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Advancing Excellence in Pain Assessment (Part 2)

December 10, 2008
by Steven B. Littlehale, MS, GCNS-BC, Jane M. Niemi, MSN, RN, LHNA, and Sheila G. Capitosti, MHSA, RNC, NHA
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Elements for an effective pain management program

This approach involves administration and evaluation of pain medications in a sequence of nonopioids, such as NSAIDs/acetaminophen; mild opioids such as hydrocodone; and then strong opiods such as morphine. The approach should be individualized and dosage should start low and increase until the desired level of pain control is reached by the resident. Medications can be administered around the clock, as needed, or in a combination approach. PRN (as needed) medications are effective for breakthrough pain but should not be substituted for regularly administered medications. If the resident has received frequent PRN medications, pain is not being effectively managed. When side effects occur, consider lowering the dose of the opioid and introducing an NSAID. This is an effective way of getting control of the side effect, while not losing control of the pain.


Monitoring and documenting the effectiveness of the resident’s pain management program is a crucial step that is often missing from a comprehensive pain management program. The effectiveness of the regimen should be clearly assessed and documented before making any changes to the plan of care. Staff should be educated on pain assessment on a regular basis, including the use of standardized pain assessment tools and cross walking the scoring of these tools to the MDS. Direct care staff assignments should be consistent whenever possible to allow staff to become familiar with the resident and their responses to the pain management plan of care. Adverse side effects of medication need to be monitored and evaluated. The plan of care must include interventions to minimize side effects that are anticipated and/or experienced by the resident.

If pain medication is found to no longer be needed, the facility is expected to discontinue or taper the dose. If discontinuing the medication is not indicated, this should be clearly documented. If the facility finds it is not successful in adequately controlling a resident’s pain and/or side effects, other resources such as consultation with pain centers and hospice organizations, can be helpful and may be appropriate.

Assessment of pain management programs is the final step in ensuring a successful overall program. Assessments should not only include evaluation of the effectiveness of resident-specific pain management programs as already described, but also evaluation of facility-level pain management policies and procedures. Aggregate data related to an individual resident’s response to a pain management program should be a part of the facility quality improvement program and reviewed on a regular basis.

When data indicate that management of resident-level pain is not successful, a review of facility-level pain management policies and procedures and adherence to the key processes of effective pain management—screening, assessment, care planning, implementing the plan and monitoring effectiveness—is in order. Ongoing assessment of both resident-level and facility-level pain management processes through the facility quality improvement program will ensure success in management of resident pain.

Steven B. Littlehale, MS, GCNS-BC, is Executive Vice President, HealthCare and Chief Clinical Officer; Jane M. Niemi, MSN, RN, LHNA, is National Account Manager, Organizational Performance Management, and Sheila G. Capitosti, MHSA, RNC, NHA, is National Account Manager, Quality Improvement Services, PointRight, Inc. (formerly LTCQ) based in Lexington, Massachusetts. PointRight Inc. is a company committed to improving the quality of care in long-term and post-acute settings by providing information-based clinical management tools and services to providers, payers, regulators, suppliers, and consumers. For further information, phone (781) 457-5909 or visit