Nursing

RN/DREXEL Home Study Program CE CENTER

CE credit is no longer available for this article. Expired July 2005

Originally posted July 2004

KAREN LAFLEUR, RN, MSN, CCRN, CCRC

KAREN LAFLEUR is an acute care clinical nurse specialist at Mercy Medical Center in Springfield, MA.

Despite a heightened awareness of the importance of pain management, many patients fail to get optimal relief. You can help reverse that pattern.

Despite our best intentions, healthcare providers often fall short when it comes to addressing patients' pain. It's estimated, for instance, that up to 75% of surgical patients fail to receive adequate pain relief.^1,2

The consequences can be severe. Undertreatment of pain can lead to complications such as infection due to an impaired immune system, and can often result in longer hospital stays, higher costs, and negative outcomes.¹ In addition, pain that's unrelieved often causes or contributes to both patients' and family members' psychological distress and dissatisfaction.

Over the past decade, there's been increasing recognition of the importance of properly assessing and managing pain, designated "the fifth vital sign" by the American Pain Society in 1995.³ In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced new pain management standards aimed at upholding patients' right to effective assessment and treatment of pain from admission to discharge.² More recently, groups such as the Institute for Clinical Systems Improvement and the National Pharmaceutical Council have issued new or updated pain management guidelines.

So why do we continue to undertreat pain and what can you do to change things?

Avoid these barriers to effective pain relief

Pain can be caused by virtually anything: illness, medical or surgical procedures, trauma, immobility, wounds, even such routine nursing care as turning or starting an IV. It may be acute (resolves when the underlying injury heals) or chronic (lasting longer than the healing period).¹

Whatever the cause or the duration of pain, however, the same principle applies: A patient's self-report is the most reliable indicator of the intensity of his pain. Because pain is subjective and patients undergoing the same procedure can experience markedly different levels of discomfort, it's crucial to believe and respond quickly to a patient who tells you he's in pain.⁴

Unfortunately, there are numerous barriers to effective pain management among both patients and clinicians. Age, gender, culture, ethnicity, or religious beliefs may not only affect a patient's perception of pain, for example, but how or whether he seeks pain relief.

Some patients may hesitate to report pain because they don't want to be seen as "difficult," or consider it a sign of weakness to complain. Others may not want to take analgesics because of the side effects or because they fear drug addiction.¹ And patients who are cognitively impaired or unresponsive may not be able to report their pain or ask for pain relief at all.⁵

Healthcare providers' attitudes may affect their actions as well.¹ Your opinion of how much pain relief a patient needs or how a patient in pain should look or act, for instance, can lead to undertreatment—as can the belief that a patient is exhibiting drug-seeking behaviors.

A physician's or nurse's lack of understanding of medications or alternative therapies for pain may also interfere with treatment.² Concerns about serious adverse reactions such as respiratory depression, for example, may lead to unnecessary limits on the amount of analgesic a patient gets. Following practice guidelines and standards can help overcome such barriers to effective pain relief.^4,6

Every patient needs a pain assessment

Talk to patients about pain when they arrive at the hospital or on your unit. Explain that pain management is a key part of patient care and that it's important that they tell you when they're in pain.

Whenever possible, include the family in your discussion. It may help to use printed materials, such as the patient handout.

A patient who acknowledges having pain will need a thorough pain assessment to identify both new and existing problems.⁴ Ask about the location and intensity of the pain and whether it's continuous or intermittent.⁷ Tell him to describe the pain in simple terms, such as sharp, dull, crushing, or squeezing. Determine when it started, how often it occurs, and whether or not the intensity has changed recently. Find out, too, what makes the pain better or worse and whether there's anything he has done to relieve it.

Picking the right assessment scale

There are several scales you can use to gauge the intensity of a patient's pain. Each has advantages and limitations, depending upon the patient's age, communication skills, cognitive ability, and physical impairment.⁶ For consistency, it's best to use the same tool throughout the patient's stay.

