COMPREHENSIVE PAIN MANAGEMENT POLICY

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					                                               UTMDACC INSTITUTIONAL POLICY # CLN0991



                                               COMPREHENSIVE PAIN MANAGEMENT
                                               POLICY


PURPOSE
The purpose of this policy is to provide a comprehensive pain management plan for M. D. Anderson
Cancer Center Division of Nursing that assures all patients:

        Are assessed for pain by nurses (RN, LVN).

        Receive a comprehensive pain assessment that is appropriate for age and abilities if the patient
         states they have had pain in the previous 24 hours and/or are receiving treatment for pain.

        Are provided with an individualized pain management plan.

        Receive a regular reassessment/follow-up of pain that will occur throughout the patient’s
         continuum of care.

        Have the right to pain management and will be informed that adequate pain management is a
         priority.


POLICY STATEMENT
It is the policy of the University of Texas M. D. Anderson Cancer Center (M. D. Anderson) to provide pain
relief for patients in accordance with the latest evidenced based standards of pain management practice.

Pain is managed and/or referred for specialty pain management based on the individualized needs of the
patient.

Regular assessment, reassessment, and follow-up will occur throughout the patient’s continuum of care
and the effectiveness of the comprehensive pain management plan will be monitored through outcomes
measurement.

Consistent care and good communication between health care teams will be utilized to achieve adequate
pain management.

Pain management for patients includes the following principles:

        The patient’s stated level of pain intensity is the best indicator of the pain he/she is experiencing.

        The patient’s Personal Pain Goal (PPG) is the best indicator describing the intensity of pain that
         will allow the patient to achieve comfort in physical, functional, and psychosocial domains.




                                                                                                                   Page 1 of 15

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


        Every inpatient will have his/her pain intensity and personal pain goal assessed on arrival, on
         admission, and reassessed as appropriate.

        Patients will be assessed for pain intensity using a pain scale appropriate for the cognitive,
         developmental, and language abilities of the patient.

        Inpatient pain assessments and actions taken to alleviate pain will be documented in the medical
         record.

        Treatment of pain is personalized to meet the patient’s Personal Pain Goal (PPG).


SCOPE
This policy applies to all Division of Nursing employees who assess and administer medications for pain
management; only RN’s and/or LVN’s will assess all patients for the presence of pain.


STRATEGIC VISION
Strategic Goal 1: Patient Care
Enhance the excellence, value, safety, and efficiency of our patient care.

Strategic Goal 7: Resources
Safeguard and enhance our resources.


DEFINITIONS
Aggravating Factors: Factors which exacerbates the pain.

Alleviating Factors: Measures that provide pain relief.

Bag Volume: Volume to be infused for the epidural PCA pump.

Characteristics/Quality: Patient description of the pain (e.g., sharp, dull, aching).

Clinician Dose (Clin Dose): A dose of medication programmed and administered by an RN via epidural
PCA pump.

Clinically Severe Obesity: Body Mass Index (BMI) ≥ 40 or BMI ≥ 35 and presence of serious comorbid
conditions.

Dermatome: An area of skin whose sensory nerves all come from a single spinal nerve root.

EDS: Electronic Document System.

EtCO2: Capnography or end-tidal (exhaled) carbon dioxide (CO2) monitoring provides non-invasive,
continuous measurement of respiratory rate and exhaled carbon dioxide concentration over time,
measured at peak of expiration.



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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


Epidural:
    Bolus Attempted (BA): The total number of times the patient presses the dose button for the
       infusion period.

        Bolus Given (BG): The total number of doses the patient receives after the patient presses the
         dose button for the infusion period.

Epidural Analgesia: The introduction of local anesthetic and/or analgesia opioid via the epidural space
for pain management.

Frequency: How often the pain occurs.

FUPN: Follow up and progress notes.

Hard Limit: A limit beyond which the operator is no longer allowed to continue programming the PCA
pump at the current programmed dose. The user will be forced to “Reprogram” the current dose within
the Hospital established “Best Practice” dose ranges for that specific drug and “Patient Profile.”

