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Pain
Management
Ahmad Thanin
DIFFENETION
An unpleasant sensory and emotional experience associated with
actual or potential tissue damage.
Most common reason for seeking health care.
Pain is considered the 5th vital sign.
Pain Management – is a process of assessing, treating and re-assessing
pain utilizing non-pharmacologic and pharmacological method.
Common Misconceptions among Elderly and
Nurses
Pain is unavoidable. Pain is a punishment.
Asking for pain
medication is too
demanding and means
I’m not a good patient.
Pain medication are
addictive.
Taking pain
medications means I’ll
lose my independence
and mental clarity.
Pain is not harmful.
Nurses don’t have the
time to give extra
medication.
Elderly patients have
decreased sensations
of pain.
Elderly patients who
are cognitively
impaired don’t feel
pain.
A sleeping patient is
not in pain.
Elderly patients
complain more about
pain as they age.
Narcotics will hasten
death.
Potent analgesics are
addictive.
Potent pain meds will
cause respiratory
depression.
Descriptions of pain:
Descriptions of
pain:
Duration
How long has
been going on?
Location
Where does it
hurt?
Etiology
What is causing
the pain?
Intensity
Mild, moderate, or
severe. Usually
scaled 1-10.
Quality
aching, annoying,
burning, gnawing,
heavy, crushing,
sharp, etc.
Temporal pattern
acute, chronic,
constant,
intermittent,
spasmodic, etc
Associated
characteristics
fear, muscle
spasms, nausea,
visual
disturbances, etc.
Pain assessment:
• Should be as automatic as taking pulse and BP.
• Pain is the 5th vital sign
• amount of pain
stimulation a
person requires
before feeling pain.
Pain
threshold:
• the highest
intensity of pain
that the person is
willing to tolerate.
Pain
tolerance:
The categories of pain:
•recent onset and commonly associated with a specific injury. Generally, lasts from seconds to 6
Acute
•constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a
specific cause or injury. May have poorly defined onset and is often difficult to treat because the cause or origin may
be unclear. Defined as pain that lasts for longer than 6 months
Chronic
•Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that after fear of
dying, it is the second most common fear of newly diagnosed cancer patients
Cancer – Related Pain
•transitory exacerbations of severe pain over a baseline of moderate pain. Can be incident pain or pain that is
precipitated by a voluntary act such as movement or coughing
Breakthrough Pain
Effects of acute pain:
• Widespread endocrine, immunologic and inflammatory changes occur with stress and can
have significant negative effects.
Neuroendocrine response to stress:
• Increased metabolic rate and cardiac output
• Impaired insulin response
• Increased production of cortisol
• Increased retention of fluids
• Increased risk for physiologic disorders (e.g. MI, pulmonary infection, thromboembolism, and
paralytic ileus)
• Decreased deep breathing and immobility—may lead to pneumonia or decubitis.
Stress response consists of the following:
Effects Chronic Pain:
Suppressed immune function
Resultant increased tumour growth
Depression and lack of motivation
Anger
Fatigue
What alternative therapies can close the gate?
Focused relaxation and breathing can help decrease pain by easing muscle tension.
Progressive muscle relaxation enables patients to feel more in control and experience less pain.
Art therapy: contributes to client sense of well-being.
Music therapy works best when guided by an individual trained in using it. Can be effective while playing
music, song writing, or listening to it.
•Gate control theory of pain proposes that the stimulation of fibers that transmit non-painful sensations can block or decrease the
transmission of pain impulses .
•Massage has an impact through the descending control system, and also promotes comfort through muscle relaxation.
Cutaneous stimulation and massage:
•ice on acute injury immediately after, and only 20 minutes at a time. Heat increases blood flow to an area and contributes to pain reduction
by speeding healing .
Ice and heat:
• uses a batter unity with electrodes applied to the skin to produce a tingling, vibrating, or bussing sensation in the area of pain.
• Used in acute and chronic pain relief and thought to decrease pain by stimulating non-pain receptors in the same areas as fibers that transmit the
pain.
• A placebo effect has also been documented in the research .
TENS:
• helps relieve both acute and chronic pain (Johnson & Petrie, 1997).
• Works by stimulating the descending control system resulting in fewer painful stimuli being transmitted to the brain .
Distraction:
• Skeletal muscle relaxation is believed to reduce pain by relaxing tense muscles that contribute to pain.