The numeric rating scale (NRS), verbal graphic rating scale (VGRS), and Wong-Baker FACES scale are among the most common assessment tools. With the NRS, you simply ask the patient to rate his pain on a scale of 0 – 10, with 0 indicating no pain and 10 representing the worst imaginable pain.¹

The VGRS requires patients to rate the intensity of their pain by using words such as "none, mild, moderate, or severe." And the Wong-Baker FACES scale, consists of a series of drawings of facial expressions ranging from happy to sad, with a number assigned to each face. It's ideal for children older than age 3, as well as for adults who are unable to speak or are cognitively impaired but can point to the expression that best matches how they feel.⁸

If your patient can't communicate at all, you can use observation to do your assessment. Grimacing, rigidity, wincing, closing eyes, moaning, and clenching fists are common indicators of pain.⁹ The Face Legs Activity Cry and Consolability (FLACC) tool, described in the "The Face Legs Activity Cry and Consolability (FLACC) pain scale" box, is a behavioral assessment scale that uses body movements and sounds to assess the pain of infants and toddlers as well as cognitively or verbally impaired patients.

Physiologic changes can also play a role—albeit a limited one—in pain assessment. Patients in acute pain may experience physiologic changes as a result of the activation of the central nervous system. The catecholamine stress response can lead to elevated blood pressure, tachycardia, tachypnea, dilated pupils, diaphoresis, and muscle tension.^4,5 Unfortunately, though, many medications can block or prevent these changes, and patients with chronic pain often have normal vital signs.⁵

So what role can behavioral and physiological indicators play? They may help to reinforce what the patient has told you about his pain and, on the flip side, they may help to identify patients who are too stoic or fearful to honestly report their pain.

Define a goal before starting therapy

Once you've identified a patient who needs treatment for pain, alert his healthcare provider immediately. Talk to the patient about his attitudes and expectations regarding pain and analgesics, whenever possible, before initiating treatment. Find out whether he expects to be entirely pain-free, and alleviate his fears by assuring him that much can be done to bring relief.^5,6

Ideally, the patient and his healthcare team will work together to establish an acceptable target—a 3 on a scale of 0 – 10, for example, and the providers will work to keep the pain at or below that level.

Keep in mind, however, that there's considerable variation in the amount of pain that patients are willing or able to tolerate and that pain relief goals should be frequently reassessed.

Simple measures may bring relief

While treatment may include non-pharmacologic interventions, medications, or both, always begin by checking for easily correctable causes of pain or discomfort. Examine dressings, casts, and wounds for signs of infection or irritation, for instance.⁵ Easing a patient's pain is sometimes as simple as changing his dressing or catheterizing him.

If the patient is not in severe pain, stimulating the skin with hot or cold compresses, vibration, or massage may bring relief.^5,6 A quiet environment and diversions such as music therapy, pet visitation, or television may reduce stress and discomfort, as well.^4,6 Even such simple measures as adjusting the room temperature or the patient's position, providing a glass of water or pillows, or keeping the bed clean, dry, and free of wrinkles may be helpful.⁵

Anxiety frequently accompanies pain—and can intensify it. You can address your patient's anxiety by reassuring him that you'll do all you can to relieve his pain, and by building a trusting relationship with him and his family. If your patient can't relax, discuss the patient's need for anti-anxiety medications or sedatives with the physician. If necessary, explain to the patient the differences between sedatives and analgesics, emphasizing that anti-anxiety meds won't relieve pain.

Most pain patients need drug therapy

Non-opioids and opioids are the hallmarks of pain management. Depending upon the patient's condition and level of pain, adjuvant therapies may be used, as well.⁵

Non-opioids include acetaminophen and non-steroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin), naproxen (Anaprox, Aleve, others), and fenoprofen (Nalfon). They're typically prescribed for mild pain¹ and are generally well tolerated. However, adverse reactions can occur if a patient is intolerant to aspirin, or has impaired platelet function or a history of gastric bleeding, for example.

