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Pain and JCAHO Readiness:
Pain Assessment of the Nonverbal Patient
Additional References:
City of Hope Pain/Palliative Care Resource Center website.
Scroll to IV. Special Populations & click on Pediatrics. Scroll to Educational Materials/Curriculum
Scroll to IV. Special Populations & click on Pain in the Elderly. Scroll to Guidelines/Clinical Pathways, then 5. State of the Art Review of Tools for Assessment of Pain in Nonverbal Older Adults.
Ware LJ, Epps CD, Herr K, Packard A. Evaluation of the revised faces pain scale, verbal descriptor scale, numeric rating scale, and iowa pain thermometer in older minority adults. Pain Management Nursing. 2006 Sep;7(3):117-25. [Available from Paul Arnstein 617-724-8517
pmarnstein [at] partners.org]
Herr K, Coyne PJ, Key T, Manworren R, McCaffery M, Merkel S, Pelosi-Kelly J, Wild L. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Management Nursing. 2006 Jun;7(2):44-52.
Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. Journal of Pain and Symptom Management. 2006 Feb;31(2):170-92.
Pasero, C & McCaffery, M. No self-report means no pain intensity rating. American Journal of Nursing 2005;105(10):50-53.
Arnstein P. Comprehensive analysis and management of chronic pain. Nursing Clinics of North America. 2003 Sep;38(3):403-17. [Available in Treadwell Library]
Range Orders for PRN Analgesics
Additional References:
Manworren RC. A call to action to protect range orders. A consensus statement supports this important nursing responsibility. American Journal of Nursing. 2006 Jul;106(7):65-8.
Pasero C, et al. IV Opioid Range Orders for Acute Pain Management. American Journal of Nursing. Feb 2007;107(2):52-59.
Gordon DB, Dahl J, Phillips P, Frandsen J, Cowley C, Foster RL, Fine PG, Miaskowski C, Fishman S, Finley RS; American Society for Pain Management Nursing; American Pain Society. The use of 'as-needed' range orders for opioid analgesics in the management of acute pain: a consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Home Healthcare Nurse. 2005 Jun;23(6):388-96.
Gordon DB, Dahl J, Phillips P, Frandsen J, Cowley C, Foster RL, Fine PG, Miaskowski C, Fishman S, Finley RS; American Society for Pain Management Nursing, American Pain Society. The use of "as-needed" range orders for opioid analgesics in the management of acute pain: a consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Management Nursing. 2004 Jun;5(2):53-8. [Available from Paul Arnstein 617-724-8517
pmarnstein [at] partners.org]
"PCA by Proxy"
PCA is the abbreviation for "Patient-Controlled Analgesia." PCA by proxy is an obsolete and confusing term that refers to the practice of a person other than the patient pushing the demand button on the PCA pump. The primary safety feature of PCA as a therapy is that the patient uses only as much analgesic as needed without significant sedation and no respiratory depression. In fact, if the patient begins to become sedated, s/he is no longer able to push the button and further sedation is prevented. This important safety feature is bypassed if another person pushes the button. Well-meaning family members and even clinicians who have misunderstood the treatment have caused significant harm to patients--including several deaths from opioid toxicity.
The MGH Patient Controlled Analgesia Procedure does not use this term (PCA by proxy). However, it does expressly state: "Only the patient should push the button for the demand dose. If the patient is unable to do so or cannot understand the relationship between pushing the button and pain relief, PCA therapy should be reconsidered." The patient/family education brochure on PCA, which was developed by PATA and PACU nurses, instructs families not to push the demand button.
There is some research evidence to support the safe use of the demand button by specifically authorized and trained people when the patient is unable to do so. However, this practice requires systematic selection, training, and close nursing supervision of the authorized party. MGH does not currently support this practice.
Additional References:
Patient controlled analgesia by proxy. Sentinal Event Alert #33 Dec 20, 2004
American Society for Pain Management Nursing (ASPMN) Position Statement on Authorized and Unauthorized (“PCA by Proxy”) Dosing of Analgesic Infusion Pumps.
Additional MGH Pain Resources
Sponsored by MGH Cares About Pain Relief
For additional information,
contact Paul Arnstein, PhD, RN
617-724-8517
pmarnstein [at] partners.org
This page last updated 26 February 2007