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Managing Pain in Our Patients Pat Volker, RN, BSN June 2007.

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Presentation on theme: "Managing Pain in Our Patients Pat Volker, RN, BSN June 2007."— Presentation transcript:

1 Managing Pain in Our Patients Pat Volker, RN, BSN June 2007

2 Program Objectives Define pain Discuss the concept of attentive analgesic care List the 7 standards of pain assessment Identify the elements of a pain reassessment Discuss the appropriate use of the FACES, PAINAD, and CRIES pain scales

3 Program Objectives Identify required documentation for pain care Discuss emergency management of over sedation Identify the components of patient/family education and involvement in pain management Recognize age-specific indications of pain

4 Patient Scenario #1 Andrew is 17 years old and this is his first day after abdominal surgery. As you enter his room, he smiles at you and continues talking and joking with his visitor. Your assessment reveals: BP 120/80, HR-80, R-18. He rates his pain as “8” on a 1-10 scale. What would you document Andrew’s pain level as? Andrew’s pain level is 8.

5 Patient Scenario #2 Robert is 14 years old and this is his first day after abdominal surgery. As you enter his room, he is lying quietly in bed and grimaces as he turns. Your assessment reveals: BP 120/80, HR-80, R-18. He rates his pain as “8” on a 1-10 scale. What would you document Robert’s pain level as? McCaffery and Pasaro1999 Robert’s pain level is 8.

6 Patient Scenario # 3 Elise is a 6 year old post appendectomy. She complains of “bad” pain at her incision-”it hurts a lot”. The TV is on and she is playing a video game with her dad. Your assessment reveals: BP 90/55, HR-100, R-20. She rates her pain as “8” on a 1-10 scale. What would you document Elise’s pain level as? McCaffery and Pasaro1999 Elise’s pain level is 8.

7 Pain Pain Why we care……. Unrelieved pain impacts: –Healing Increases HR and BP Decreases cough which can lead to respiratory complications Can cause urinary retention Decreases GI motility Can cause immune system depression Leads to sleeplessness, confusion and depression

8 Pain Pain Why we care……. Unrelieved pain impacts: - Length of stay - Patient compliance - Patient satisfaction Can be impacted by complications such as pneumonia and phlebitis Regimes such as coughing and deep breathing, exercise and getting out of bed may be diminished due to pain Patient’s may feel their pain management regimes were ignored or their complaints of pain were not believed.

9 Pain - Pain - What is it? Pain is… Anything the patient says it is and exists whenever the patient says it does.

10 Pain - Pain - What is it? Pain is personal and subjective. The patient’s own report of pain should be accepted, respected and acted upon. Research has shown that healthcare providers underestimate pain if they do not obtain pain ratings from the patient.

11 Pain - Pain - What is it? Be very careful that your own experiences/biases regarding pain do not influence the pain management you provide to your patients!!!

12 Attentive Analgesic Care What is it? An appropriate and timely systematic approach used by healthcare providers to monitor and assess pain. This process includes assessing pain and managing patients to prevent, identify and treat pain. It also includes evaluating outcomes of pain relieving interventions. This does not mean we can guarantee patients they will never be in pain. It does mean that we will have them rate their pain, will act on that, will evaluate our interventions and will modify our plan to improve pain management.

13 Legal Aspects of Pain Management Consider the following: –An elderly patient with terminal, metastatic prostate cancer was admitted to a nursing home with an order for opioid analgesia to manage his pain. The supervising nurse refused to give it because she believed it would lead to addiction. The family filed a lawsuit as they were distraught over their loved one’s painful death. The jury awarded $7.5 million for several months of unnecessary suffering and another $7.5 million in punitive damages. –The defendants in the case were the nurse and the nursing home.