• Few studies support relaxation as reducing post-operative pain.
• This may be due to the relatively small role skeletal muscles play in post-operative pain or need for client to practice relaxation .
• One technique is abdominal breathing at a slow rate, focusing on slow rate.
• Focusing on breathing is a distraction.
Relaxation techniques:
• using one’s imagination in a special way to achieve a specific positive effect .
• Close eyes and imagine muscle tension being breathed out, carrying pain away from the body.
• Imagine healing energy flowing to the area of discomfort. Client must usually practice 5 minutes, 3x/day to master this technique.
Guided Imagery:
• effective in reducing amount of analgesic agents required. Effectiveness depends on hypnotic susceptibility of the client. Sometimes clients can
learn to perform self-hypnosis, but it is not a first-line defence against pain.
Hypnosis:
Let’s try an experiment….
• Have each attendant take pen and place
over nail bed and push. Describe sensation
to neighbor. All the same?
• Now try counting backwards from 10 while
holding pressure on nail bed. Is the pain as
bad?
Translation of the experiment
Mechanical, chemical, or thermal events that injure tissue usually stimulate nociceptors.
Injured cells and tissue-repair mechanisms release one or more chemical substances
that bind to peripheral nociceptors and activate the nerve fiber, whereas others
sensitize the nerve for activation with a smaller stimulus than usually required.
These chemicals cause A-delta and C-fibers to become excited and transmit an action
potential toward the spinal cord.
Presence of these chemicals increases the amount of pain a person perceives.
Blocking release or production of these chemicals is one peripheral mechanism to
inhibit pain perception.
Pharmacological management:
Selection of appropriate drug, dose, route and interval
Aggressive titration of drug dose
Prevention of pain and relief of breakthrough pain
Use of coanalgesic medications
Prevention and management of side effects
Analgesic Ladder
The World Health Organization
(WHO) has produced an
analgesic ladder to be used as
a guide for prescribing
analgesics.
If a patient does not
experience pain relief
on one step of the
analgesic ladder, they
should progress to the
next step.
Oral analgesic drugs are
usually the first line treatment
for treating pain. The choice of
analgesic should be based on
the severity of the pain rather
than the stage of the patient's
disease.
Analgesics should be
taken regularly and the
dose gradually
increased, as necessary.
•Step One
•The first step of the analgesic ladder is to use a non-opioid analgesic (these have ceiling effect which is dose beyond
which no further analgesic effect) for example paracetamol.
•Adjuvant drugs to enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and provide
independent analgesic activity for specific types of pain may be used at any step (eg NSAIDS).
Step One
•Step Two
•If the pain is persisting or worsening despite step one then a mild opioid such as codeine should be added (not
substituted).
•Examples are combination preparations including co-proxamol and co-codamol. Tylenol #3, Percocet, Vicodin, Lorcet,
Hydrocodone.
Step Two
•Step Three
•When higher doses of opioid are necessary, the third step is used.
•At this step an opioid (no ceiling effect) for moderate to severe pain is used, eg morphine.
•The dose of the stronger opioid can then be titrated upwards, according to the patient's pain as there is no ceiling
dose for morphine.
•Medications for persistent pain should be prescribed on a regular basis and patient should always have extra
medication available to take in between doses if they experience break-through pain.
•Morphine, oxycodone, dilaudid, methadone, fentanyl
Step Three
Breakthrough Pain
Use extra (rescue) doses of opioids.
Use the immediate-release form of same opioid they are on.
Rescue dose 5-15% of the 24-hour dose.
If 3 or more rescue doses needed/24 hrs—need to titrate routine drug to effect
(25-100% current dose).
Pain Management through Medication and/or
Neurosurgery
•clients are usually started on oral analgesia before the PCA is discontinued, and they must request from the nurse.
•Analgesics such as Morphine elixirs, Tramadol, NSAIDS, and Paracetamol either combined with codeine or on its own are all
useful in pain reduction.
•It is essential to teach clients side-effects of pain medications, so complications don’t develop (e.g., constipation, drowsiness,
decreased ability to perform fine motor skills, etc.).
Oral Analgesia
•standard for acute post-operative pain management at present.
•Affords client greater control and optimizes their pain relief.
•Can be administered IV, subcutaneous, or epidural routes.
PCA (Patient-controlled analgesia)
•division of certain tracts of the cord.
