Document Title: PAIN AND ITCH ASSESSMENT AND MANAGEMENT FOR THE

BURNS PATIENT (ADULTS)

Document 15025 Version Number: 2.0

Reference/Register no:

Document type: (Policy/ Guideline To be followed by: Burns specific Medical &
Guideline/ SOP) (Target Staff) Nursing Staff

Ratification Issue Date: 14th January 2019 Review Date: 13th January 2022
(Date document is uploaded
onto the intranet)
Developed in response to: Best Practice

Contributes to HSC Act 2008 (Regulated Activities) Regulations 2014(Part

3); and CQC Regulations 2009 (Part 4)
CQC Fundamental Standards of Quality and Safety: 9,11
Issuing Integrated Pain Management Service
Division/Directorate:

Author/Contact: (Asset Jayne Somerset, CNS, IPMS

Administrator)
Hospital Sites: MEHT
(tick appropriate box/es to □ BTUH
indicate status of policy □ SUH
review i.e. joint/ independent)
Consultation: (Refer to page 2)

Approval Group / n/a Date: n/a

Committee(s):

Professionally Approved Dr David Barnes Date: 10th December 2018

by: (Asset Owner) Clinical Lead for the Burns Department

Ratification Group(s): Documents Ratification Approval Date: 8th January 2019

Group Chair’s Action

Executive and Clinical
Directors (Communication of
minutes from Document
Ratification Group
Date: January 2019 Distribution Hard copies to all wards-Burns
Method: Reference Folder in Metavision
(EPR), & departments. Intranet &
website.
Staff meetings and email
 Adult Burns Patients Pain & Itch Management/ 15025/2.0

Consulted With: Post/ Approval Committee/ Group: Date:

Dr Tom Durcan Lead Consultant for Acute Pain 10/12/2018
Dr Patricia Richardson Consultant Anaesthetist
Dr Pete Berry Consultant Anaesthetist
Lynne Mustard IPMS Service Manager
Jackie Wallis Burns Pharmacist

Related Trust Policies (to be read
in conjunction with)
Policy for the Use of Medicines
Observation Policy
06001 Management of Procedural Pain
06000 Use of Entonox for Procedural Pain
06007 Severe Pain Management
06043 Oral Ketamine or Midazolam in Burns patients
09072 Intranasal Diamorphine for Burns Patients
11027 Pain Assessment and Management on Wards

Document Review History:

Version No: Authored/Reviewer: Summary of amendments/ Issue Date:
Record documents superseded by:
1.0 Jayne Somerset 22nd December 2015
2.0 Jayne Somerset/Patricia Full Review 14th January 2019
Richardson

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 Adult Burns Patients Pain & Itch Management/ 15025/2.0

INDEX

1. Purpose

2. Background

3. Scope of Practice

4. Staff and Training

5. Pain Assessment

6. Pain Management

7. Infection Control

8. Non-Compliance with this Guideline

9. Audit & Monitoring

10. References

11. Appendices

Appendix 1: Pain and Itch assessment Score Chart

Appendix 2: Procedural pain relief for burn wound inspections
Appendix 3: Abbey Pain Score and guidance
Appendix 4: Adult Acute Pain Management Protocol
Appendix 5: Itch Management Algorithm
Appendix 6: Preliminary Equality Analysis
Appendix 7: Equality Impact Assessment

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1. Purpose
1.1 The guideline has been developed to assist in the pain assessment and management
of patients who have suffered burns. This covers both immediate, post burn
rehabilitation, and procedural burns pain assessment and management. The guideline
has been developed for patients who are 18 years or older. Note there is a separate
guideline for Paediatric management in this group.

2. Background

2.1 Burn injuries are very painful and the intensity of the pain can be difficult to predict
from the visual appearance of the injury and the size of wound. Deep burns can be
relatively painless but burns are often not of uniform depth. Fear, anxiety and pain on
previous inspection of the injury can lead to worse pain than the healthcare worker
may expect, and with healing, the pain will evolve, making it better, or sometimes
worse. Consequently, an effective assessment of pain is necessary to guide titration
of analgesia.