14 Legal Aspects of Pain Management An 85 year old man with terminal lung cancer was admitted to the hospital in severe pain. His pain level was documented as 7 – 10 for 5 days. He was discharged to home with hospice care (with a documented pain level of 10 at discharge). A hospice nurse secured a prescription for morphine which brought his pain under control. He died shortly thereafter. Legal action was undertaken by the family. The jury awarded $1.5 million citing that the failure to manage the pain was elder abuse. The defendants in this case were the physician and the hospital.

15 Pain Pain Where we are…… What message are you giving your patients and their family? Are you saying you are concerned about their pain and want to do everything you can to help manage it? »OR Are you saying, “It’s not time for your next dose of pain medication” and not seeking further relief? »OR Are you administering the ordered dose for moderate pain when the patient is complaining of severe pain?

16 Pain …. Pain …. Where we need to be What does the Joint Commission say? –As of 2001 pain standards require: Pain assessments that are age appropriate Treatment or referral for treatment for patients in pain Initial pain assessments Assessment of pain with vital signs and with known pain producing procedures Reassessment of pain following interventions Documentation of pain education

17 Pain Assessment and Management RN Role Assess, plan, intervene, and evaluate patient care related to pain Provide patient education related to pain management Document all aspects of pain care Pursue management of unrelieved pain Set up and program pumps for PCA and Epidural analgesia

18 Pain Assessment and Management LPN Role Observe, report and document pain needs and response to interventions. Report unrelieved pain Follow Nursing Care Plan and physician orders Provide and document patient education related to pain management Retrieve history, clear volume, discontinue PCA pump

19 Pain Care Unlicensed Assistive Personnel (UAP) Role In alert and oriented patients, obtain and document pain intensity score Report unrelieved pain

20 Pain Assessment and Management Consider the following: –The nursing assistant asks a post C-section patient, Mary, what her pain rating is. She is quietly lying in bed and states “2”. The NA leaves the room. –An LPN is giving the patient her a.m. medications. The LPN reminds the woman to use her incentive spirometer. At this time the LPN notices Mary had only been medicated for pain once during the night. She reviews Mary’s pain medication options with her. After asking the patient her pain rating (again stated as “2”), the LPN leaves the room.

21 Pain Assessment and Management –When the RN attempts to get Mary out of bed, she refuses. The RN asks the patient what her pain level is. Mary states “2”. The RN then asks the patient what her pain level is when she is getting out of bed, the pain score increases to “7 – 8”. The RN reinforces with the patient the need to maintain a pain level that allows participation in normal and necessary post operative recovery activities.

22 Standards of Pain Assessment 1.Location 2.Intensity 3.Quality 4.Onset/Duration/Variation 5.Aggravating/Relieving Factors 6.Interference with Activities 7.Comfort/Function Goal These standards of assessment are required by the Joint Commission. Forms have been revised to include these 7 areas.

23 Standards of Pain Assessment 1. Location Ask the patient to state or to point where pain is Remember, in young children, pain may not be the word to use –hurt, booboo, ouchie may be more effective May be more than one location Make sure we are treating the right pain, I.e. headache vs. incisional pain 2. Intensity How badly does it hurt? Use pain scale (see next slides)

24 Pain - Pain - What is it? Hierarchy of Importance of Pain Intensity Measures most 1.Self Report-single most reliable indicator of a patient’s pain level. If the patient is alert enough to rate their pain as “7” that is what we should treat. 2.Presence of pathologic condition or procedure that is known to be pain producing.

25 Pain Pain - What is it? 3.Pain Behaviors (crying, restlessness, change in activity, guarding) – these behaviors should not be used to assess pain as they may be normal responses due to other causes, especially in children 4. Physiologic signs (  Heart rate,  BP) – can have many other causes (McCaffrey/Passaro,1999) As we go down this list of pain intensity measures our assessment is LESS accurate.

26 Standards of Pain Assessment FACES/Numeric Scale Use for Adults without cognitive impairment and Children over 4 years of age INSERT SCALE

27 Standards of Pain Assessment FACES Scale –May take a few explanations before patient “gets it”. –Should not be used by caregiver to compare faces but by patient to choose which face his or her pain makes them feel like. –Reliability tested on preschoolers by Whaley and Wong.