•Performed cutaneously to interrupt the transmission of pain.
•Care must be taken to destroy only sensory tracts of pain, leaving motor function intact
Cordotomy:
•A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input.
•sensory nerve roots are destroyed where they enter the spinal cord
Rhizotomy:
Universal Side
Effect
Constipation.
Nausea and Vomiting.
Itching.
Respiratory Depression.
Narcotic agents may be classified
into four categories:
Morphine and codeine - natural alkaloids of opium.
Synthetic derivatives of morphine such as heroin.
Synthetic agents which resemble the morphine
structure.
Narcotic antagonists which are used as antidotes for
overdoses of narcotic analgesics.
OVERVIEW
The main pharmacological action of analgesics is on the
cerebrum and medulla of the central nervous system.
• Another effect is on the smooth muscle and glandular secretions of the
respiratory and gastro-intestinal tract.
• The precise mechanism of action is unknown although the narcotics
appear to interact with specific receptor sites to interfere with pain
impulses.
Analgesics may relieve pain by preventing the release of
acetylcholine.
• Enkephalin molecules are released from a nerve cell and bind to analgesic
receptor sites on the nerve cell sending the impulse.
• The binding of enkephalin or morphine-like drugs changes the shape of
the nerve sending the impulse in such a fashion as to prevent the cell from
releasing acetylcholine.
• As a result, the pain impulse cannot be transmitted, and the brain does
not perceive pain.
Examples of
Narcotic
Analgesics
• Morphine
• Pethidine
Narcotic analgesics
• Tramal
Controlled Analgesic drugs
Placebo
• Placebo (e.g. normal saline)
should not be given to treat
pain even with written
medical order.
• Using placebo to diagnose or
treat pain is considered
unethical and violating
patient right to have optimal
pain relief
Pain Assessment tools
Numeric Pain
Rating Scale.
Wong-Baker Face
Pain Rating Scale.
FLACC Scale. NIPS Pain Scale.
CRIES Pain Scale.
Critical Care Pain
Observation Tool
or CPOT.
Comfort Pain
Scale
Why have a
pain scale?
Sometimes hard to put words to pain
Pain is multi-faceted (How long? Where?
How intense? What kind feeling?
Visual scales help us understand where pain
located.
Faces help us understand how pain makes
patient feel.
Numeric scales help quantify pain using
numbers.
• Visual scales have pictures of human anatomy to help you explain where your pain is located.
• A popular visual scale — the Wong-Baker Faces Pain Rating Scale — features facial
expressions to help you show your doctor how the pain makes you feel. This scale is
particularly useful for children, who sometimes don't have the vocabulary to explain how
they feel.
Visual.
• Verbal scales contain commonly used words such as "low," "mild" or "excruciating" to help
you describe the intensity or severity of your discomfort.
• Verbal scales are useful because the terminology is relative, and you must focus on the most
characteristic quality of your pain.
Verbal.
• Numerical scales help you to quantify your pain using numbers, sometimes in combination
with words.
• To be most accurate, pain scales are best used as the pain is occurring.
• Over time, with treatment, your doctor can use pain scales to record how your pain is
changing and to see if treatment is having the intended effect.
Numerical.
Wong-Baker Faces Pain Rating Scale
•Explain to the patient that each face is for a person who feels happy because he has no pain (hurt or, whatever
word the patient uses) or feels sad because he has some or a lot of pain.
•Ask the patient to point to each face using the words to describe the pain intensity.
•Face 0 doesn’t hurt at all.
•Face 2 hurts just a little bit.
•Face 4 hurts a little more.
•Face 6 hurts even more.
•Face 8 hurts a whole lot.
•Face 10 hurts as much as you can imagine.
•The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate
interventions in response to Faces Pain Ratings
Instructions:
•Adult and child (> 3 years old) in all patient care settings
Indications
Numeric Pain Rating Scale
Instructions:
•The patient is asked: What number on a 0 to 10 scale, where 0 means no pain and 10 as worst pain, would you give your current
pain intensity?