Opioids, which have an immediate onset of action, are used most often for acute pain and cancer pain that is moderate to severe.⁴ There are two main categories of opioids: mu agonists, which include morphine (Duramorph, Roxanol, others), hydromorphone (Dilaudid), and fentanyl (Duragesic, Actiq, others); and agonist-antagonists. Mu agonists, and especially morphine, are more frequently used than agonist-antagonists, which include buprenorphine (Buprenex) and butorphanol (Stadol).⁴

Patients who take opioids for an extended period of time—typically, more than a week—may begin to develop tolerance and physical dependence.^4,6 Tolerance is a state of adaptation that occurs as the body becomes accustomed to the drug and dose; once it develops, the patient requires progressively higher doses to obtain the same effect. Physical dependence refers to the appearance of signs and symptoms such as sweating, dilated pupils, tachycardia, vomiting, hypertension, fever, irritability, and anxiety when the drug is withdrawn or the dose rapidly decreased.^4,6

Be sure your patient understands that tolerance and physical dependence are expected responses to the continued use of opioids and aren't necessarily evidence of addiction. Reassure patients that even if they develop tolerance, they'll still receive enough medication to relieve their pain, and that the symptoms of physical dependence can be avoided or minimized by gradually reducing the dose over several days.

Explain that addiction is characterized by a loss of control over a drug and a preoccupation with obtaining more of it despite being pain-free.⁴ And reassure him that patients being treated with opioids for pain rarely develop addiction.¹

Adjuvant therapies, including antiemetics, psychotropics, antidepressants, and anticonvulsants, are typically administered primarily for other purposes but often bring some measure of pain relief. Taking an antiemetic to relieve nausea that's a side effect of morphine, for instance, or antidepressants or antipsychotics for an underlying psychiatric disorder can lead to an improvement in function and sense of well-being.^1,4

Take a moment when giving that med

Before administering any pain medication, check to see that you are giving the right drug to the right patient, and that the dose and route ordered are appropriate for the patient's age, weight, and comorbidities.⁴ Check for allergies, and evaluate the patient's medication history, including his use of over-the-counter products and alternative medicine. In addition, be alert for potential drug interactions.

Although there are many methods of administering pain medication, the oral route is usually preferred for patients who can easily swallow because it's safe and convenient. IM administration is avoided, if possible, because of both the risk of abscesses with continued use and pain from the injection.⁴ IV administration typically requires smaller but more frequent doses than IM administration, and may be preferable when a patient needs to receive medication continuously.⁶

Show patients who will receive patient-controlled analgesia (PCA) how the pump works and how to use it. Encourage them not to wait for the pain to get severe before hitting the button on the PCA pump, and reassure them that the device is designed to prevent them from getting more medication than the prescriber ordered. Finally, stress that the patient himself should be the only one to activate the pump.

Analgesics should be administered on a schedule or continuously, with bolus dosing as needed for breakthrough pain.^5,6 Giving pain meds prn isn't recommended because of the possibility of long delays in treatment. Allowing pain to build makes it more difficult for the medication to bring adequate relief.

If your patient has been prescribed pain meds on an as-needed basis, however, tell him to ask for medication before participating in an activity or undergoing a procedure, such as a dressing change, that might be painful. Instruct him to notify you immediately if the medication is not working or he experiences excessive sleepiness, nausea, vomiting, rash, constipation, difficulty breathing, dizziness, or a change in his mental state.

Assess how well the patient's pain is being managed just before administering any analgesic and no more than an hour after giving it.⁵ If the medication hasn't reduced the pain to an acceptable level, ask the doctor to reevaluate the plan of care.^5,6

Documentation is a crucial part of that plan of care. Record your initial pain assessment, interventions, and drug treatment, and the results of each reassessment, according to your facility's policies.

JCAHO's pain management standards require that a patient's need for pain management be addressed not only throughout his hospitalization, but as part of the discharge process as well. Tell the patient who will go home with a prescription for analgesics to contact his healthcare provider if the pain intensifies. Similarly, remind the patient who is pain-free to contact his doctor if he develops pain.