2.2 Healing burns can also be very itchy. The mechanism of this is not clearly defined but
involves nerve pathways often associated with pain transmission. Gabapentin has
been shown to be effective in the management of itch, but there is no ‘one size fits all’
therapy. The antihistamines have also been shown to be of some benefit, especially
in combination with gabapentin. As with the management of pain, itch intensity must
be assessed and documented to guide therapy.

2.3 Implementation of the guidelines should have minimal impact on staff workload or
cost of service but will have a significant positive effect on quality of patient care.
Improvement in the quality of pain and itch management strategies will reduce patient
suffering, enhance psychological well-being and functioning and may reduce the
anxiety felt by patients with regard to potentially painful clinical procedures. Good
quality pain management in the acute phase of burn injury may reduce the incidence
of chronic pain syndromes in the later phases of recovery.

3. Scope of Practice
3.1 The guideline is intended to be used to help all nursing, relevant allied health care
professionals, and medical staff in the accurate assessment and management of pain
and itching for patients who have suffered any degree of burn injury. Further it is
aimed to guide the doctor in prescribing the most appropriate analgesia required to
treat burn pain.

4. Staff and Training

4.1 Approved guidelines are accessible from the staff intranet under clinical guidelines.

4.2 In addition, the clinical guideline will be disseminated to the ward through Pain Link
nurses within their ward setting.
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4.3 The new guideline will be introduced to anaesthetic staff through anaesthetic
meetings.

4.4 Pharmacy are involved and made aware of the new guideline.

4.5 Training and education is provided by the IPMS (integrated pain management
service), both formally and informally for all clinical staff. The IPMS is available for
advice and consultation via the pager system, and through the PAS referral system.

4.6 Corporate services will ensure that the guideline is uploaded to the intranet and
notified to staff via Focus.

4.7 Awareness of the guideline and the cascading of information within it can be
conveyed in the twice daily consultant-led ward rounds carried out on the Burns Unit.

5. Pain Assessment

5.1 All burns patients should have their pain and itch score assessed. Pain scores are the
‘fifth vital sign’, and should be recorded at least twice a day while the patient is in the
hospital. Greater frequency of assessment is indicated if pain is uncontrolled, and
when analgesic responses require regular evaluation.

5.2 Additional pain assessment is essential to determine analgesic needs for patients
undergoing painful procedures such as dressings, manipulation or physiotherapy.
Pain should be scored and recorded before, during and after all potentially painful
procedures.

5.3 Management of pain must be individually tailored according to the patient’s

requirements, own choices and clinical status. A holistic approach is required,
addressing anxieties and queries as part of the pain management.

5.4 Patients requiring expert support to establish objective pain assessment and
management, such as vulnerable adults, non-English speaking patients, and or the
cognitively impaired, must be referred to the appropriate specialty as indicated.
Separate assessment tools can be used. For cognitively impaired – the Abbey Scale
(see Appendix 3), for non-English speaking patients – Translated assessment tools
can be requested.

5.5 A specific combined Pain and Itch (See Appendix 1) assessment tool is used on the
Burns Unit.

6. Pain Management

6.1 Analgesic prescriptions and administration must be evidence-based, and multi-modal,

taking into consideration variability in individual responses, and contra-indications or
cautions for certain clinical conditions.

6.2 All staff prescribing or administering analgesia, are responsible, and accountable for
understanding the actions and adverse effects of the drugs given.

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6.3 Analgesic needs must be evaluated regularly, as clinically indicated, and tailored
accordingly. Escalation or reduction of dosage, change or cessation of drugs must be
based on clinically sound evaluation.

6.4 Non-pharmacological pain management strategies should be used in addition to

pharmacological methods whenever available and appropriate.

6.5 Patients with complex pain issues which are unresponsive to standard analgesics
may be referred to the IPMS for advice and further management.

6.6 Sources of information for analgesic doses and actions are: Pharmacy dept., IPMS,
BNF (British National Formulary).

6.7 An analgesic ladder specific to the Burns Unit has been formulated from evidence
based information, hard copies can be found within the unit (See Appendix 4).

