Chapter 13 Pain Management

Patient-Centered Care Creating comfortable environments for patients and applying principles of pain management are priorities for health care agencies. Pain is unique to each individual: Coping style Physical status Past pain experiences Culture and ethnicity Emotional health Use therapeutic communication to gather an objective, accurate, and timely pain assessment from the patient and family.

Safety Acute uncontrolled pain can threaten a person’s well-being. Assess previously used successful pain remedy. Use least invasive therapies first. Know the actions and side effects of medications. Monitor for and respond to adverse responses.

Skill 13.1 Nonpharmacolgical Pain Management Nonpharmacological interventions trigger a relaxation response. They can be combined with pharmacological interventions. Collaborate with other health care providers for best possible pain relief.

Skill 13.1 Nonpharmacolgical Pain Management (cont’d) Assess pain using PQRSTU: Precipitating/palliative factors Quality Region/radiation Severity Timing How is pain affecting U (patient) Use an approved pain rating scale to: Assess initial pain. Reassess pain after an intervention. In cognitively impaired patients obtain a proxy pain intensity rating from the primary caregiver.

Procedural Guideline 13.1 Relaxation and Guided Imagery Mind-body therapies are used frequently for anxiety/depression and musculoskeletal conditions. Teach relaxation when the patient is not in severe pain. Patients can practice relaxation at any time. Guided imagery uses focused concentration of one or more senses to create a desired image. Use an approved pain rating scale to assess the patient’s pain before and after the intervention.

Skill 13.2 Pharmacological Pain Management Nonopioids treat mild-to-moderate pain. No suppression of central nervous system No interference with bowel or bladder function Opioids and opioid-like analgesics treat moderate-to-severe pain. Can produce respiratory depression Can cause nausea, vomiting, constipation, and altered mental status Adjuvants or coanalgesics enhance pain control. Can cause drowsiness, impaired coordination, and decreased mental alertness

Skill 13.2 Pharmacological Pain Management (cont’d) Perform a complete pain assessment before administering medications. Assess the type of pain the patient is experiencing. Review the last medication administered (dose, route, frequency, and degree of relief). Medicate for pain: As soon as it occurs. Before it increases in severity. Before pain-producing procedures or activities. Routinely, around-the-clock, or on a scheduled basis. Provide care during peak analgesic effects. Monitor for adverse effects.

Skill 13.3 Patient-Controlled Analgesia Self-administered analgesics for acute and chronic pain Patients must be able to understand how, why, and when to administer a dose. Patients must be able to physically depress the button on the device. Patient-controlled analgesia by proxy Nurse-controlled Family-controlled

Skill 13.3 Patient-Controlled Analgesia (cont’d) Individually programmed dose and timing: Continuous basal rate Bolus dose (patient initiated) Both (combined continuous and bolus) Advantages: Allows more constant serum levels Better pain relief with fewer side effects Requires careful, ongoing monitoring Be familiar with the patient-controlled analgesia model in use, agency policy regarding documentation of patient attempts, doses delivered, and amount of drug administered. Monitor and treat side effects.

Skill 13.4 Epidural Analgesia Administration of analgesics into the epidural space for specific conditions Improved pain control with fewer side effects May use opioids and anesthetics, separately or in combination Short-term use epidural catheters exit from insertion site in the back. Long-term catheters are “tunneled” subcutaneously and exit on the side or abdomen. Individually programmed dose and timing Monitor insertion site. Prevent catheter disruption with patient movement.

Skill 13.4 Epidural Analgesia (cont’d) No supplemental opioids or sedatives given Increases risk of respiratory depression Monitor sensory function and urinary retention. Specially certified health care providers initiate or administer bolus doses. Contraindications: Coagulopathies Abnormal clotting studies History of multiple abscesses Sepsis Specific skeletal or spinal abnormalities

Skill 13.5 Local Analgesia Infusion Pump Catheter is inserted into joint replacement surgical site to deliver local anesthetic. Pump may have demand and continuous features. Patients may still require oral analgesics. Catheter is left in place approximately 48 hours. Review operative report for catheter position. Determine level of activity allowed per orders. Instruct patient how to remove catheter at home per surgeon orders.