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Comprehensive Pain Assessment – Best Practice 1

Documentation of Comprehensive Pain Assessment in Outpatient Medical Oncology –

Best Practice

Poster Handout of Supporting Material and References

N770 Scholarship Poster Presentation Session

March 26, 2013

Michelle K. H. Wald, MSN, RN, CNP


Needs Assessment - Chart Audit Tool

Clinic number Prior pain level o 0-10 o N/A

Gender o Female o Male

Pain score 1 – 3 o NSAID o Tylenol o Slow titration of short-acting opioid o No action

Age Opioid naïve: Pain score 4 – 6 o MSIR 5–15mg po o Oxycodone 5-10mg po o Dilaudid 2-4mg po o Other o No action

Type of visit o Initial consult o Follow-up

Opioid naïve: Pain score 7 – 10 o MSIR 5-15mg po o Oxycodone 5-10mg po o Dilaudid 2-4mg po o Other o No action

Date of visit Opioid tolerant: Pain score 4 – 6 … 10-20% of previous 24 hr dose?

o Yes o No o Other o No action

Primary site of cancer Opioid tolerant: Pain score 7 – 10 … 10-20% of previous 24 hr dose?

o Yes o No o Other o No action

Stage of disease o I / II o III o IV

Reassessment following change in therapy? o Yes o No o N/A

Care provider o Staff o Fellow o NP / PA

Bowel regimen addressed? o Yes o No o N/A

Documentation of pain score o Yes o No

Patient education documented? o Yes o No o N/A

Current pain level (0 – 10) Consistent w/ NCCN guidelines? o Yes o No o N/A


Needs Assessment – Provider Survey Tool

1) Who are you?

a. Consultant b. Fellow c. NP/PA

2) Number of years in practice?

a. Fellowship b. 0-5 years c. 6-10 years d. 11-15 years e. 16-20 years f. 20+ years

3) Pain management is an important component of oncologic practice …

a. Strongly agree b. Agree c. Neutral d. Disagree e. Strongly disagree

4) Pain is an issue in _______ of the patients I see …

a. None b. A few c. Some d. Most e. All

5) My knowledge of assessing and managing pain is based on …

a. Formal medical/nursing education (i.e. residency or fellowship training) b. Established clinical guidelines c. Self-directed (i.e. personal experience, advice from colleagues, or CME content) d. Pain consultation recommendations e. Other


6) Clinical vignette: 67-year old woman with non small cell lung cancer and metastatic disease to the bones presents c/o increasing pain in her left hip. She has been taking oxycodone 5mg/acetaminophen 325mg (Percocet) tablets … 16 tablets per day provide control of her pain. She is experiencing mild nausea and needs to take a pill during the middle of the night. The next appropriate step in drug therapy for this patient would be:

o Morphine (oral) 50mg = oxycodone 30mg = fentanyl (transdermal) 25mcg = 12.5mg po hydromorphone (Dilaudid)

a. Oxycontin 20mg po bid b. MS Contin 45mg po bid c. Transdermal fentanyl 100mcg/hr patch d. MS Contin 60mg po bid e. Oral hydromorphone 4mg po q 3hrs

7) Clinical vignette: 34-year old man with metastatic melanoma whose pain is controlled

with 8mg hydromorphone po q4h ATC. If the patient is late with a dose or awakened at night, he is in severe pain. He is experiencing nausea related to the opioid. You want to convert him to a long-acting pain medication and switch him to morphine to see if he will have less nausea. You check your equianalgesic table:

Opioid Oral Equivalent Parenteral Equivalent Hydromorphone Morphine Oxycodone

7.5mg 30mg 20mg

1.5mg 10mg

What would be an appropriate starting regimen when converting from hydrocodone to morphine (combination long-acting [SR] and short-acting [IR])?

a. MS Contin 30m po bid w/ morphine IR 15mg po q4h prn b. MS Contin 60mg po bid w/ morphine IR 15mg po q4h prn c. MS Contin 90mg po bid w/ morphine 30mg po q4h prn d. MS Contin 120mg po bid w/ morphine IR 30m po q4h prn

8) Clinical vignette: 53-year old woman with metastatic breast cancer, recently discharged

from the hospital on OxyContin 20m po bid. Her pain is well-controlled (3 out of 10 worst pain during the day) and she takes one dose of 5mg breakthrough per day. She is looking for a less expensive alternative and is willing to try morphine.