6.8 A Burns specific quick reference algorithm tool is used to manage Procedural pain
specific to this group (See Appendix 2)

6.9 A specific Itch management algorithm is used within the Burns Unit (See Appendix 5).

7. Infection Control

7.1 The Trust policy for prevention of cross infection is to be adhered to for all patient
contact procedures. The infection prevention practice within MEHT is for all staff to
have strict hand hygiene before and after patient contact. Any equipment must be
cleaned between patients unless it is a single use item which will be disposed of
appropriately as per the Waste Management Policy.

7.2 Use Aseptic Non-Touch Technique (ANTT) when administering injections.

8. Non-Compliance with this Guideline

8.1 Failure to provide regular assessment and effective pain management is a breach of
patient rights, and has clinical and non-clinical repercussions:
 Patient satisfaction and well-being is compromised
 Accountability and professional responsibility is breached
 Clinical risk is increased, due to multi-systemic influence of pain
 Delayed discharge from hospital decreases Trust efficiency and increases risk of
hospital-inquired infection

8.2 A Datix form should be completed and submitted to the Risk Management
Department for non-compliance with this guideline.

8.3 Incidence of clinical risk or patient complaints resulting from non-compliance with this
guideline are to be recorded via the central risk events database and PALS (Patient
Advisory Liaison Service) if involved.

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9. Audit & Monitoring

9.1 The use of this guideline will be monitored by review of any reported incidents and
annual audit.

9.2 Clinical meetings for Link nurses are held three times a year. Potential audit
discussion and problems can be evaluated in this meeting.

9.3 The IPMS manager and lead consultant will liaise at corporate level to put strategies
in place to address issues that may arise.

9.4 Pharmacist involvement within the Burn’s Unit review individual patient prescription
charts. Issues that may raise concern can be readily discussed with the patient’s
medical or surgical teams.

9.5 Daily patient ward rounds are carried out within the Burns Unit. Any incident that may
arise can be discussed and reported to the relevant persons at that time.

10. Equality Impact Assessment

10.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that
is fair, accessible and meets the needs of all individuals.
(Refer to Appendix 7)

11. References
Goutos, I, Clarke, M, Upson,C, Richardson, Pand Sudip J. Ghosh (2010) Review of
therapeutic agents for burns pruritus and protocols for management in adult and
paediatric patients using the GRADE classification. Indian Journal of Plastic Surgery
Sep 2010, vol. 43, p. S51.

P. Richardson, L. Mustard (2009) The management of pain in the burns unit. Journal
of the International Society for Burn Injuries Nov 2009 vol. 35, no. 7, p. 921-936

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APPENDIX 1 Pain and Itch Score chart

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Appendix 2
Procedural pain relief for burn wound inspections
The following is guidance to provide direction only.
Senior (consultant) advice is always available if the best course of action is unclear.

Initial burn assessment

Age, co-morbidities, burn, mechanism and mental state will all need to be taken into account when
planning analgesia hence location for assessment of a burn injury.

>20% Burn assessment under GA required on admission

10-20% Assessment under GA required. Timing to be decide by senior staff

5- 10% Likely to require GA. Those admitted late and/or unstarved to wait until morning

<5% Oral/intranasal analgesia or entonox should be considered.

Injuries that require surgical excision within 24 hours should have minimal intervention on admission.
Take photographs and dress burn with jelonet for comfort.

Analgesics useful for burns procedures

The following information is a guide ONLY to aid the choice of analgesic. Onset /offset times will vary
and renal/ hepatic failure will prolong the effects of opiates; children and the elderly tend to be more
sensitive. Always review information from previous procedure.

Short acting Medium acting Antedotes:

Entonox. Can be used to
supplement other analgesia.
May cause nausea.
Onset:15secs/Offset 45sec
Intra nasal diamorphine
Protocol on intranet. Not for
use < 10kg or 1 yr
Onset: 5 mins/ Offset 30 mins
Fentanyl lozenge
(not for patients < 16 years)
200mcgs - 600mcgs dose
(depending on previous
opiate use)
Onset: 5-15 mins/ offset 60
mins
Effects can last up to 4 hours.
Consider lower dose in opiate
naive patents and the elderly
Oramorph
0.2mg/kg (check BNF under
1yr)
Onset: Highly variable. 30 to
90 minutes
Offset: Variable. 2-3 hours
Oral ketamine (anesthetist
only to prescribe)
Onset: Highly variable but
likely within 40 mins
Offset: Highly variable, may
be several hours
Always call a doctor if
administered. Antedotes
often require re-
administration as short acting
Naloxone for opiates
e.g. oramorph, morphine ,
diamorphine, fentanyl
Adult: 400mcg repeated if
necessary
Child: 100mcg-400mcg
Flumazenil for
benzodiazepines
e.g. midazolam, diazepam
Adult: 200mcg/15secs IV
Child: 10mcg/kg every minute
(max per dose 200mcg)
Please check BNF for
guidance

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General points when considering analgesic regimes

In-patients and out-patients

Adults and Children

Background pain should be controlled as part of managing procedural pain.

In-patients should receive regular paracetamol, and ibuprofen where appropriate **.

The use of distraction should always be considered.

Out patients should be advised to take paracetamol and ibuprofen (where appropriate, see
below) before leaving home.
Adults Children

The elderly are particularly sensitive to Avoid intra-nasal diamorphine in patients

opiates and reduced doses should be under 10kg and under 1 year.
considered.
Neo-natal analgesia is a specialist area.
If opiates are used, the patient should be Refer to protocol on metavision.
advised not to drive.
DVLA guidance states that drivers can drive
a car ONLY whilst taking the prescribed dose
opiates AND if they feel their ability to drive is
not impaired. It is an offence to drive
otherwise and is the driver’s responsibility to
gauge this. It is an offence to drive after
ketamine use. (See DVLA website for details)

**NSAID drugs are effective analgesics, especially in inflammatory (e.g. donor site) pain, but have
notable contraindications due to their wide spread effects. Do not use in patients with compromised
renal function, including the elderly, resuscitation burns, those with peptic ulceration or significant
cardiovascular/cerebro-vascular disease.
Check with BNF for a full list of contra-indications.

Principles of good management

Patients should not suffer undue pain. Negative consequences of pain are wide ranging and include
heightened anxiety and enhanced pain perception at subsequent burn wound inspections. If undue
pain or distress during any procedure it must STOP and a more effective analgesic method be
employed. Management options include require wrapping of the wound and preparing for a GA* with
appropriate starvation and planning theatre time.

Each and every burn and patient is unique and it is not possible to provide a ‘one size fits all’ method
of analgesia. Feedback from previous procedures is the best guide for an individual.

Assessment of pain should be continuous throughout. Please record pain scores on the dressing
chart from before, during and after the procedure with your advice for the next procedure.

Partial thickness skin loss (e.g. scalds and TENS) results in exposed intact nerve ending. These
injuries are notoriously painful. Please handle the wound with great care.

P Richardson Nov 2018

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APPENDIX 3 Abbey Pain Score and Guidance

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Adapted ABBEY PAIN AND AGITATION ASSESSMENT GUIDANCE Appendix 3

 Pain is scored on movement or activity, i.e. mobilising, moving in the bed, moving a particular joint that may be painful

 To be used for all patients with diagnosis of dementia, or cognitive impairment

 If patient is asleep document asleep in care documents. Wake the patient to assess pain only if clinically required, e.g. clinical deterioration, post-operative observations, etc.
 Comments about pain behaviours by family or usual care givers can be useful