•When the question above is not understood by the patient, it is sometimes helpful to further explain or conceptualize the
Numeric Rating Scale in the following manner:
•0 = No Pain
•1-3 = Mild Pain (nagging, annoying, interfering little with ADLs)
•4–6 = Moderate Pain (interferes significantly with ADLs)
•7-10 = Severe Pain (disabling; unable to perform ADLs)
•The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in
response to Numeric Pain Ratings
Indication
•Adults and children (< 9years old) in all patient care settings who are able to use numbers to rate the intensity of their pain
Pain Management
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Pain Management

  • 2. DIFFENETION An unpleasant sensory and emotional experience associated with actual or potential tissue damage. Most common reason for seeking health care. Pain is considered the 5th vital sign. Pain Management – is a process of assessing, treating and re-assessing pain utilizing non-pharmacologic and pharmacological method.
  • 3. Common Misconceptions among Elderly and Nurses Pain is unavoidable. Pain is a punishment. Asking for pain medication is too demanding and means I’m not a good patient. Pain medication are addictive. Taking pain medications means I’ll lose my independence and mental clarity. Pain is not harmful. Nurses don’t have the time to give extra medication. Elderly patients have decreased sensations of pain. Elderly patients who are cognitively impaired don’t feel pain. A sleeping patient is not in pain. Elderly patients complain more about pain as they age. Narcotics will hasten death. Potent analgesics are addictive. Potent pain meds will cause respiratory depression.
  • 4.
  • 5. Descriptions of pain: Descriptions of pain: Duration How long has been going on? Location Where does it hurt? Etiology What is causing the pain? Intensity Mild, moderate, or severe. Usually scaled 1-10. Quality aching, annoying, burning, gnawing, heavy, crushing, sharp, etc. Temporal pattern acute, chronic, constant, intermittent, spasmodic, etc Associated characteristics fear, muscle spasms, nausea, visual disturbances, etc.
  • 6. Pain assessment: • Should be as automatic as taking pulse and BP. • Pain is the 5th vital sign
  • 7.
  • 8.
  • 9. • amount of pain stimulation a person requires before feeling pain. Pain threshold: • the highest intensity of pain that the person is willing to tolerate. Pain tolerance:
  • 10. The categories of pain: •recent onset and commonly associated with a specific injury. Generally, lasts from seconds to 6 Acute •constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. May have poorly defined onset and is often difficult to treat because the cause or origin may be unclear. Defined as pain that lasts for longer than 6 months Chronic •Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that after fear of dying, it is the second most common fear of newly diagnosed cancer patients Cancer – Related Pain •transitory exacerbations of severe pain over a baseline of moderate pain. Can be incident pain or pain that is precipitated by a voluntary act such as movement or coughing Breakthrough Pain
  • 11. Effects of acute pain: • Widespread endocrine, immunologic and inflammatory changes occur with stress and can have significant negative effects. Neuroendocrine response to stress: • Increased metabolic rate and cardiac output • Impaired insulin response • Increased production of cortisol • Increased retention of fluids • Increased risk for physiologic disorders (e.g. MI, pulmonary infection, thromboembolism, and paralytic ileus) • Decreased deep breathing and immobility—may lead to pneumonia or decubitis. Stress response consists of the following:
  • 12. Effects Chronic Pain: Suppressed immune function Resultant increased tumour growth Depression and lack of motivation Anger Fatigue
  • 13. What alternative therapies can close the gate? Focused relaxation and breathing can help decrease pain by easing muscle tension. Progressive muscle relaxation enables patients to feel more in control and experience less pain. Art therapy: contributes to client sense of well-being. Music therapy works best when guided by an individual trained in using it. Can be effective while playing music, song writing, or listening to it. •Gate control theory of pain proposes that the stimulation of fibers that transmit non-painful sensations can block or decrease the transmission of pain impulses . •Massage has an impact through the descending control system, and also promotes comfort through muscle relaxation. Cutaneous stimulation and massage: •ice on acute injury immediately after, and only 20 minutes at a time. Heat increases blood flow to an area and contributes to pain reduction by speeding healing . Ice and heat:
  • 14. • uses a batter unity with electrodes applied to the skin to produce a tingling, vibrating, or bussing sensation in the area of pain. • Used in acute and chronic pain relief and thought to decrease pain by stimulating non-pain receptors in the same areas as fibers that transmit the pain. • A placebo effect has also been documented in the research . TENS: • helps relieve both acute and chronic pain (Johnson & Petrie, 1997). • Works by stimulating the descending control system resulting in fewer painful stimuli being transmitted to the brain . Distraction: • Skeletal muscle relaxation is believed to reduce pain by relaxing tense muscles that contribute to pain. • Few studies support relaxation as reducing post-operative pain. • This may be due to the relatively small role skeletal muscles play in post-operative pain or need for client to practice relaxation . • One technique is abdominal breathing at a slow rate, focusing on slow rate. • Focusing on breathing is a distraction. Relaxation techniques: • using one’s imagination in a special way to achieve a specific positive effect . • Close eyes and imagine muscle tension being breathed out, carrying pain away from the body. • Imagine healing energy flowing to the area of discomfort. Client must usually practice 5 minutes, 3x/day to master this technique. Guided Imagery: • effective in reducing amount of analgesic agents required. Effectiveness depends on hypnotic susceptibility of the client. Sometimes clients can learn to perform self-hypnosis, but it is not a first-line defence against pain. Hypnosis:
  • 15. Let’s try an experiment…. • Have each attendant take pen and place over nail bed and push. Describe sensation to neighbor. All the same? • Now try counting backwards from 10 while holding pressure on nail bed. Is the pain as bad?