Opioid Oral Equivalent Parenteral Equivalent Hydromorphone Morphine Oxycodone

7.5mg 30mg 20mg

1.5mg 10mg


What is the correct dose of morphine to prescribe?

a. MS Contin 15mg po bid w/ morphine IR 10 mg po q4h prn b. MS Contin 30mg po bid w/ morphine IR 10mg po q4h prn c. MS Contin 45mg po bid w/ morphine IR 20mg po q4h prn d. MS Contin 60mg po bid w/ morphine 20mg o q4h prn

9) What prevents you from assessing your patient’s pain?

a. Lack of knowledge b. Lack of time c. “Not my job” d. Didn’t think of it e. Patient didn’t initiate conversation f. Other

10) What prevents you from documenting your patient’s pain?

a. Lack of knowledge b. Lack of time c. “Not my job” d. Didn’t think of it e. Other


Level of Effectiveness / Evidence Guides

* Level of Effectiveness

Effective: Research validates the effectiveness of the nursing activity or intervention, preferably with Level 1 or Level 2 evidence. Possibly Effective: There are some research studies that validate the effectiveness of the nursing activity or intervention, but with insufficient strength to recommend that nurses institute the activity or intervention at this time. Generally more research is needed. Not Effective: Research has shown that the nursing activity or intervention is not effective and generally should not be used. Possibly Harmful: There are some studies that show harm to clients when using the nursing activity or intervention and the nurse should evaluate carefully whether the activity is ever appropriate.

Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care

guidelines: Medical-surgical interventions. St. Louis, MO: Mosby Elsevier.

** Level of Evidence

Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results. Level II: Evidence obtained from at least one large (multi-site) well-designed RCT. Level III: Evidence obtained from well-designed controlled trials without randomization (i.e., quasi-experimental). Level IV: Evidence from well-designed case-control or cohort studies. Level V: Evidence from systematic reviews of descriptive and qualitative studies. Level VI: Evidence from a single descriptive or qualitative study. Level VII: Evidence from the opinion of authorities and/or reports of expert committees.

Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care



Stakeholders

o Chair Institutional Outpatient Clinical Practice Committee

o Medical Oncology Division Chair

• Medical Oncology Clinical Practice Committee Chair

o Supervisor – Nurse Practitioners (NPs) and Physician Assistants (PAs)

• Sarcoma / Head & Neck Clinic NP

o Nurse Administrator / Manager

• Registered Nurses (RNs)

o Supervisor – Clinical Assistants

• Clinical Assistants

o Supervisor – Medical Secretaries

• Assistant Supervisor – Medical Secretaries

o Medical Oncology Administrator

• Medical Oncology Operations Manager

• Systems and Procedures Staff


RN Tools

Pain Assessment Intake / Documentation Guide Based on NCCN guidelines (Swarm et al., 2010)

• Location

• Intensity (0-10)

• Interference with activities o Mood / Sleep / Appetite / General activity

• Timing

o Onset / Duration / Persistent / Intermittent

• Description / Quality o Aching / Stabbing / Throbbing / Pressure … somatic pain in skin, muscle, bone? o Gnawing / Cramping / Aching / Sharp … visceral pain in organs or viscera? o Sharp / Tingling / Ringing / Shooting … neuropathic pain?

• Aggravating / Alleviating factors

• Other current symptoms

• Current pain management plan (prescription, OTC, & non-pharmacologic) o What meds? o How much? o How often? o Who prescribes?

• Response to current therapy

o Relief / Adherence / Side effects … specific attention to constipation and nausea

• Prior pain therapies o Reason for / Length of use o Response o Why stopped?

• Special issues

o Beliefs / Patient goals & expectations

• Psychosocial o Family & other support o History of substance abuse o Risk for diversion

• Patient education needs


RN Tools

Constipation … Guide to Prophylaxis & Management Based on NCCN guidelines (Swarm et al., 2010)

Prevention: • Stimulant laxative +/- stool softener … such as senna +/- ducosate

o Senokot S, Peri-Colace are both examples of senna + ducosate 2 tabs orally (PO) every morning Max 8-12 tabs per day

• Increase dose of laxative when increasing dose of opioids • Maintain adequate fluid intake (8-10 glasses of clear liquid daily) • Maintain adequate dietary fiber intake

o Metamucil and like compounds are not recommended (risk of impaction) o Oral mineral oil is effective for hard stool, but should not be used for routine

prevention as it may interfere with absorption of some nutrients • Exercise (if feasible)

If Develops:

• Rule out (r/o) obstruction • r/o impaction • Increase stool softener / laxative as above

o Goal of one non-forced BM every 1-2 days If Persists:

• r/o obstruction • r/o impaction • Consider adding another agent:

o Magnesium hydroxide (Milk of Magnesia) 30-60 mls PO daily

o Bisacodyl (Correctol laxative, Dulcolax, Ex-lax Ultra) 2-3 tablets PO daily OR 1 rectal suppository daily

o Lactulose 30-60 mls PO daily

o Sorbitol 30 mls PO every 2 hrs x 3, then prn

o Magnesium citrate 8 oz PO daily

o Polyethelene glycol (MiraLAX, GoLYTELY) 1 capful in 8 oz water PO twice daily

• Fleet, saline, or tap water enema • Consider use of prokinetic

o Metoclopramide (Reglan) 10-20 mg PO every 6 hrs • In advanced disease, for opioid-induced constipation unresponsive to above, could

consider … o Methylnaltrexone (Relistor)