Intensity: Severity of pain as stated by the patient using a 0 - 10 scale or Wong-Baker FACES Scale or
the Riley Infant Pain Assessment Scale (patient, 36 months) as appropriate to the patient’s age, ability to
communicate, cultural preferences, and developmental status.

Location: Site from which complaint of pain is arising.

MAR: Medication Administration Record.

Motor Ability: Assess the intensity of the motor block or the patient’s strength and ability to move the
upper and lower extremities.

NRS: Numerical Rating Scale.

Onset: When the pain began.

Pain Categories: When using 0 – 10 scale to measure pain the following serves to categorize pain:

             No pain in rated as 0.

             Mild Pain is pain rated as 1 – 3.

             Moderate Pain is pain rated as 4 – 6.

             Severe Pain is pain rated as 7 or greater.

PCA: Patient controlled analgesia.

        Total Delivered: The total number of doses the patient receives after the patient presses the PCA
         dose button for the infusion.

        Total Demands: The total number of times the patient presses the PCA dose button for the
         infusion period.



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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


PCA by Proxy: When someone other than the patient pushes the dose button on the PCA pump to
administer PCA medication, even at the patient’s request.

PCA Dose and Continuous Infusion: The PCA pump program delivers a preset continuous rate and
permits the patient to receive a PCA dose.

PCEA: Patient controlled epidural analgesia.

Personal Pain Goal (PPG): The verbal or written goal stated by the patient describing the desired
level/intensity of pain that will allow the patient to achieve comfort in physical, functional, and
psychosocial domains.

Richmond Agitation Sedation Scale (RASS): Used to determine the patient’s level of sedation and
agitation as rated +4 to -5.

Riley Infant Pain Assessment Scale (RIPS): An infant pain assessment tool used with patients <36
months of age.

RN Bolus Dose: A dose of medication programmed and administered by an RN via PCA pump.

RR: Respiratory Rate.

SpO2:   Provides continuous, noninvasive monitoring of functional oxygen saturation of arterial
Hemoglobin (SpO2) and pulse rate.

Twenty-Four Hour Total: Total amount of medication infused for the past time period (up to 24 hours) of
the infusion at any given time.

VAS: Visual Analogue Scale.

VTBI: Volume to be infused.

Wong-Baker FACES: A pain intensity rating scale that is primarily used in pediatric settings to measure
pain intensity.


PROCEDURE

1.0   Guidelines for Documenting the Admission Pain Assessment

      1.1    Admission pain is assessed and documented on institutionally approved pain documentation
             forms or in the EDS.

      1.2    All new admissions will receive a pain intensity and PPG assessment within two hours of
             admission.

      1.3     Ask all patients, “Have you experienced any pain during the past 24 hours?”

             A.     If no, then document “0” for intensity.

             B.     If yes, document a complete pain assessment.


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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


             C.     If pain is unable to be assessed, document the reason for inability to assess the patient’s
                    pain in the medical record.


2.0   Guidelines for Documenting on the Daily Pain Assessment (DPA)

      2.1    The DPA is to be completed daily for ongoing pain assessment, intervention, and
             reassessment, except for those patients receiving PCA/Epidural infusions.

      2.2    A Pain Assessment Key is available as a guide.

      2.3    Areas  using     electronic    documentation                system       (EDS)       will    document        pain
             assessment/interventions in the EDS.

      2.4    A pain intensity assessment must be completed a minimum of every shift and documented on
             the DPA.

      2.5    If pain is assessed using the Riley Infant Pain Assessment Scale (RIPS), the intensity is
             documented from 0-18.

      2.6    If pain is assessed using the Wong-Baker Scale FACES, the intensity level is documented at 0
             to 5.

      2.7    If using the Visual Analogue Scale/Numerical Rating Scale (VAS/NRS) the level is 0 to 10, or
             if pain is assessed and the pain intensity is at 0/18 on the RIPS, a "0" pain intensity must be
             documented on the form.

      2.8    If pain is assessed and the pain intensity level is documented at 0/10 on the VAS/NRS or 0/5
             on the Wong Baker FACES Scale, a “0” pain intensity must also be documented on the form.