28 Standards of Pain Assessment Cognitively impaired patient Attempt to use FACES scale-see if patient can respond to terms like mild, moderate, severe There is wide variability in expressing pain through behavior Behavioral observations may be misleading if the patient is only observed at rest Behavioral/physiologic data may be difficult to interpret

29 Standards of Pain Assessment Consider the following true story: –A psychiatric patient kept pulling the fire alarm. When a nurse took the time to fully investigate and asked where the fire was, the patient pointed to his chest. She asked how bad the fire was and he pointed to “9” on the FACES scale. –The patient was having an MI.

30 Standards of Pain Assessment PAINAD Scale – for use with cognitively impaired patients

31 Standards of Pain Assessment Consider the following: –An elderly patient, Sara, who previously suffered a stroke and has language impairment, has fallen and fractured her hip. You need to evaluate her pain. She is frowning, her hand on the unaffected side is in a tight fist. Sara pushes you and the family away whenever you try to reposition her. She moans frequently and occasionally seems short of breath. When her granddaughter holds her hand and reads to her she is less restless. –How would you score Sara’s pain using the PAINAD scale?

32 Standards of Pain Assessment Sara’s pain score is 5. She should be medicated for pain.

33 Standards of Pain Assessment Children Under age 4

34 Standards of Pain Assessment Consider the following: –Kristy, your 3 month old post-op patient, is crying inconsolably. Her heart rate is 150 (pre-op HR 120). She is on 3 liters of O2. She has not had any periods of uninterrupted sleep and you notice facial grimacing in the short periods where she is not crying. –How would you score her pain using the CRIES scale?

35 Standards of Pain Assessment Kristy’s pain score is 7. She should be medicated for pain.

36 Standards of Pain Assessment 3. Quality What does the pain feel like? (ache, burning, cold, cramping, sharp, dull, throbbing, shooting, tingling, numbing, pressing) 4. Onset/Duration/Variation When did the pain start (or when does it usually start)? How long does the pain last?

37 Standards of Pain Assessment 5. Aggravating/Relieving Factors Heat, cold, positioning eating,walking, bathing,noise, light Distractions: TV, radio, visitors, music, video games Remember, one person’s aggravating factor may be another person’s relieving factor! 6. Interference with Activities What does the patient do (or not do) because of the pain? (eat less, walk less, C&DB, exercise, read, cook, schoolwork)

38 Standards of Pain Assessment 7. Establish Comfort/Function Goal A pain rating that will allow the patient to participate in recovery or quality of life activities Patients may need guidance to establish Pain rating above “3” significantly interferes with activity and a rating above “5”with quality of life If the patient is unable to establish a goal,a pain rating of “3” or less will be used

39 Standards of Pain Assessment Additional considerations for patients unable to identify pain: APPUse the term APP (Assume Pain is Present) when the patient cannot report pain AND known painful procedures /conditions exist Examples of painful procedures/conditions: Mechanical ventilation, endotracheal suctioning, tubes in place(chest tubes and removal), traction, wound care, turning and positioning – rated by patient’s as one of the most painful procedures performed!)

40 Standards of Pain Assessment Timing of Pain Assessment With Full sets of vital signs (note that when patients require very frequent vital signs and pain control is adequate pain assessment may be done less often) After any known pain producing procedure With each new report of pain

41 Standards of Pain Assessment Timing of Pain Assessment Once sufficient time has passed for medication to reach peak effect – REMEMBER, REASSESSMENT IS JUST AS IMPORTANT AS YOUR INITIAL ASSESSMENT – IT LETS YOU KNOW WHETHER YOUR INTERVENTION WAS EFFECTIVE! When pain control is continuously adequate, reassessment should occur once per shift

42 Standards of Pain Assessment Documentation All aspects of pain management need to be documented on the appropriate forms At intake or admission, all forms should contain the required information. For ongoing care, all flow sheets should have the same grid to document pain intensity and interventions and reassessment.

