Pain Assessment and Management Please read the article “Physiology and Treatment of Pain”, Critical Care Nurse, 2008; 28: prior to completion of this CBL.

Pain is the most common reason patients seek health care. Research shows that under management of pain in hospitalized persons inhibit the ability and willingness to recover from illness. Statistics show that nationwide, we as healthcare providers tend to under medicate patients due to many factors. For these reasons, this is provided to enhance the healthcare providers skills and knowledge of assessment, management, and evaluation of pain.

“Pain is whatever the experiencing person says it is, existing whenever he or she says it does.” Margo McCaffrey, RN 1980

Reasons for Pain Management  Patient Advocacy  Improve patient satisfaction/comfort  TJC initiative

Physiology of Pain  Reception: nerve receptors in the skin and tissues respond to stimuli resulting from actual or potential tissue damage. Noxious (pain) stimuli may be thermal, mechanical, chemical or electrical.  Perception: is the point at which a person experiences pain. (Research states that ideally, patients should be given pain medicine during the PERCEPTION stage).  Reaction: is the physiological and behavioral responses that occur after pain is perceived.

TJC Standards for Pain TJC Standards for Pain  Every patient will be assessed for pain  Patients without pain will be continually reassessed.  The family will be included in pain management for the patient.

Standard of Care: Assessment & Intervention for Pain Purpose: To evaluate and manage our patient’s pain, through prompt attention, to achieve an outcome of pain intensity ratings on a scale of All patients can expect to:  Have their pain assessed on admission and reassessed at regular intervals to ensure that patient’s pain is being managed and controlled.  The frequency of pain reassessments should be increased during the first post-operative day, or if the pain is poorly controlled, or the intervention has changed.  A pain assessment is required before and after each dose of PRN pain medication.  Reassessment of pain status should occur with each physical assessment by the registered nurse and within “one hour” of pain management intervention.  The appropriate pain assessment tool will be used with the patient, dependent upon their developmental ability. “WNL” or “within normal limits” is an unacceptable phrase to assess pain….remember “0” represents no pain.

What needs to be considered in Pain Assessment & Management  Cultural differences  Individuals are different  Biases & myths (i.e., elders & children DO feel pain, addiction, etc.)  Recognize the cost of failure to treat pain.

Common biases about Pain  Drug abusers & alcoholics overreact to pain False—they are actually giving you a more truthful perception since inhibitions are lowered.  Clients with minor illnesses have less pain False—for that patient, the experience could be major depending on previous experience.  Giving analgesics regularly will start drug dependency False—studies show only 3% of patients ever develop a true addiction  Amount of damage dictates pain intensity False—minor injuries may cause excruciating pain  Psychogenic pain is not real False—in that patient’s mind, the experience is real)  Health care personnel know best the nature of the patient’s pain False—the patient knows best his or her pain)

Pain Assessment  P recipitating/Alleviating Factors: What causes the pain? What aggravates it? Has medication or treatment worked in the past? What causes the pain? What aggravates it? Has medication or treatment worked in the past?  Q uality of Pain: Ask the patient to describe the pain using words like “sharp”, dull, stabbing, burning” Ask the patient to describe the pain using words like “sharp”, dull, stabbing, burning”  R adiation Does pain exist in one location or radiate to other areas? Does pain exist in one location or radiate to other areas?  S everity Have patient use a descriptive, numeric or visual scale to rate the severity of pain. Have patient use a descriptive, numeric or visual scale to rate the severity of pain.  T iming Is the pain constant or intermittent, when did it begin, and does it pulsate or have a rhythm Is the pain constant or intermittent, when did it begin, and does it pulsate or have a rhythm

Pain Assessment Tools: Wong-Baker

Pain Assessment Tools: Non-Verbal Pain Scale (FLACC)

Guidelines for Individualizing Pain Relief  Establish a relationship of mutual trust  Use different types of pain-relief measures  Provide pain-relief measures before pain becomes severe.  Consider the client’s ability or willingness to participate in pain-relief measures.  Choose pain-relief measures on the basis of the client’s behavior reflecting the severity of pain.  Use measures that the client believes are effective.  If therapy is ineffective at first, encourage the client to try it again before abandoning it.

Guidelines cont….  Keep an open mind about what might relieve pain  Keep trying  Protect the client  Educate the client about pain

Pharmacological Interventions  Opioids: for moderate or severe pain for moderate or severe pain Agonists Agonists Agonists-antagonists Agonists-antagonists  Nonopioids: Used alone or in conjunction with opioids for mild to moderate pain Used alone or in conjunction with opioids for mild to moderate pain Acetaminophen Acetaminophen NSAIDS NSAIDS  Adjuvants: Used for analgesic reasons and for sedation and reducing anxiety. Used for analgesic reasons and for sedation and reducing anxiety. Multipurpose Multipurpose Tri-cyclic antidepressants Tri-cyclic antidepressants Anticonvulsants Anticonvulsants

Non-Pharmacological Pain Management  Heat & Cold applications  Relaxation techniques, distraction  Imagery  TENS application  Music therapy  Massage NOTE: The above management techniques are meant to supplement, not replace pharmacological interventions.

Special Considerations for the Management of Pain in the Elderly  Elderly can suffer from multiple chronic and painful problems and take multiple medications. They are at greater risk for drug-drug and drug-disease interactions.  Pain assessment can be difficult due to changes associated with aging.  Some consider pain to be a normal part of aging. The elderly are often stoic and are at risk for under treatment of pain.  Aging need not alter pain thresholds or tolerance.

Special Considerations for Elderly  Cognitive impairment, delirium, and dementia are serious barriers to assessing pain in the elderly.  Observe for behavioral responses such as restlessness or agitation.  NSAIDs can be used safely in elderly patients but watch for gastric and renal toxicity.  Elderly patients are sensitive to opiate drugs. They experience higher peak effect and longer duration of pain relief.

Special Considerations for Elderly  Speak slowly, clearly, and loudly enough.  Ensure the appropriate aids for hearing and seeing are available.  Use enlarged visual aids.  Reinforce that pain relief promotes recovery by using tangible examples: “You need enough pain relief to use the incentive spirometer properly. It will help prevent pneumonia.”  Involve family members in pain management plan.

Terminal Care Pain Control

Resources  American Pain Society  Helms, Jennifer & Barone, Claudia. “Physiology and Treatment for Pain”, Critical Care Nurse, 2008; 28:  Wegman, Deborah. “Tool for pain assessment”, Critical Care Nurse, 2005; 25:  The Joint Commission

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