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- 2. Pain The patient is the only one who knows whether pain is present and what the experience is like Recognize unique nature of pain and assist in the selection of appropriate therapies Critical thinking and integration is used to consider both pharmacological and nonpharmacological therapies Copyright © 2018, Elsevier Inc. All rights reserved. 2
- 3. Principles for Practice Patient’s report of pain must be addressed and appropriately treated Cognitive impairments make pain assessment challenging Two types of pain: acute (transient) and chronic (persistent) Chronic includes cancer and noncancer pain Copyright © 2018, Elsevier Inc. All rights reserved. 3
- 4. Principles for Practice (Cont.) Types of analgesics: Nonopioids and nonsteroidal antiinflammatory drugs (NSAIDS) Opioids (narcotics) Adjuvants or coanalgesics (antidepressants and muscle relaxants) ATC rather than prn administration is preferred Multimodal analgesia is current approach Copyright © 2018, Elsevier Inc. All rights reserved. 4
- 5. Patient-Centered Care Pain management should be patient-centered Individualize plan by teaching patient about pain treatment with dignity and caring Pain is unique to each individual Effective communication is key to gathering information Respect cultural considerations Every patient with pain has the right to be treated with dignity, respect, management Copyright © 2018, Elsevier Inc. All rights reserved. 5
- 6. Evidence-Based Practice Chronic low back pain Interdisciplinary biopsychosocial rehabilitation interventions more effective than usual care For work outcomes, interdisciplinary rehabilitation more effective than physical treatment, not more effective than usual care Biopsychosocial approach considers the person, their health problem, and their social context Copyright © 2018, Elsevier Inc. All rights reserved. 6
- 7. Quick Quiz! The nurse cautions an elderly patient to limit her use of Tylenol. Why would the nurse make this statement to the patient? A.Risk of liver damage is present. B.Elderly always abuse Tylenol. C.The medication is ineffective. D.Tylenol causes drowsiness. Copyright © 2018, Elsevier Inc. All rights reserved. 7
- 8. Quick Quiz! (Cont.) While caring for a 50-year-old Native American woman, the nurse asks about her pain level after a mastectomy. The patient seems hesitant to talk to the nurse and remains quiet. What action should the nurse take? A.Assume that the patient’s pain is under control and leave her to rest. B.Insist that the patient consent to a patient-controlled analgesia (PCA) pump for pain control. C.Call the patient’s family and ask them to report the pain level. D.Continue to engage in conversation with the patient. Copyright © 2018, Elsevier Inc. All rights reserved. 8
- 9. Safety Guidelines 1. Monitor patients who receive opioids (by any route) for signs and symptoms of oversedation and respiratory depression. 2. Monitor activities such as standing, ambulation, transfer to a chair if patient has received an opioid. 3. Monitor for potential side effects of opioid analgesics and recommend or institute supportive measures. Copyright © 2018, Elsevier Inc. All rights reserved. 9
- 10. Safety Guidelines (Cont.) 4. Epidural analgesia IV infusion lines should be clearly labeled and identified as such to prevent accidental connection with tubing of a different type. 5. Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new or increased pain; this is tolerance, not an early sign of addiction. Copyright © 2018, Elsevier Inc. All rights reserved. 10
- 11. Safety Guidelines (Cont.) 6. Drug-drug interactions, including enhanced or reduced effects or side effects, often occur with the multiple drug use required by people with chronic pain. 7. Know agency policy for frequency of pain assessment and timing for follow-up assessments. Copyright © 2017, Elsevier Inc. All rights reserved. 11
- 12. Pain Assessment and Basic Comfort Measures Skill 16-1 Assessment of pain: find cause of pain, identify perception of pain, and determine effect of pain on individual Effective pain management may not eliminate pain, but it gets it to an acceptable level Use the nursing process Copyright © 2018, Elsevier Inc. All rights reserved. 12