43 Standards of Pain Assessment

44 Standards of Pain Assessment Assessing Undesirable Side Effects from Analgesics Presence of hepatic or renal impairment may increase risk of toxic side effects Drug metabolism may differ among very young and elderly

45 ADMINISTERING OPIOIDS

46 Standards of Pain Assessment Assessing Undesirable Side Effects from Analgesics Sedation Scale – must be used on all patients receiving opioids! No action Required: S=Sleep, easy to arouse 1=Awake and alert 2=Slightly drowsy, easily aroused Action Required: 3=Frequently drowsy, arousable, drift off to sleep during conversation/play 4=Somnolent, minimal or no response to physical stimulation

47 Standards of Pain Assessment Assessing Undesirable Side Effects from Analgesics In patients receiving opioids, sedation must be observed by the nurse each time the pain level is assessed. If patient is awake and alert and reports a pain level of “9”, medication should be given. IF RESPIRATORY RATE IS BELOW 8 IN ADULTS AND IS DECREASED FROM BASELINE IN CHILDREN THE NURSE MUST TRY TO AWAKEN THE PATIENT!

48 Standards of Pain Assessment Assessing Undesirable Side Effects from Analgesics Respiratory Depression Most likely: At onset or peak effect of opioid Within first few doses When opioids are administered epidurally,intrathecally or continuous IV infusion Patients at highest risk are infants, opioid naïve patients who are elderly, those with coexisting conditions (pulmonary disease, major organ failure, obesity, sleep apnea)

49 Standards of Pain Assessment Assessing Undesirable Side Effects from Analgesics Respiratory Depression  depth/quality usually precedes decrease in rate of respirations ( and may be related to increased sedation) Report hypoventilation, respiratory rate of 8 or less, dyspnea, snoring, pulse oximetry of below 92% In pediatric patients: observe for  respiratory rate, tachypnea, nasal flaring or retractions. Report pulse oximetry below 93% Measure pulse oximetry if evidence of increased sedation

50 Standards of Pain Assessment Undesirable Side Effects from Analgesics Nausea/vomiting Constipation Itching Hypotension Delirium Mental status changes Every patient is unique and may have some, none or all of these side effects. Occurrence of side effects is NOT a reason to not manage patient pain! Other medications, medication combinations or alternative therapies may be effective.

51 Pain Assessment for Opioid Analgesics Route Peak Effect Assessment of Pain, Sedation Level and Respirations Additional Assessments for Sedation Level of 3 or 4 IV Bolus (Not PCA) minutesEvery 15 min X 2 after each bolus dose Obtain blood pressure, pulse, pulse oximetry if evidence of respiratory depression or sedation of 3 or 4. IV PCA, Continuous, or PCA Plus Continuous Minutes 15 minutes after the initial dose or increase in dose X 2 then every 2 hrs. X 24 hrs. Every 4 hrs. if pain control is adequate without excessive sedation. Obtain blood pressure, pulse, pulse oximetry if evidence of respiratory depression or sedation of 3 or 4. Oral /Rectal1-2 hrs1 - 2 hours after initial dose or increase in dose then every 4 hrs if pain control is adequate without excessive sedation. Obtain blood pressure, pulse, pulse oximetry if evidence of respiratory depression or sedation of 3 or 4. IM/SQ30 minutes30 minutes of initial dose or increase in dose and then every 4hrs if pain control is adequate without excessive sedation. Obtain blood pressure, pulse, pulse oximetry if evidence of respiratory depression or sedation of 3 or 4. Epidural or Intrathecal Fentanyl has rapid peak time of 10 to 20 minutes. Morphine has slower peak time – 90 to 120 minutes. Adult Every 30 minutes X 4 after initial dose or increase in dose then every 2hrs X 24 hrs., then every 4 hours for the duration of therapy and an additional 24 hours following completion of therapy. Pediatric: Every hour for the first 24 hrs then every 2 hrs if adequate pain control is maintained. Assess respirations and pulse oximeter reading every 1 hr for the first 24 hrs or after dosage change then if stable, every 2 hrs. Check every 4 hrs. BP and pulse, insertion site, and external pump function. Check sensory and motor strength of lower extremities first time out of bed, for adults every 4hrs and pediatrics every 2hrs. Check every 8 hrs. changes in bowel and bladder function, back tenderness. Check pulse oximetry if evidence of respiratory depression or sedation level of 3 or 4.