0.15 mg/kg SQ … max 1 dose / day


RN Tools

Nausea … Guide to Prophylaxis & Management Based on NCCN guidelines (Swarm et al., 2010)

Prevention:

• For patients with a prior history of opioid-induced nausea, prophylactic treatment with antiemetic agents is highly recommended (see below)

If Develops:

• Assess for other causes o Constipation o CNS pathology o Chemotherapy o Radiation therapy o Hypercalcemia

• Consider: o Prochlorperazine (Compazine)

10 mg PO every 6 hrs as needed o Thiethylperazine (Torecan)

10 mg PO every 6 hrs as needed o Haloperidol (Haldol)

0.5-1 mg PO every 6-8 hrs o Metoclopramide (Reglan)

10-20 mg PO every 6 hrs as needed If Persists:

• Despite as needed regimen o Administer antiemetics ATC for 1 week, then change to as needed

• Consider adding a serotonin antagonist o Granisetron (Kytril)

2 mg PO daily o Ondansetron (Zofran)

8 mg PO three times daily o Dolasetron (Anzemet)

100-200 mg PO o Palonosetron (Aloxi)

300 mcg/kg IV Use with caution as constipation is a side effect

• Consider dexamethasone If Persists > 1 Week:

• Reassess cause and severity of nausea • Consider opioid rotation


RN Tools

Pain Assessment RN Documentation Shorthand Template

PAIN ASSESSMENT ONSET/DURATION: {@INPUT description of onset and/or duration of pain} TIMING: {@INPUT timing of pain @SINGLE @SEP=", " Persistent Intermittent } QUALITY: {@INPUT Quality of pain @SEP=", " Aching Stabbing Throbbing Pressure Gnawing Cramping Sharp Tingling Burning Shooting Electric/Shocking {@REM select for other quality description}{@INPUT -other quality description} } INTERFERENCE WITH ACTIVITIES: {@INPUT Interference of pain with activities @SEP="{@KEY enter}" ADLs: {@REM ADLs - select for further description}{@INPUT further description regarding interference with ADLs} Mood: {@REM Mood - select for further description}{@INPUT further description regarding interference with mood} Sleep: {@REM Sleep - select for further description}{@INPUT further description regarding interference with sleep} Appetite: {@REM Appetite - select for further description}{@INPUT further description regarding interference with appetite} Ability to work: {@REM Ability to work- select for further description}{@INPUT further description regarding interference with ability to work} Ability to walk: {@REM Ability to walk - select for further description}{@INPUT further description regarding interference with ability to walk} Relationships: {@REM Relationships - select for further description}{@INPUT further description regarding interference with relationships} Enjoyment of life: {@REM Enjoyment of life - select for further description}{@INPUT further description regarding interference with enjoyment of life} {@REM other-enter on next screen}{@INPUT enter other interferences with activities}


No interference. } AGGRAVATING/ALLEVIATING FACTORS: {@INPUT factors that aggravate or alleviate pain} OTHER CURRENT SYMPTOMS: {@INPUT other current pain related symptoms} CURRENT PAIN MANAGEMENT PLAN: Pharmacologic: {@INPUT Pharmacologic @SEP="{@KEY enter}" Acetaminophen: {@REM Acetaminophen- select for dose, route, frequency}{@INPUT Acetaminophen dose, route, frequency} NSAIDs: {@REM NSAIDs- select for dose, route, frequency}{@INPUT NSAIDs dose, route, frequency} Morphine: {@REM Morphine - select for dose, route, frequency}{@INPUT Morphine dose, route, frequency} Hydromorphone: {@REM Hydromorphone - select for dose, route, frequency}{@INPUT Hydromorphone dose, route, frequency} Fentanyl: {@REM Fentanyl - select for dose, route, frequency}{@INPUT Fentanyl dose, route, frequency} Levorphanol: {@REM Levorphanol - select for dose, route, frequency}{@INPUT Levorphanol dose, route, frequency} Methadone: {@REM Methadone- select for dose, route, frequency}{@INPUT Methadone dose, route, frequency} Oxycodone:{@REM Oxycodone - select for dose, route, frequency} {@INPUT Oxycodone dose, route, frequency} Hydrocodone: {@REM Hydrocodone- select for dose, route, frequency}{@INPUT Hydrocodone dose, route, frequency} Oxymorphone:{@REM Oxymorphone - select for dose, route, frequency} {@INPUT Oxymorphone dose, route, frequency} Codeine: {@REM Codeine - select for dose, route, frequency}{@INPUT Codeine dose, route, frequency} Antidepressant: {@REM Antidepressant - select for dose, route, frequency}{@INPUT Antidepressant dose, route, frequency} Anticonvulsant: {@REM Anticonvulsant - select for dose, route, frequency}{@INPUT Anticonvulsant dose, route, frequency} Corticosteroid:{@REM Corticosteroid - select for dose, route, frequency} {@INPUT Corticosteroid dose, route, frequency} Topical agent:{@REM Topical agent - select for dose, route, frequency} {@INPUT Topical agent dose, route, frequency} {@REM Other-Enter med, dose, route, frequency on next screen}{@INPUT Enter med, dose, route, frequency} None. } Non-Pharmacologic: {@INPUT non-pharmacologic @SEP="{@KEY enter}" Ice: {@REM Ice}{@INPUT ice} Heat:{@REM Heat}{@INPUT heat} Massage: {@REM Massage}{@INPUT massage}