      2.9    A PPG assessment must be completed a minimum of every shift.

      2.10 A pain intensity reassessment will be completed within one hour of any pain intervention and
           documented on the next line of the appropriate pain form or in the EDS.

             If more space is needed to document information related to patient’s pain assessment,
             intervention, and follow-up, a PIE note is indicated.

      2.11 Pain scores greater than zero document the following:

             Date/Time/IntensityScore/Location/Characteristics/Onset/Frequency/Alleviating
             Factors/Aggravating Factors/Interventions/Evaluation/Initials.


3.0   Epidural

      3.1    Epidural Initiation

             A.     When programming (for additional information refer to the website curlinmedical.com
                    for Pain Smart 6000 information on demand) the bag volume, subtract 10cc (e.g., when
                    programming a 250cc bag, program it for 240cc).

             B.     Initiate an Epidural Record when initiating an epidural infusion and for daily use while the
                    epidural catheter remains in place.


                                                                                                                   Page 5 of 15

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                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


             C.     Record the 24-hour running total Volume Infused (Vol. Inf.) as of 0600.

                          Do not clear pump.

                          Document Total Volume Infused as of 6 am in box on Epidural Record.

             D.     Select pain scale used.

                          If pain is assessed using the Wong-Baker Scale FACES, the intensity level is
                           documented at 0 to 5.

                          If using the Visual Analogue Scale/Numerical Rating Scale (VAS/NRS), the level is
                           0 to 10.

                          If using the RIPS (patient < 36 months), the level is 0 to 3.

                          A “0” pain intensity must also be documented on the form.

             E.     Pain intensity assessment should be completed a minimum of every 4 hours by an RN
                    and documented on the Epidural Record.

             F.     A PPG assessment must be completed a minimum of once per day.

                          Document the PPG in the box on the form.

                          If there is any change in the PPG, a PIE note is required. (Refer to Health e-
                           connect Forms Anywhere.)

             G.     Complete Medication Order Section.

             H.     Transcribe the most current physician order with date, time, drug/concentration, Units
                    (mL), Administration Route (Epidural), Load Dose (usually 0), Basal Rate, Patient Bolus,
                    Bolus Interval, Number of Boluses, and Clinician Dose.

             I.     Two nurses must verify transcription of the medication order.

             J.     If the order changes, but the medication and/or concentration remains the same,
                    complete the next Medication Order Box and cross through the previous order.

             K.     If more than one page of the Epidural Record is needed, number the pages in sequence.

             L.     A copy of the most current physician order is to be kept with the Epidural Record.

             M.     Epidural Priming Process—refer to the website curlinmedical.com for Pain Smart 6000
                    information on demand and see chart at end of document.

      3.2    Changes in Drug/Concentration

             A change in the drug or drug concentration requires a new form.

             A.     The total amount of drug infused must be documented on the previous Epidural Record
                    in the (Total Infused as of 6 am box) on the form.




                                                                                                                   Page 6 of 15

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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


      3.3    Epidural Assessment and Pump Documentation

             A.     At the start of every shift and a minimum of every 4 hours, document the pain
                    assessment and pump status on the Epidural Record.

             B.     If pain score greater than the patient’s stated PPG, document the following:

                          Time/IntensityScore/Location/Characteristics/Onset/Frequency/Duration/
                           Alleviating Factors/Aggravating Factors/Interventions/Evaluation/Initials.

                          Time/VTBI(BagVolume)/ClinicianDoseGiven/BolusGiven/SpO2/
                           RASS/RR/Comments.

             C.     Assess sensory status every shift.

             D.     Assess motor status every shift and prior to ambulation.

             E.     Assess epidural catheter insertion site at the start of the shift. (Refer to the Mosby
                    Nursing Skills database under the section Epidural Catheters.)

                          Asses the site to assure the dressing is dry and intact.

                          Assess for signs of infection.

             F.     Additional pain medications will be documented as an intervention on the Epidural Form
                    and the MAR (e.g., date, time, and initial).