- 13. Delegation and Collaboration Assessment of a patient’s pain cannot be delegated to nursing assistive personnel (NAP) NAP may screen patients for pain and provide selected nonpharmacological strategies as instructed by the nurse The nurse directs NAP to: Eliminate environmental aggravations Provide maximum rest periods Turn/place patients as directed Observe signs in patients unable to self-report Ask patients to report pain using supplied scale Report pain above predetermined goal Screen for pain during transfer/other activity Copyright © 2018, Elsevier Inc. All rights reserved. 13
- 14. Recording and Reporting • Record and report in nurses’ notes the character of pain before intervention, therapies used, and patient response to interventions • Record inadequate pain relief, reduction in patient function, adverse effects from pain interventions, and any patient or family education given Copyright © 2018, Elsevier Inc. All rights reserved. 14
- 15. Special Considerations Teaching Assess understanding/use of pain scale Explain potential behavioral changes Discuss common misconceptions Pediatric Pain scale use = 3 years or older Respond to pain differently than adults May fear consequences of reporting pain Copyright © 2018, Elsevier Inc. All rights reserved. 15
- 16. Gerontological May understand a categorical pain scale better than a numeric scale May require a more lengthy explanation of the pain scale Home care Consider home conditions; assess pain-management attitude of care provider Copyright © 2018, Elsevier Inc. All rights reserved. 16 Special Considerations (Cont.)
- 17. Patient-Controlled Analgesia Skill 16-2 Patient self-administers analgesics PCA devices may be programmed to deliver continuous infusion, a bolus dose, or both A preprogrammed delay time or “lockout” prevents overdosing PCA has many advantages Concerns include errors and pump failure Copyright © 2018, Elsevier Inc. All rights reserved. 17
- 18. Delegation and Collaboration The task of administration of PCA cannot be delegated to NAP The nurse directs NAP to: Immediately report to the nurse new symptoms or change in patient status, like unrelieved pain or oversedation Notify nurse if patient has questions about the PCA Never administer a PCA dose for the patient Copyright © 2018, Elsevier Inc. All rights reserved. 18
- 19. Recording and Reporting • Record drug, concentration, dose, time started, lockout time, and amount of IV solution infused and remaining solution. Many agencies have special PCA documentation forms • Record regular assessment of patient response to analgesia on PCA medication form, in nurses’ notes, on pain-assessment flow sheet, or on other documentation according to institutional policy Copyright © 2018, Elsevier Inc. All rights reserved. 19
- 20. Special Considerations Teaching Give instructions while patient is pain free or in pain- reduced state Push PCA button at first pain indication Only the patient pushes the button Explain regimen to the family Inform patient of nonpharmacological strategies Copyright © 2018, Elsevier Inc. All rights reserved. 20
- 21. Special Considerations (Cont.) Pediatric May be used as young as 5 years old Safe when calibrated to child’s weight Untreated pain may become chronic Gerontological Dosage considerations Adjust PCA use if patient becomes confused Copyright © 2018, Elsevier Inc. All rights reserved. 21
- 22. Quick Quiz! In relation to pain management, what activity can the nurse delegate to NAP? A.Performing initial pain assessment B.Turning and positioning patient C.Changing pain scale as needed D.Administering pain medication Copyright © 2018, Elsevier Inc. All rights reserved. 22
- 23. Epidural Analgesia Skill 16-3 Used for acute pain during labor, after surgery; chronic pain Safe, efficient; rarely complications Administered into the epidural space 23 Copyright © 2018, Elsevier Inc. All rights reserved.
- 24. Epidural Analgesia Skill 16-3 (Cont.) Patient is placed in lateral side-lying or sitting position, with shoulders and hips aligned and hips and head flexed during catheter insertion 24 Copyright © 2018, Elsevier Inc. All rights reserved.
- 25. Epidural Analgesia Skill 16-3 (Cont.) Catheter placement Temporary or short- term Permanent or long- term 25 Copyright © 2018, Elsevier Inc. All rights reserved.