Acupuncture: {@REM Acupuncture}{@INPUT Acupuncture} TENS: {@REM TENS}{@INPUT TENS} Ultrasound:{@REM Ultrasound}{@INPUT ultrasound} Relaxation:{@REM Relaxation} {@INPUT relaxation} Guided imagery/hypnosis:{@REM Guided imagery/hypnosis} {@INPUT Guided imagery/hypnosis} None. {@REM select to type additional non-pharmacologic or further description on next screen}{@INPUT enter additional non-pharmacologic or further description} } RESPONSE TO CURRENT PAIN THERAPY: {@INPUT Response to current pain therapy @SEP="{@KEY enter}" Degree of pain relief: {@REM degree of pain relief-select to enter comments on next screen }{@INPUT enter degree of pain relief} Patient adherence: {@REM patient adherence- select to enter comments on next screen}{@INPUT enter comments regarding patient adherence} Pain medication adverse effects: {@REM Pain medication adverse effects}{@INPUTFILE adverse effects.txt} } PRIOR PAIN THERAPIES: {@INPUT enter prior pain therapies} SPECIAL ISSUES RELATED TO PAIN: {@INPUT special issues related pain @SEP="{@KEY enter}" History of substance abuse: {@INPUT further description of history of substance abuse} Risk for diversion: {@INPUT further description of risk for diversion} Psychosocial support: {@INPUT further description of psychosocial support} {@REM select for other special issues}{@INPUT enter other special issues} None. } PATIENT EDUCATION: {@INPUT Patient Education Pamphlet(s) @SEP="{@KEY enter}" Informational pamphlet(s) were provided and reviewed with the patient: Common Concerns About Medications for Cancer Pain (MC5236). Pain Control: A Guide for Those with Cancer and Their Loved Ones (ACS276845). Pain Control: Support For People with Cancer (NCI243542). Reinforced principles of pain medication administration and common side effect management. {@REM Free text regarding patient education}{@INPUT Free text regarding patient education} } {@REM Standard Patient Education Template}{@INPUT Standard Patient Education Template @SEP=", " {@REM Standard Patient Education Text}Ready to learn, no apparent learning barriers were identified; learning preferences include listening. Patient expressed understanding of the content. {@REM None} }


Example – Completed Pain Template in EMR


Outcome Evaluation – Chart Audit Tool

www.project-redcap.org

ConfidentialOutcome Evaluation Chart Audit - Pain Management MedOnc

Page 1 of 2

Outome Evaluation Chart Audit

Clinic Number __________________________________

Gender FemaleMale

Age __________________________________

Type of Visit Initial ConsultFollow-up

Date of Visit __________________________________

Primary Site of Cancer BreastGIHead & NeckLungSarcoma

Stage of Disease I / IIIIIIV

Care Provider StaffFellowNP/PA

RN Involved in Visit? YesNo

Docmentation of Pain Score YesNo

Current Pain Level 012345678910No pain score provided

Pain Assessment Documented YesNo

Assessment Documented By StaffFellowNP/PARN

Pain score consistent with provider note? YesNo

Is pain score reconciled in RN note? YesNo


www.project-redcap.org

ConfidentialPage 2 of 2

Prior Visit Pain Level 012345678910No pain score providedn/a (No prior visit)

Documentation of Treatment Plan YesNo

Treatment Plan Documented By ... StaffFellowNP/PARN

Reassessment Following Change in Therapy? YesNon/a

Bowel Regimen Addressed? YesNon/a

Bowel Regimen Addressed By ... StaffFellowNP/PARN

Patient Education Documented? YesNon/a (no needs identified, no change in rx, etc.)

Patient Education Documented By ... StaffFellowNP/PARN

Consistent with NCCN Guidelines? YesNo

Comments __________________________________


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