ALGORITHM FOR PAIN ASSESSMENT AND MANAGEMENT AT BIMC
JCAHO Standard Rl.1.2.8
Patients have the right to appropriate assessment and management of pain.
The staff assesses for the
presence of pain on admission
The patient has pain. The patient denies pain
The patient will rate their pain using the Continue to assess pain q 8 h
0 - 10 rating scale or the Wong Faces hours and prn.
scale. The nurse will use PQRST
to further assess pain (*see Key Point #4)
The pain score is > 4
Sedation score is
< 3 (*See Key Point #2) The pain score is < 5 (*See Key Point #1)
Assess if there is an order
for pain medication and administer. Continue to assess pain every 8 hours.
Consider acetaminophen, NSAID, and/or
non pharmacologic approaches. If pt. desires,
notify prescriber and obtain order.
If no order, prescriber is notified re.
pain assessment data (see above). Assess for relief of pain:
♦ 10 - 15 minutes after IV dose
♦ 30 - 45 minutes after an oral or
♦ 1 - 2 hours after nonpharm.
Prescriber evaluates patient
Pain score > 4 Pain score is < 5
Follow algorithm as above
Prescriber orders pain medication or Prescriber requests consultation from a
and/or other intervention pain specialist.
The pain specialist evaluates patient and
The nurse administers the pain designs a pain mge. plan of care.
medication or other modality. Follow Algorithm as above.
Pain Assessment and Management Algorithm Key Points
1. A pain score of 4 is arbitrary in regard to the initiation of treatment. It is important to assess the acceptable
pain level for every individual patient and intervene accordingly. The patient should be asked, "Is this pain
score acceptable to you?" If the patient says it is not, the staff should follow the treatment algorithm. The
Patient/Family Interdisciplinary Education Record (should we call this something else so it is consistent with
the other hospitals?) is completed and placed in the patient's chart.
2. If the patient does not understand the 0 - 10 scale or Wong Faces scale, pain may also be assessed by asking if
the pain is "mild, moderate or severe." Pain that is moderate or severe in intensity should be a trigger for
further follow up and treatment.
3. If the patient has chronic pain, a sedation score of 3 and 4 may be acceptable for the individual such as at end
of life or for intractable pain syndromes. Pharmacologic intervention may be provided in these instances based
on a comprehensive physical and psychosocial assessment and collaboration with the patient and family.
4. In addition to pain intensity, the following must be assessed and documented on
all patients with pain:
• P = palliative/provocative. What makes the pain better or worse?
• Q = quality of pain. For example, is the pain felt as aching, throbbing, stabbing, shooting, etc.
• R = regions/radiation. Where is the pain? Does it radiate?
• S = severity of pain. Use the 0 - 10 scale or Wong Faces Scale to assess severity.
• T = temporal. What time of the day is the pain better or worse.
5. All pain assessment, intervention, evaluation and teaching should be documented on the Admission Assessment,
Nursing Care Flow Sheet (pain score), progress notes and Interdisciplinary Patient/Family Education Record.
6. Any issues or concerns regarding instituting this Algorithm should be reported and discussed with the Nurse
Manager, Nursing Supervisor, or responsible practitioner.
7. Non pharmacologic pain management interventions may be very effective as primary pain management therapies
with some patients. They can also be adjunctive modalities to pharmacologic therapy. These may include:
• relaxation and deep breathing
• visualization and guided imagery
• heat or cold massage
8. Discharge Plan
All patients with pain must have appropriate discharge planning to address their pain needs. This may include a
prescription for pain medication or other treatment modality, a home care or institutional referral where the
pain management plan is communicated, or referral to a health care provider that will address pain. Patients
and significant others must have the phone number of the responsible practitioner that will address their pain
needs at home. This discharge plan is documented on the Discharge Form.