             G.     Areas using EDS will document pain assessment, intervention, and re-assessment in
                    the EDS.

      3.4    Reassessment of patient must occur within 1 hour with the following:

             A.     Initiation of an Epidural infusion.

             B.     Administration of a clinician dose.

             C.     Administration of unscheduled pain medication.

             D.     Epidural order changes.

             E.     Any intervention(s) that affect pain intensity levels (e.g., massage, acupuncture).

                          A pain intensity reassessment will be completed within one hour of any pain
                           intervention and documented on the next line of the pain form or in the EDS.

                          If more space is required to document information related to patient’s
                           pain assessment, intervention, or follow-up, a PIE note is indicated.

      3.5    Two licensed provider signatures is required with the following:

             A.     Medication order change.

             B.     New bag hung.

             C.     Shift change.

                                                                                                                   Page 7 of 15

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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


             D.     Bolus administration.

             E.     Prior to patient transfer on the sending unit and upon patient arrival on the receiving unit.

      3.6    Infusion Setup and Bag Change

             At every epidural infusion bag change two licensed providers initials are required with the
             following:

             A.     Verify the most recent physician order; verify pump settings and medication orders.

             B.     Identify the patient by using two patient identifiers; refer to the Patient Identification
                    Policy (UTMDACC Institutional Policy # CLN0579).

             C.     Sufficient volume is left in the bag.

             D.     Absence of air in the tubing.

             E.     Medication expiration date has been verified.

      3.7    Discontinued Orders – Epidural

             When an order is written to discontinue the infusion, follow these steps:

             A.     Give transition pain medication, if ordered, prior to discontinuing the Epidural infusion.

             B.     Do not clear the pump and document the 24-hour total on the Epidural Record.

             C.     Record on the Epidural Record the volume remaining.

             D.     Stop the pump.

             E.     Disconnect the pump from the patient and cap the epidural catheter using sterile
                    technique.

             F.     Remove the bag from the pump and document the amount of medication
                    remaining.

             G.     Waste as appropriate and document amount wasted.

             H.     Obtain and initiate a Daily Pain Assessment (DPA) for remainder of day’s pain
                    management documentation, as appropriate, or continue documenting the pain
                    assessment and interventions in the EDS.


4.0   PCA

      4.1    For PCA Setup

             A.     When setting up the PCA pump, select “Standard Dose” therapies for all patients except
                    Chronic Pain, Supportive Care, and Pediatric patients.

             B.     Contact the physician for clarification of orders if when programming the PCA pump the
                    dosing limits activate a “Hard Limit.”


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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


             C.     Activation of the “Hard Limit” indicates the dose program is outside the standard dosing
                    parameters. The nurse should clarify the original order, and the physician should
                    generate a new PCA Order Set located in CinicStation under the Order Sets folder.

             D.     The patient profile must be selected to match the correct patient population at the time
                    the device is placed on a patient. The PCA pump profile Adult, Pediatrics, and
                    Outpatient (OP) Oncology.

             E.     Administration set tubing and syringes are changed every 72 hours. Refer to the
                    Infection Control Associated with Intravascular Devices Policy (UTMDACC
                    Institutional Policy # CLN0441).

             F.     In special circumstances the Curlin Pain Smart infusion pump may be utilized for PCA
                    infusions; refer to website curlinmedical.com for Pain Smart 6000 for infusion and
                    pump information.


      4.2    PCA Initiation

             A.     Initiate a new PCA Record daily at 0600 and record the running total infused as of 0600.

                          Record the Total Infused in the 6 AM box on PCA form.

                          Do not clear the pump.

             B.     Select pain scale used.

                          Pain is assessed using the Wong Baker Scale FACES, the intensity level is
                           documented at 0 to 5.

                          Using the Visual Analogue Scale/Numerical Rating Scale (VAS/NRS), the level is 0
                           to 10.

                          Pain is assessed and the intensity level is documented at 0/10 on the VAS or 0/5
                           on the Wong Baker Scale FACES.

                          Using the RIPS the intensity level is 0-18.

                          A “0” pain intensity must also be documented on the form.