Your attention to your patient's pain relief will send him an important message. It will tell him that you and the rest of his healthcare team will always take his complaints of pain seriously and that you will do everything you can to help provide him with relief. Your patients deserve nothing less.

REFERENCES

1. National Pharmaceutical Council and the Joint Commission on Accreditation of Healthcare Organizations. "Pain: Current understanding of assessment, management, and treatments." 2001. www.jcaho.org/news+room/health+care+issues/pain+mono_npc.pdf (22 Apr. 2004).

2. Phillips, D. M. (2000). JCAHO pain management standards are unveiled. JAMA, 284(4), 428.

3. American Pain Society. "Pain: The fifth vital sign." 1995. www.ampainsoc.org/advocacy/fifth (22 Apr. 2004).

4. McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd ed.). St. Louis: Mosby.

5. Nettina, S. M. (Ed.). (2001). The Lippincott manual of nursing practice (7th ed.). Philadelphia: Lippincott Williams & Wilkins.

6. Jacobi, J., Fraser, G. L., et al. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med, 30(1), 119.

7. Puntillo, K. A. (2003). Pain assessment and management in the critically ill: Wizardry or science? Am J Crit Care, 12(4), 310.

8. Wong, D. L., Hockenberry-Eaton, M., et al. (1999). Whaley and Wong's nursing care of infants and children (6th ed.). St. Louis: Mosby.

9. Puntillo, K. A, White, C., et al. (2001). Patients' perceptions and responses to procedural pain: Results from Thunder Project II. Am J Crit Care, 10(4), 238.

Patient Information

Pain relief

Pain is a common part of illness and medical treatment, but everyone experiences it differently. It's important that you answer your healthcare provider's questions about pain honestly so that he can treat it. The following information should help you during that discussion.

Pain facts

• Pain can be acute (lasting only a short time) or chronic (lasting a long time).

• Although pain is common after surgery and with many illnesses, most patients can be kept comfortable with simple treatments.

• You are the only one who really knows if you're in pain and how bad it is. There are no tests or scans to measure how much pain you have. That's why it's important to tell your nurses and doctors about your pain.

Treatments

If you have pain, it may be treated with or without medicine.

Some treatments that don't involve drugs are:

• Relaxation techniques

• Hot or cold packs

• Massage

• Hypnosis

• Music therapy

• Acupuncture

• Chiropractic adjustment

• Imagery (using your imagination to create mental pictures or situations to relieve pain).

Some medicines used to reduce pain are:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)—This includes aspirin and "aspirin-like" drugs such as ibuprofen (Motrin, Advil).

• Acetaminophen (Tylenol)

• Opioids—This includes morphine, hydromorphone, fentanyl, and others. Opioids may be given through your vein (IV), by mouth, by a patch, or by injection.

Keep in mind that most pain medicines have side effects, but your nurses and doctors can help you reduce or eliminate them. Also, some people need more and more of a drug to relieve their pain. That does not mean that they will become addicted. In fact, patients who take opioids rarely become addicted.

Getting pain under control

• Talk to your nurse or doctor about pain control options and what to expect.

• Help your healthcare providers measure your pain by telling them where it is, what it feels like, and when and how it changes.

• Take or ask for medicine when the pain first starts, rather than waiting until it gets bad.

• Report any side effects of the medicine you're given without delay.

Sources: 1. Gordon, D., Kwekkeboom, K., & Ward, S. (2000). "Pain management: What everyone should know." www.cityofhope.org/prc/pdf/4922.pdf (9 Apr. 2004). 2. Torpy, J. M., Lynm, C., & Glass, R. M. (2003). JAMA patient page: Pain management. JAMA, 290(18), 2504.

The Face Legs Activity Cry and Consolability (FLACC) pain scale

FLACC is a behavioral scale used to assess the pain level of infants and young children, and older patients who are cognitively impaired or can't speak. You simply evaluate and score the patient in each of the five categories shown below and add all the numbers to arrive at a total pain score of 0 – 10.