- 26. Epidural Analgesia Skill 16-3 (Cont.) Medication administration Bolus injection Patient-controlled epidural analgesia (PCEA) Continuous infusion via implanted infusion pump Copyright © 2018, Elsevier Inc. All rights reserved. 26
- 27. Delegation and Collaboration The skill of epidural analgesia administration cannot be delegated to nursing assistive personnel (NAP) The nurse directs NAP to: Observe the dressing over the insertion site when repositioning or ambulating patients to prevent catheter disruption Avoid pulling patient up in bed while he or she is lying flat on the back Report any catheter disconnection or leakage from dressing immediately Immediately report to the nurse any change in patient status, comfort level, or loss of sensation or movement Copyright © 2018, Elsevier Inc. All rights reserved. 27
- 28. Recording and Reporting • Record on appropriate medication record drug, dose, method, and time given or time begun and ended. Specify concentration and diluent • With continuous/demand infusion, obtain readout; review with next shift pump settings/usage Copyright © 2018, Elsevier Inc. All rights reserved. 28
- 29. Recording and Reporting (Cont.) • Record in nurses’ notes or on appropriate flow sheet regular periodic assessments of patient’s status • Report to health care provider immediately any adverse reactions or complications • Document evaluation of patient learning Copyright © 2018, Elsevier Inc. All rights reserved. 29
- 30. Special Considerations Teaching Explain catheter use, drug interactions, pain scale/pain management, and regulation of activity Pediatric Application of EMLA cream Dosing regimens must be adapted Hourly assessments are recommended in first 12 hours Copyright © 2018, Elsevier Inc. All rights reserved. 30
- 31. Special Considerations (Cont.) Gerontological Same risks of complications and medication adverse effects as any adult Home care Teach patient and caregiver catheter care, medication administration and potential side effects, and aseptic technique Provide emergency contact number and community resource information Copyright © 2018, Elsevier Inc. All rights reserved. 31
- 32. Local Anesthetic Infusion Pump for Analgesia Skill 16-4 Used for joint replacement surgery Local anesthetic is pumped directly into the wound bed If oral analgesic is used, total dosage is often reduced One-time use only 32 Copyright © 2018, Elsevier Inc. All rights reserved.
- 33. Delegation and Collaboration The skill of managing local anesthetic infusion pump analgesia cannot be delegated to nursing assistive personnel (NAP) The nurse directs NAP to: Pay close attention to the insertion site when providing care, to avoid dislocation Report if the dressing becomes moist; report any catheter disconnection immediately Notify nurse immediately of a change in patient’s status or level of comfort Copyright © 2018, Elsevier Inc. All rights reserved. 33
- 34. Recording and Reporting • Record drug, concentration, date catheter inserted, and type of demand feature (continuous or demand) in MAR in the electronic health record (EHR) or chart • Record location of catheter, patient’s pain rating, response to anesthetic, and additional comfort measures given in nurses’ notes in the electronic health record (EHR) or chart Copyright © 2018, Elsevier Inc. All rights reserved. 34
- 35. Recording and Reporting (Cont.) • Record additional analgesics as necessary to control pain • Record adverse reactions to local anesthetic • Report damp dressing and/or displaced catheter to surgeon Copyright © 2018, Elsevier Inc. All rights reserved. 35
- 36. Special Considerations Teaching Device operation (preoperative) Breakthrough pain management Pediatric Use of local continuous infusion pumps for children undergoing orthopedic surgery Special catheter precautions Copyright © 2018, Elsevier Inc. All rights reserved. 36
- 37. Special Considerations (Cont.) Gerontological Continuous/demand dosing dependent on mental competency Home care Instructing patient and caregiver about wound monitoring, device management, extremity movement, and pump removal Copyright © 2018, Elsevier Inc. All rights reserved. 37
- 38. Nonpharmacological Pain- Management Skill 16-5 Pain management does not always mean the elimination of pain Nonpharmacological interventions may be used to supplement pharmacological interventions, not to replace them They alter a patient’s perception of pain, diminish the physical effects of pain, and provide a sense of control Copyright © 2018, Elsevier Inc. All rights reserved. 38