             C.     A pain intensity assessment should be completed a minimum of every four hours by an
                    RN/LVN and documented on the pain documentation form or in the EDS.

             D.     A PPG assessment must be completed a minimum of every shift

                          Document the PPG in the box on the form.

                          If there is any change in the PPG it must be followed by a PIE note; refer to Health
                           e-Connect Forms Anywhere.

                          Complete Medication Order Section.

             E.     Transcribe the most current physician order with date, time, drug/concentration, basal
                    dose, delay, and RN bolus.

                                                                                                                   Page 9 of 15

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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


             F.     Two nurses must verify transcription of the medication order.

             G.     If the order changes, but the medication and/or concentration remains the same,
                    complete the next Medication Order Box and cross through the previous order.

             H.     If more than one page of the PCA Record is needed number the pages in sequence.

             I.     A copy of the most current physician order is to be kept with the PCA Record.

             J.     EtCO2 monitoring is to be initiated for all postoperative surgical patients for the first 24
                    hours after initiation of the PCA infusion.

             K.     Clinically severe obese patients on PCA should have EtCO2 monitoring for duration of
                    therapy, unless otherwise ordered by their physician or designee.

      4.3    Changes in Drug/Concentration

             A.     A change in the drug or drug concentration requires a new form.

             B.     The total amount of drug infused will be documented on the previous PCA Record.

      4.4     PCA Assessment and Pump Documentation

             A.     A pain intensity assessment will be completed a minimum of every 4 hours by an
                    RN/LVN and documented on the PCA Record or in the EDS.

             B.     A PPG assessment will be completed a minimum of once per day.

                          Document the PPG in the box on the PCA Record.

                          If there is any change in the PPG it will be documented on a PIE note.

             C.     For a pain score greater than the patient’s stated PPG, document the following:

                          Time/IntensityScore/Location/Characteristics/Onset/Frequency/Duration/
                           Alleviating Factors/Aggravating Factors/Interventions/Evaluation/Initials.

                          Time/VTBI/Bolus Given/SpO2/ETCO2/RASS/RR/Comments.

             D.     Documentation of unscheduled pain medications will be documented as an intervention
                    on the PCA Record and the MAR (e.g., date, time, initial).

             E.     Areas using EDS will document pain assessment, interventions, and reassessment in
                    the EDS.

      4.5    A pain intensity reassessment of patient will occur within 1 hour with following:

             A.     Initiation of a PCA infusion.

             B.     Administration of a bolus dose.

             C.     Administration of additional pain medication.

             D.     Changes in the PCA order.


                                                                                                                  Page 10 of 15

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991


             E.     Any intervention(s) that affect pain intensity levels (e.g., massage, acupuncture):

                          A pain intensity reassessment will be completed within one hour of any pain
                           intervention and documented on the next line of the pain form or in the EDS.

                          If more space is required to document information related to patient’s pain
                           assessment, intervention, or follow-up, a PIE note is indicated.

      4.6    Two licensed provider signatures is required with the following:

             A.     Medication order change.

             B.     New syringe insertion.

             C.     Shift change.

             D.     Bolus administration.

             E.     Prior to patient transfer on the sending unit and on patient arrival on the receiving unit.

      4.7    Syringe Setup and Change

             With every PCA syringe change two licensed providers initials are required with the following:

             A.     Verify the most recent physician order; verify pump settings and medication orders.

             B.     Identify the patient by using two patient identifiers; refer to the Patient Identification
                    Policy (UTMDACC Institutional Policy # CLN0579).

             C.     Sufficient volume is left in the syringe (if less than 3 hours remaining in syringe, notify
                    pharmacy for a syringe replacement).

