2015: Pain Assessment, the Key to Treating Pain in the Inpatient Setting-Yi
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
Considerations in The Aging And Palliative Populations
Apply the Pain Assessment Hierarchy to pain
assessment and reassessment in all patient
Review importance of sedation assessment
Make the connection between good assessment and
Hierarchy Of Pain Assessment
Assume or Anticipate
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
Some elderly patients may prefer to describe their pain as
mild, moderate, or severe
A Reminder About the FACES Tool:
DO NOT choose a face for the patient based on how
Behavioral Score Does Not Equal Intensity!!!!
Example= Two people may have the same cut on
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.
Pain and the Dying patient
Pain is not automatic!
Pain must be assessed, just like with any other
• Don’t misinterpret other signs/symptoms of dying
• 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
Respiratory Variations in the Dying patient- NOT
indicator of pain
Diminishing tidal volume
Distressing to family, not to
Oxygen variably effective
Palliative Patients are at Increased Risk of Pain
Immobility (who’s driving this??)
Skin break down
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
PO / PR/ IM
A little longer than IV
30 min 60 min
Why is the Sedation Assessment
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
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!
The pain medication you gave made your patient sedate. If the
respiratory assessment is abnormal, wake the patient up! Further
evaluation is required.
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?
Do our Current Assessment Tools
Self-report= gold standard
Problem with self-report using a uni-dimensional
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
Good Assessment is what Makes Good
PO / PR/ IM
A little longer than IV
30 min 60 min
Peak effect: 20 minutes
Half-life: 2-4 hours
Continuous morphine infusion :
Time to steady state: 10-20
Time to Drip Steady State
164 8 12
Time ( hours )
Pain Management with Geriatric Patients
Analgesic therapy issues
Recommend reducing initial opioid dosing
by 25-50% in elderly patient
• Retrospective study at UC San Diego
• Patients who died while receiving Continuous
Morphine Infusion (CMI) from 2012-2013
• 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
• 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
What is the Goal?
Continuous Infusion Bolus
• Achieve continuous pain/agitation
control by administering a
continuous infusion (at the lowest
possible dose to minimize
• Assess the effect of the continuous
drip rate when steady state is
(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
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
Continuous Infusions- Back to Basics! Bolus 1st!
Still have pain? Re-
No more pain? If
painful stimuli is
constant, titrate up!
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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