  • 16. Translation of the experiment Mechanical, chemical, or thermal events that injure tissue usually stimulate nociceptors. Injured cells and tissue-repair mechanisms release one or more chemical substances that bind to peripheral nociceptors and activate the nerve fiber, whereas others sensitize the nerve for activation with a smaller stimulus than usually required. These chemicals cause A-delta and C-fibers to become excited and transmit an action potential toward the spinal cord. Presence of these chemicals increases the amount of pain a person perceives. Blocking release or production of these chemicals is one peripheral mechanism to inhibit pain perception.
  • 17. Pharmacological management: Selection of appropriate drug, dose, route and interval Aggressive titration of drug dose Prevention of pain and relief of breakthrough pain Use of coanalgesic medications Prevention and management of side effects
  • 18. Analgesic Ladder The World Health Organization (WHO) has produced an analgesic ladder to be used as a guide for prescribing analgesics. If a patient does not experience pain relief on one step of the analgesic ladder, they should progress to the next step. Oral analgesic drugs are usually the first line treatment for treating pain. The choice of analgesic should be based on the severity of the pain rather than the stage of the patient's disease. Analgesics should be taken regularly and the dose gradually increased, as necessary.
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  • 21. •Step One •The first step of the analgesic ladder is to use a non-opioid analgesic (these have ceiling effect which is dose beyond which no further analgesic effect) for example paracetamol. •Adjuvant drugs to enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and provide independent analgesic activity for specific types of pain may be used at any step (eg NSAIDS). Step One •Step Two •If the pain is persisting or worsening despite step one then a mild opioid such as codeine should be added (not substituted). •Examples are combination preparations including co-proxamol and co-codamol. Tylenol #3, Percocet, Vicodin, Lorcet, Hydrocodone. Step Two •Step Three •When higher doses of opioid are necessary, the third step is used. •At this step an opioid (no ceiling effect) for moderate to severe pain is used, eg morphine. •The dose of the stronger opioid can then be titrated upwards, according to the patient's pain as there is no ceiling dose for morphine. •Medications for persistent pain should be prescribed on a regular basis and patient should always have extra medication available to take in between doses if they experience break-through pain. •Morphine, oxycodone, dilaudid, methadone, fentanyl Step Three
  • 22. Breakthrough Pain Use extra (rescue) doses of opioids. Use the immediate-release form of same opioid they are on. Rescue dose 5-15% of the 24-hour dose. If 3 or more rescue doses needed/24 hrs—need to titrate routine drug to effect (25-100% current dose).
  • 23. Pain Management through Medication and/or Neurosurgery •clients are usually started on oral analgesia before the PCA is discontinued, and they must request from the nurse. •Analgesics such as Morphine elixirs, Tramadol, NSAIDS, and Paracetamol either combined with codeine or on its own are all useful in pain reduction. •It is essential to teach clients side-effects of pain medications, so complications don’t develop (e.g., constipation, drowsiness, decreased ability to perform fine motor skills, etc.). Oral Analgesia •standard for acute post-operative pain management at present. •Affords client greater control and optimizes their pain relief. •Can be administered IV, subcutaneous, or epidural routes. PCA (Patient-controlled analgesia) •division of certain tracts of the cord. •Performed cutaneously to interrupt the transmission of pain. •Care must be taken to destroy only sensory tracts of pain, leaving motor function intact Cordotomy: •A lesion is made in the dorsal root to destroy neuronal dysfunction and reduce nociceptive input. •sensory nerve roots are destroyed where they enter the spinal cord Rhizotomy:
  • 24. Universal Side Effect Constipation. Nausea and Vomiting. Itching. Respiratory Depression.