             D.     Absence of air in the syringe and PCA tubing and infusion line.

             E.     Medication expiration date has been verified.

      4.8    Discontinued Orders – PCA

             When an order is written to discontinue the PCA infusion:

             A.     Give transition pain medication, if ordered, prior to discontinuing the PCA infusion.

             B.     Do not clear the pump and document the 24-hour total on the PCA Record.

             C.     Stop the pump infusion.

             D.     Remove the syringe from the pump and document the amount of medication remaining.

             E.     Record on the PCA Record the volume remaining.

             F.     Waste as appropriate and document in the PYXIS.

             G.     Obtain and initiate a Daily Pain Assessment form (DPA) for remainder of day’s pain
                    management documentation or continue documenting the pain assessment and
                    interventions in the EDS.

                                                                                                                  Page 11 of 15

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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991



5.0   Guidelines for Documenting Pain Assessment in the Ambulatory Areas.

      5.1    All ambulatory centers utilize the standard pain assessment form, which is in each center’s
             follow-up and progress notes (FUPN).

      5.2    All ambulatory nurses will assess and document pain on the designated pain assessment
             FUPN.

      5.3    Complete The Pain Assessment section at each center visit.

      5.4    Complete the pain assessment history on the form. If the pain is new, worse, or above the
             patient’s acceptable level, continue the pain assessment.

      5.5    Complete appropriate interventions and for any medications administered utilize the
             Outpatient Medications Administration Record (OMR); refer to the Outpatient Medication
             Record (OMR) Policy (UTMDACC Institutional Policy # CLN0645).

      5.6    If pain medication is given, a documented response within 1 hour is required on the outpatient
             MAR.




                                                                                                                  Page 12 of 15

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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991




REFERENCES
Alaris Medley System with Guardrails Suite MX Operation/Procedure Manual, Alaris Medical System,
2006.

American Pain Society. (2003). Principles of analgesic use in the treatment of acute and cancer pain.
Fifth Edition. APS, IL: 37-38.

Cohen, M. R. & Kilo, C. M. (1999). “High-alert medications: Safeguarding against Error.” In Medication
Errors. Edited by Michael R. Cohen, 5.1 – 5.40. Washington, DC: American Pharmaceutical Association.

Cox, F. J. & Scott, K. (2008). Improving epidural safety through new documentation. Nursing Times,
104(12), 26-27.

curlinmedical.com for Pain Smart 6000 information on demand.

For Step-by-Step Instructions for Use of the Alaris Infusion System, See the Quick Reference Guides
Attached to the Infusion System and the Alaris Infusion Manual.

Health e-Connect Forms Anywhere.

McCaffery, M., Ferrell, B. R. & Turner, M. T. (1996). Ethical issues in the use of placebos in cancer pain
management. Oncology Nursing Forum, 23, 1587-1593.

Mosby Nursing Skills - Epidural Catheters.

National Comprehensive Cancer Network (2006). Cancer Pain: Clinical Practice Guidelines in Oncology
Adult, Pediatric and Palliative care – V. 1.2006: http://www.nccn.org.

National Institutes of Health: Statement on First Federal Obesity                                     Clinical    Guidelines:
http://www.nhlbi.nih.gov/new/press/6-98.htm (accessed October 12, 2008).

Outpatient Medication Record (OMR) Policy (UTMDACC Institutional Policy # CLN0645).

Patient Identification Policy (UTMDACC Institutional Policy # CLN0579).

Sentinel Event Alert. (1999). High-Alert Medications and Patient Safety. The Joint Commission. Issue 11.




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distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                         UTMDACC INSTITUTIONAL POLICY # CLN0991




                                                                                                                  Page 14 of 15

This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.
                                                                                 UTMDACC INSTITUTIONAL POLICY # CLN0991


Approved With Revisions Date: 12/19/2008
Approved Without Revisions Date:
Implementation Date: 12/19/2008


Governors
Summers,Barbara L -VP, Nursing Prac & Chf Nrsg Off


Stewards
Burns,Latasha R -Assoc Dir, Nrsg Accreditation


Content Experts
Arlington,Rosanne G -Advanced Practice Nurse
Massey,Robert L -Dir, Clinical Nursing




                                                                                                                             Page 15 of 15

      This document is the property of The University of Texas M. D. Anderson Cancer Center and, with few exceptions, may not be used,
      distributed, or reproduced outside of M. D. Anderson without written permission from the Institutional Compliance Office.