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Pain (any cause) Nurse Management Guidelines

Red Flag Exclusion Criteria

  • Child at risk of significant harm

  • Suspected non-accidental injury

  • Unplanned repeat ED presentation

  • Infant < 6 months

  • Pain score ≥ 7

  • Chest pain

  • Abdominal pain

  • History of workplace injury

  • Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Observation Charts

Additional Observations

Complete formal assessment of pain using one of the following methods.

Numerical rating score

  • Appropriate for patients aged 6-8 years and over

  • Ask patient ro rate pain on scale below (either verbal or point on scale)

Figure 1- National Institute of Clinical Studies (2011) Emergency Care Pain Management Manual

  • Pain Score Severity

    • No pain = Pain Score of 0

    • Mild pain = Pain Score of 1-3

    • Moderate pain = Pain Score of 4-6

    • Severe pain = Pain Score ≥7 (Red Flag)

Faces Rating Scale

  • Can be used for younger children (≥ 4 years). Also work well for people with a culturally or linguistically diverse background (CALD).

  • Ask patient to choose the face that best describes how they feel

Figure 2- National Institute of Clinical Studies (2011) Emergency Care Pain Management Manual / International Association for the Study of Pain

FLACC Behavioural Pain Assessment Scale

  • Can be used for paediatrics between 2 months and 7 years (also CALD).

  • Each of the 5 aspects is scored from 0 - 2. Scores are tallied to give a pain score 0 - 10.

Figure 3- National Institute of Clinical Studies (2011) Emergency Care Pain Management Manual / © University of Michigan Health System

Additional History

  • Thorough pain assessment:
    • Circumstances of pain onset / relieving factors

    • Location / intensity / radiation / characteristics of pain

    • Any other associated symptoms

    • Any treatment including previous medications

    • Medical / surgical history

Management Principles

  1. According to pain scale and medication standing orders, administer paracetamol or Panadeine®

  1. Under the following circumstances, administer ibuprofen for mild pain as an alternative to paracetamol

  • Allergy or contra-indication to paracetamol

  • Patient has received 1g of paracetamol within the last 4 hours

  • Patient has received 4g of paracetamol within the last 24 hours

  1. If patient has associated nausea, consider administration of an antiemetic as per Standing Orders

Ondansetron 4mg tablet / wafer


For adult patients ≥ 20 years only, administer metoclopramide with the following considerations:

  • Tablet: if patient has not vomited in the past hour and is tolerating small frequent amounts of oral fluid

  • Parenteral: if patient is currently vomiting and is unable to tolerate small amounts of oral fluid

  1. Reassess patient using appropriate pain scale to assess effectiveness of intervention
  2. Document assessment findings, intervention and outcomes.

References / Further Resources

  1. ECI Patient Factsheet - Pain Management

  2. ECI Patient Factsheet - Back Pain

  3. Acute Pain Management: Scientific Evidence (4th edition) - Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine

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