- 39. Nonpharmacological Pain- Management Skill 16-5 (Cont.) Relaxation A cognitive and/or physical strategy Guided imagery A cognitive strategy that creates a positive psychophysiological response Copyright © 2018, Elsevier Inc. All rights reserved. 39
- 40. Nonpharmacological Pain-Management Skill 16-5 (Cont.) Massage Application of touch and movement to muscles, tendons, and ligaments without manipulation of the joints Heat and cold Applications of heat and cold relieve pain and promote healing Distraction A cognitive strategy that refocuses attention away from the pain Copyright © 2018, Elsevier Inc. All rights reserved. 40
- 41. Delegation and Collaboration Assessment of a patient’s pain cannot be delegated to nursing assistive personnel (NAP). The skill of nonpharmacological pain-management strategies can be delegated to NAP. The nurse directs the NAP to: Identify/explain which nonpharmacological measures work best for the patient Identify the need to adapt strategies to patient restrictions Report worsening of patient’s pain Copyright © 2018, Elsevier Inc. All rights reserved. 41
- 42. Recording and Reporting • Record in nurses’ notes in the electronic health record (EHR) or chart patient’s assessment findings, procedure and technique(s) used, preparation given to patient, patient’s response to procedure or technique, change in overall condition, and further comfort needs related to event. Incorporate pain-relief technique into nursing care plan Copyright © 2018, Elsevier Inc. All rights reserved. 42
- 43. Recording and Reporting (Cont.) • Report patient’s response to nonpharmacological interventions to the staff at change of shift or in a care plan meeting • Report any unusual responses to techniques (e.g., uncontrolled or aggravated pain, or muscle spasms) to nurse in charge or health care provider Copyright © 2018, Elsevier Inc. All rights reserved. 43
- 44. Special Considerations Teaching Provide patient information about each nonpharmacological therapy Fatigue increases pain perception Pediatric Adapt distraction and relaxation strategies to the developmental level of the child; engage parents’ help Copyright © 2018, Elsevier Inc. All rights reserved. 44
- 45. Special Considerations (Cont.) Gerontological Ensure that all assistive devices are in place (glasses, hearing aids, etc.) Sensory impairment may impede the effectiveness of some techniques Tailor to the individual Home care Plan time to reduce noise/other stimuli to promote patient relaxation Copyright © 2018, Elsevier Inc. All rights reserved. 45
Editor's Notes
- This chapter reviews five skills: pain assessment and basic comfort measures, patient-controlled analgesia, epidural analgesia, local anesthetic infusion pump for analgesia, and nonpharmacological pain management.
- Pain is the most common reason that people seek health care, yet it is often under recognized, misunderstood, and inadequately treated.
- [Review Box 16-1: The Joint Commission Pain Standards with the students] The Joint Commission requires that a patient’s reports of pain are to be addressed and appropriately treated (Box 16-1). Patients’ cognitive impairments represent special challenges to pain assessment. Carefully observe a patient’s behavior and nonverbal responses to pain when he or she is unable to self-report. [Review Box 16-2: Pain Assessment in Nonverbal Patients with the students] The two types of pain that you observe in patients are acute (transient) and chronic (persistent), which includes cancer and noncancer pain.
- The most effective pain management combines pharmacological and nonpharmacological strategies with the administration of pharmacological agents. Timely analgesic administration before a patient’s pain becomes severe is crucial for optimal relief. Pain is easier to prevent than to treat. In most situations administration of pharmacological agents “around-the-clock” (ATC) rather than on an “as-needed” (prn) basis is preferable. The American Pain Society and the American Association of Pain Medicine (2009) supports ATC administration if pain is anticipated for the majority of the day. The current pharmacological approach to acute and chronic pain management is to provide multimodal analgesia, which combines drugs with at least two different mechanisms of action so that pain control can be optimized. Make every effort to include complementary/integrative methods, which generally do not require a health care provider’s order (check agency policy). Complementary strategies provide an opportunity for a patient to assume an active role in achieving a higher level of comfort and in some instances freedom from pain.