Documentation
SCORE
Document pain score in care round document. WhereABSENTadditional analgesiaMILD (PRN) is required document what was MODERATE
given in the care document indicating a variance (V) SEVERE
in care. SCORE
0 1 2 3
Re-assess pain, and document in care document the effect. An Abbey pain score here is all that is required, do not write ‘given with good effect’ for example.
VOCALISATION Occasional moan or groan, *patient Negative low level speech e.g. whimpering on Repeatedly crying out, constant loud moaning or
If the patient’s pain is not controlled the patient may require additional analgesia, or a different type of analgesia, e.g. an anti-neuropathic analgesic. Also, consider this may be agitation and not pain
*Some patient’s may be able to vocalise None complaining of pain e.g. ‘it’s a bit movement, *patient complaining of pain e.g. ‘it’s crying, *patient complaining of pain e.g. ‘it’s
related – reassessment is key. Giving opiates to a patient who is agitated and not in pain can cause respiratory depression.
their pain directly sore’, ‘it’s slightly painful’ very painful’, ‘it only hurts when I move’, ‘it’s very agony’, ’it’s excruciating’
sore’
FACIAL EXPRESSION Smiling, Looking tense, especially when Sad, frowning Grimacing, patient looks frightened, crying,
relaxed approached by care giver appears angry or disgruntled
CHANGE IN BODY LANGUAGE None Tense, fidgeting, fiddling with Guarding part of the body Withdrawn, rigid, fists clenched. Knees pulled up.
possessions / dressings Body tensed
BEHAVIOURAL CHANGE Refusing to eat, agitated, rocking, alterations in Pulling or pushing away, aggressive outbursts
None Increased confusion usual pattern (think about the patient’s pre-
admission behavioural pattern).

PHYSIOLOGICAL CHANGE Occasional laboured breath, Increased heart rate and BP, change in Change in pulse, BP, respiratory rate and
Normal increased heart rate respiratory rate e.g. may increase or decrease, perspiring, flushed or pallor. Panicking,
patient holding their breath to brace themselves hyperventilating
for moving
PHYSICAL CHANGES
**The list is not exhaustive, these are None **Skin tears, morning stiffness from **Pressure sores, arthritis, post fall injuries, 1- **Immediate to 1-2/52 post- surgery, trauma,
examples only and are dependent on the arthritis 2/52 post uneventful recovery from surgery multiple pressure sores, fractures, conservatively
patient and their pain treated fractures, abscesses

TOTAL SCORE:

0-2 = NO PAIN 3-7 = MILD PAIN 8-13 = MODERATE PAIN 14+ SEVERE PAIN
Monitor for any pain behaviour Consider Paracetamol Consider paracetamol plus Ibuprofen if no Consider paracetamol plus Ibuprofen if no
Ibuprofen if no contraindications contraindications contraindications
Comfort measures, positional change, Plus mild opiate e.g. buprenorphine patch for Plus opiates for example, Oramorph
heat, chronic pain START LOW AND GO SLOWLY TO TITRATE

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Appendix 4
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Appendix 5: Itch management algorithm

MEHT Itch management algorithm

Step 3 Step 4

Cetirizine Chlorpheniramine
Adult:
5mg bd or 10mg od

Child: Adult:
2-6 years 2.5mg bd or 4mg tds to 4 hourly
5mg od
6-11 years 5mg bd
>12 years 10mg od
Step 2
and
Gabapentin
Cyproheptadine Child:
Adult: 1-2 years 1mg bd
Day 1 300mg od Adult: 2-5 years 1mg 4-6 hourly
Day 2 300mg bd 4mg od up to qds 6-12 years 2 mg 4-6 hourly
Day 3 300mg tds Max dose 20mg/day

Child:
Day 1 5mg/kg od Child:
Day 2 5mg/kg bd 2-6 years 2mg bd/tds
Day 3 5mg/kg tds (max dose of 12mg/day)
Step 1 Increase to 10mg/kg 7-14 years 4mg bd/tds
per dose if ineffective (max dose 16mg/day)
Moisturise and cool and tolerated well

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Appendix 6: Preliminary Equality Analysis

This assessment relates to: Adult Burns Patients Pain & Itch Management 15025

A change in a service to patients A change to an existing policy X A change to the way staff work

A new policy Something else Review and update of appendices

(please give details)
Questions Answers

1. What are you proposing to change? Review and update of appendices

2. Why are you making this change? Update clinical practice

(What will the change achieve?)

3. Who benefits from this change and how? Patients and clinical staff provided with evidence based up to date research

4. Is anyone likely to suffer any negative No

impact as a result of this change? If no,
please record reasons here and sign and date
this assessment. If yes, please complete a
full EIA.

5. a) Will you be undertaking any Yes

consultation as part of this change?
b) If so, with whom? Refer to page 1 & 2
Preliminary analysis completed by:

Name Jayne Somerset Job Title Governance pain CNS Date 03/12/2018

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