52 Pain Management Patient Care Considerations Administer analgesics as ordered,according to pain rating. Notify MD if pain medication is ineffective Consider use of pain therapy before,during and after diagnostic and therapeutic procedures

53 Pain Management Patient Care Considerations Administer regularly scheduled doses of pain medication(ATC). Awaken patient if necessary Manage anxiety Consider use of non-pharmacologic approaches -heat, cold, rest, massage, positioning, distractions (TV, radio, video games, reading)

54 Pain Management Patient Care Considerations Use of the Equianalgesic Dosing Chart

55 Pain Management Patient Care Considerations Managing unrelieved pain: Notify physician-be prepared to give full situational report Document all efforts made to manage patient pain and report unrelieved pain Suggest pain management specialist consultation If analgesic orders are not changed to support improved pain management for the patient, notify Nurse Manager or Nursing Supervisor.

56 Pain Management Patient Care Considerations Scenario-unrelieved pain Dr Brown, I am calling about your patient Martin Gonzales with prostatic cancer. His pain goal is 3 but for the last several hours his pain level has been 6-7 and he is unable to sleep or get OOB. He currently takes MS Cotin 100mg every 12 hours with Morphine Sulfate 30mg immediate release for breakthrough pain. He has needed 4 doses of the supplemental morphine since midnight. He is very alert but in pain. What do you think about increasing his dose 25-50% ?

57 Pain Management Patient Care Considerations PCA/Epidural Pump Infusions 2 RN’s or an RN/LPN/Pharmacist/MD shall independently check the PCA/Epidural pump settings *Initially *With each dose change *With pump refills Nurse will check the pump settings at shift change. For PCA therapy, the trigger will be within patient reach. Nurses shall NOT activate PCA doses unless special monitoring is in place (PACU,ICU). PCA pumps will be labeled with proxy warning tag. Visitors may not activate PCA dose delivery.

58 Pain Management Patient Care Considerations Consider the following: –A nurse was admitted to the hospital for a hysterectomy. She had told her husband to push the button on the pump every 6 minutes. Because he loved his wife and did not want to see her in pain, he dutifully did as he was asked – until his wife respiratory arrested!! –True story!! ONLY –INSTRUCT PATIENTS AND FAMILIES THAT ONLY THE PATIENT CAN ACTIVATE THE PUMP!!!

59 Pain Management Patient Care Considerations Emergency Management Patients with signs of opioid overdose with respiratory depression and/or sedation score of 3 or more Assure that Naloxone (NARCAN) is on the unit Sedation Scale of 3: *NOTIFY MD *Consider adding NSAID or acetaminophen *Oral route-hold next dose-consider NSAID or acetaminophen *IV/Epidural/Subcutaneous route-decrease opioid by 25%-50% *Remember-Patient will require resumption of analgesic at adjusted dose Nurses may independently reduce dosing for over sedation!

60 Pain Management Patient Care Considerations Emergency Management Patients with signs of opioid overdose with respiratory depression and/or sedation score of 4 with respiratory depression : *Stop administration of opioid *Notify MD *Follow reversal agents policy – Administer 0.2 mg Naloxone IV (Adult) Pediatric doses are weight based.

