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Screening for pain is an automatic process at the University of Washington Medical Center in Seattle, whether a patient comes into a clinic on an outpatient basis or is admitted to the hospital. Patients are asked if they are presently in pain or if they have had pain in the last several weeks.
If their answer is "yes," they are asked if their pain control has been a problem. Also, a comprehensive pain assessment is initiated that includes a pain intensity rating based on a pain assessment scale and a description of the type of pain, such as burning, sharp, stabbing, dull, or electrical. Patients also are asked what makes the pain better or worse, says Joan Ching, RN, MN, pain management clinical nurse specialist at the University of Washington Medical Center.
In the hospital setting, screening for pain is part of the admission medical history nurses must complete within 24 hours. If there is pain upon admission, the physician intervenes and nurses document the effectiveness of therapy whether pharmacological or nonpharmacological. Pain management is documented on a computerized charting system on the vital sign flow sheet in a section titled "Comfort."
In the outpatient setting, patients are given a self-assessment survey; if they answer "yes" to the question about pain being present, they are asked to answer the questions about the intensity and description of their pain. It becomes part of the progress notes in their medical record.
"If pain is identified as a problem upon the initial assessment at the clinic, it is added to the problem list. We have a running problem list in the medical record," says Ching. It prompts reassessment for pain on each visit.
All patients are screened for the presence or absence of pain on admission to Grant/Riverside Methodist Hospitals in Columbus, OH, its emergency department, or ambulatory care areas unless the patient is there for noninvasive diagnostic testing, says Lisa Hartkopf Smith, RN, MS, AOCN, clinical nurse specialist in pain management. If pain is identified as a problem, the physician and/or RN completes an in-depth pain assessment before a plan of care is initiated. The content of pain assessment includes:
In hospital areas pain is assessed with routine physical assessment, with new reports of pain by the patient, and after pain management interventions. The timing of each assessment following an intervention depends on the situation. For example, following pharmacological pain management interventions, pain intensity is assessed at intervals dependent on the medication and route of administration, says Hartkopf Smith.
Pain assessment information is initially documented in the admission database at Grant/ Riverside Methodist Hospitals with subsequent assessments documented in the nursing daily flow sheet and/or physician progress notes. When other disciplines assess for pain, it is documented on a multidisciplinary progress note.
"The pain assessment is included as part of existing forms, rather than separate forms to decrease the number of forms the nurse must complete," says Hartkopf Smith. Cues on the documentation forms help assure that the necessary information is assessed and documented, she says.
To make sure that pain is managed well, patients set a comfort function goal daily. This is the pain intensity rating at which patients can perform activities related to satisfactory recovery or improved quality of life. Most patients use the 0-10 pain scale to set their goal with zero being no pain and 10 being intense pain.
"The goal is used to manage the effectiveness of the pain management plan," says Hartkopf Smith. When the pain rating is higher than a patient’s comfort function goal, the nurse administers medication according to the physician’s orders and performs nonpharmacological interventions as needed. If these do not work, the physician is called for additional orders.
While having plans for the assessment and reassessment of pain in place is an important step in pain management, there also must be a plan to determine if staff are following policy. At Grant/ Riverside Methodist Hospitals, nursing documentation audits are conducted every other month on inpatient nursing units to ensure compliance.
Tracking documentation of pain assessment and reassessment is important, says Ching. Management is able to run a report each month via the computer identifying all patients assessed with pain at an intensity greater than five who are not satisfied with their pain management. A second report checks pain intensity ratings and satisfaction two hours later. "These reports give us an idea of what our follow-up rate is like and all nurse managers get that report every month," says Ching. n