- Pain management should be patient-centered, with nurses practicing patient advocacy, patient empowerment, compassion, and respect. Caring for patients in pain requires recognition that pain can and should be relieved. Teaching your patient and his or her family about pain treatment, and having an attitude of dignity and caring will allow you to individualize a patient’s pain-control plan. Pain is unique to each individual. It is important to recognize all factors influencing a patient’s pain and integrate them into an individualized plan for pain management. A timely, factual, and accurate pain assessment requires you to work closely with patients and their families. Be objective, listen carefully, and assess any symptoms that a patient expresses. Effective communication and caring are key to gathering all the information needed to accurately determine the character of a patient’s pain and its impact. Knowing these factors will help you intervene effectively to manage your patient’s pain. [Ask students: how can culture and ethnicity affect pain assessment? Discuss: cultures vary in recognition of pain, expression of pain, when to seek treatment, and what treatments are desirable. For example, some cultures tend to be stoic, whereas others tend to be more expressive.] Explore a patient’s beliefs about pain/discomfort. For example, cultures with a holistic world view of health and illness mix religious/spiritual, natural, and the supernatural in their belief systems. Use interpreters to explain pain tools and help patients report their pain as needed. The International Nurses Society on Addictions (IntNSA) and the American Society for Pain Management Nursing supports the position that every patient with pain, including those with substance use disorders, has the right to be treated with dignity, respect, and high-quality pain assessment and management.
- One of the more challenging conditions in pain management is chronic low back pain. Results of a study on pain management for low back pain include: Interdisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, interdisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care. A biopsychosocial approach to care is an individual-centered model that considers the person, their health problem, and their social context: Biological refers to the physical or mental health condition. Psychological recognizes that personal/psychological factors also influence functioning. Social recognizes the importance of the social context (e.g., work, family), pressures, and constraints on functioning.
- Correct answer: A Rationale: Use nonopioids cautiously. They may have more dangerous side effects than opioids, especially for older adults. For example, acetaminophen and NSAIDs have some very serious side effects (e.g., liver damage, gastrointestinal bleeding) even when given at recommended dosages.
- Correct answer: D Rationale: Respecting cultural differences, the nurse should continue to try to engage the patient in conversation, because it is important for the patient to report her pain level. Although the family can be of assistance when present, the nurse needs to assess the patient at this time and not make a series of phone calls. Native Americans may think that asking for pain medication is disrespectful to the nurse, because it may imply that the nurse does not know what she is doing. In this care therefore it is important for the nurse to communicate clearly with the patient so that the patient does not hold back in expressing her pain for fear of being disrespectful.
- Monitor patients who receive opioids (by any route) for signs and symptoms of oversedation and respiratory depression. Excess sedation (difficult to arouse) precedes respiratory depression, especially in opioid-naïve (patients who are not chronically receiving opioid analgesics on a daily basis) patients. Using a standard sedation scale can prevent respiratory depression by observing for and intervening for oversedation. [Review Box 16-3 with the students: Sedation Scale] Monitor activities such as standing, ambulation, transfer to a chair if patient has received an opioid. Assess patient’s blood pressure, pulse, and respirations before initiating activity. If a patient has undergone an outpatient procedure educate patient and family caregiver about precautions: patient cannot drive for 24 hours, caregiver may need to provide assistance with ambulation or take precautions to make home environment safe. Monitor for potential side effects of opioid analgesics and recommend or institute supportive measures (e.g., addition of stool softener or high fiber diet for side effect of constipation).