  • 25. Narcotic agents may be classified into four categories: Morphine and codeine - natural alkaloids of opium. Synthetic derivatives of morphine such as heroin. Synthetic agents which resemble the morphine structure. Narcotic antagonists which are used as antidotes for overdoses of narcotic analgesics.
  • 26. OVERVIEW The main pharmacological action of analgesics is on the cerebrum and medulla of the central nervous system. • Another effect is on the smooth muscle and glandular secretions of the respiratory and gastro-intestinal tract. • The precise mechanism of action is unknown although the narcotics appear to interact with specific receptor sites to interfere with pain impulses. Analgesics may relieve pain by preventing the release of acetylcholine. • Enkephalin molecules are released from a nerve cell and bind to analgesic receptor sites on the nerve cell sending the impulse. • The binding of enkephalin or morphine-like drugs changes the shape of the nerve sending the impulse in such a fashion as to prevent the cell from releasing acetylcholine. • As a result, the pain impulse cannot be transmitted, and the brain does not perceive pain.
  • 27. Examples of Narcotic Analgesics • Morphine • Pethidine Narcotic analgesics • Tramal Controlled Analgesic drugs
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  • 32. Placebo • Placebo (e.g. normal saline) should not be given to treat pain even with written medical order. • Using placebo to diagnose or treat pain is considered unethical and violating patient right to have optimal pain relief
  • 33. Pain Assessment tools Numeric Pain Rating Scale. Wong-Baker Face Pain Rating Scale. FLACC Scale. NIPS Pain Scale. CRIES Pain Scale. Critical Care Pain Observation Tool or CPOT. Comfort Pain Scale
  • 34. Why have a pain scale? Sometimes hard to put words to pain Pain is multi-faceted (How long? Where? How intense? What kind feeling? Visual scales help us understand where pain located. Faces help us understand how pain makes patient feel. Numeric scales help quantify pain using numbers.
  • 35. • Visual scales have pictures of human anatomy to help you explain where your pain is located. • A popular visual scale — the Wong-Baker Faces Pain Rating Scale — features facial expressions to help you show your doctor how the pain makes you feel. This scale is particularly useful for children, who sometimes don't have the vocabulary to explain how they feel. Visual. • Verbal scales contain commonly used words such as "low," "mild" or "excruciating" to help you describe the intensity or severity of your discomfort. • Verbal scales are useful because the terminology is relative, and you must focus on the most characteristic quality of your pain. Verbal. • Numerical scales help you to quantify your pain using numbers, sometimes in combination with words. • To be most accurate, pain scales are best used as the pain is occurring. • Over time, with treatment, your doctor can use pain scales to record how your pain is changing and to see if treatment is having the intended effect. Numerical.
  • 36. Wong-Baker Faces Pain Rating Scale •Explain to the patient that each face is for a person who feels happy because he has no pain (hurt or, whatever word the patient uses) or feels sad because he has some or a lot of pain. •Ask the patient to point to each face using the words to describe the pain intensity. •Face 0 doesn’t hurt at all. •Face 2 hurts just a little bit. •Face 4 hurts a little more. •Face 6 hurts even more. •Face 8 hurts a whole lot. •Face 10 hurts as much as you can imagine. •The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to Faces Pain Ratings Instructions: •Adult and child (> 3 years old) in all patient care settings Indications
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  • 38. Numeric Pain Rating Scale Instructions: •The patient is asked: What number on a 0 to 10 scale, where 0 means no pain and 10 as worst pain, would you give your current pain intensity? •When the question above is not understood by the patient, it is sometimes helpful to further explain or conceptualize the Numeric Rating Scale in the following manner: •0 = No Pain •1-3 = Mild Pain (nagging, annoying, interfering little with ADLs) •4–6 = Moderate Pain (interferes significantly with ADLs) •7-10 = Severe Pain (disabling; unable to perform ADLs) •The interdisciplinary team in collaboration with the patient/family (if appropriate), can determine appropriate interventions in response to Numeric Pain Ratings Indication •Adults and children (< 9years old) in all patient care settings who are able to use numbers to rate the intensity of their pain