61 Pain Management Patient Care Considerations Emergency Management You are caring for a 19 year old patient postoperative repair of multiple fractures in a MVA. She is receiving the following for pain via PCA pump : Continuous infusion of 0.3mg/hour of hydromorphone plus 0.4 mg Q15 minutes via the PCA route. She has received 3.2 mg in the last 2 hours by the PCA dosing. It is difficult to rouse her and she falls asleep while speaking to you. Her respiratory rate is 8 and shallow, her pulse ox is 90%. What will you do? Decrease dose by 25 – 50% Ask the patient to take a deep breath Administer O2 Consider adding a NSAID

62 Pain Management Patient Education Document on interdisciplinary patient education tool Prevention- make sure patient know the importance of continuous pain management Pain – use known scales Comfort Function Goal Side Effects – what to expect and how to manage Fears of addiction

63 Myths vs. Facts Regarding Children and Pain Facts Addiction –Narcotic addiction – behavioral, voluntary pattern of drug-seeking behavior for reasons other than pain relief –Drug tolerance – expected physiologic, involuntary need for larger doses to maintain analgesic effect –Physical dependence – physiologic, involuntary effect (withdrawal symptoms) when chronic use of opioids is abruptly discontinued

64 Myths vs. Facts Regarding Children and Pain Statement from the Acute Pain Management Guideline Panel (1992) –“There is no known aspect of childhood development or physiology that indicates any increased risk of physiologic or psychologic dependence from the brief use of opioids for acute pain management.”

65 Myths vs. Facts Regarding Children and Pain Respiratory Depression – numerous studies have verified the safe use of appropriately dose opioids in children Infants don’t feel pain – Infants demonstrate behavioral, especially facial, and physiologic indicators of pain. Neonates have the neural mechanisms to transmit pain by 20 weeks of gestation

66 Myths vs. Facts Regarding Children and Pain Children tolerate pain better than adults – Children’s tolerance to pain actually increases with age Children cannot tell you where they hurt – children 3 and over can use the FACES scale

67 Myths vs. Facts Regarding Children and Pain  Children always tell the truth regarding pain – if they believe they will receive an injection they will not be honest about their pain  Behavioral manifestations reflect pain intensity – children’s development level, coping abilities and temperament affect how they react to pain

68 Developmental Considerations Young Infants –General body rigidity or thrashing –Loud cry –Facial expressions of pain (brows lowered and drawn together, eyes tightly closed, grimace) –No association between approaching stimulus and subsequent pain

69 Developmental Considerations Older Infants –Deliberate withdrawal of area –Loud cry –Facial expression of pain or anger –Physical resistance –Pulling at ears, rolls from side to side –Has memory of painful experience

70 Developmental Considerations Young Children –Loud cry, screaming –Verbal expression- “It hurts” –Thrashing of arms and legs –Attempts to push stimulus away before it is applied –Uncooperative, may need physical restraint

71 Developmental Considerations Young children con’t –Requests termination of procedure –Clings to parent, nurse or other –Requests emotional support, hugs or other forms of physical comfort –May become restless and irritable with continued pain

72 Developmental Considerations School-Age Children –May see all behaviors of young child, especially during painful procedures, but less anticipation –Stalling behavior – “Wait a minute” or “I’m not ready” –Muscle rigidity –Fear body mutilation

73 Developmental Considerations Adolescents –Less vocal protest –Less motor activity –More verbal expression – “It hurts” or “You’re hurting me” –Increased muscle tension and body control

74 Conclusion No one deserves to suffer in pain The first step is identifying pain Children pose special considerations since they can not always tell or describe the pain Pay attention to your patient Listen to the parent Use known scales Use your assessment skills

75 References –TX.4 Pain Management – Adult/Child –GDL_04 Guidelines for Use of Pain Management Record –Whaley and Wong’s Nursing Care of Infants and Children 7 th edition


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