- Epidural analgesia IV infusion lines should be clearly labeled and identified as such to prevent accidental connection with tubing of a different type (e.g., tube feeding, blood infusion line). Follow these guidelines: Limit access to epidural lines to health care providers with proper education and competence. There can be serious ramifications of misconnections, infections, occlusions, or misadministration of medications. Trace an epidural catheter line from the access site into the patient’s body all the way to the end source of an infusion or capped access port before you connect or reconnect tubing or administer a medication. Communicate any practice changes, including dressing location, type of tubing and connectors with all members of the health care team who are providing care to the patient. Patients currently receiving opioids for chronic pain often require higher doses of analgesics to alleviate new or increased pain; this is tolerance, not an early sign of addiction. Confer with health care provider who might not be aware of at-home dosages. Be aware of individualized dosages and ensure that all caregivers are informed. [Review Box 16-4 with the students: Terminology Related to the Use of Opioids in Pain treatment]
- Drug-drug interactions, including enhanced or reduced effects or side effects, often occur with the multiple drug use required by people with chronic pain. This practice is termed rational polypharmacy or multimodal analgesia. Know agency policy for frequency of pain assessment and timing for follow-up assessments. The first 24 hours on opioids requires frequent assessment, at least every 4 hours.
- Accurate and factual pain assessment is necessary for determining a patient’s response, arriving at proper nursing diagnoses, and selecting appropriate therapies. A comprehensive pain assessment helps you understand the impact of pain on a patient’s life. Pain management requires you to work with a patient and family to prevent pain whenever possible and identify an acceptable intensity of pain and level of other factors, especially sleep that allows maximum patient function. This process recognizes distinct and unique differences in patient perceptions and responses to pain. The nursing process guides you in learning to know a patient and develop an individualized plan of care.
- Assessment of a patient’s pain cannot be delegated to nursing assistive personnel (NAP). NAP may screen patients for pain and provide selected nonpharmacological strategies (e.g., backrubs, heat, cold, elevation) as instructed by the nurse. The nurse directs NAP to: Eliminate environmental conditions that aggravate pain (e.g., an excessively warm, noisy room). Provide maximum rest periods; a written schedule for all to follow is ideal. Turn and place patients in a position of comfort at least every 2 hours, or remind patients to turn themselves. Encourage patients to use a pillow for splinting if needed. Observe for behavioral signs of pain in a patient who is unable to self-report. Ask patient to report pain using the pain intensity scale chosen by patient and nurse. Report in a timely manner any patient reports of pain intensity above predetermined goal and nonverbal behaviors suggestive of pain. Screen for pain during patient transfer or other activity that might provoke pain.
- Adverse effects may result from pharmacological or nonpharmacological pain interventions.
- Teaching Review patient’s and family’s understanding of the pain rating scale used and how to use it when providing pain therapies. Explain to patient and family about behavioral changes that may result from pain. Ask patient and family about fear of addiction, a common primary concern, or other misconceptions that could undermine the patient’s pain relief. Pediatric A numerical rating pain scale is a valid measure for assessing pain intensity in children with chronic pain. The absolute value of a pain-intensity score is not as important as the changes in scores in each individual child. In clinical use with individual patients, a change in pain of 2 of 10 (i.e., a change of 1 face) represents the least change that can be considered clinically significant when using a faces scale. Some children are reluctant to report pain because they have misconceptions about the cause of their pain, or because they fear the consequences (e.g., another painful procedure, an injection). Infants and children experience pain but respond to it differently than adults. For example, they cry and thrash about, have sleep disturbances, have a shortened attention span, suck or rock, refuse to eat or play, or are quiet and withdrawn. Variations in pain response are related to the child’s personality, developmental level, and previous pain experiences. Parents are a helpful source of information when a child’s pain is assessed and pain-relief therapies are planned. Most parents know how their child exhibits pain and which pain-relief interventions have been successful. Children with verbal skills can rate their level of pain on the Wong-Baker FACES pain rating scale or the Oucher pain scale.
- Gerontological Older adults who are able to express themselves can use self-report pain scales. In addition, your assessment should include how the pain is affecting function, sleep, appetite, activity, mood, and relationships with others. Some older adults may require more time for you to explain the pain-assessment scale that you select. Pain is not a natural occurrence of aging, although older adults are at risk for experiencing more pain-producing conditions. Nonverbal older adults experiencing pain typically receive fewer analgesics than similar patients who are able to report their pain. Thus be sure your assessment is thorough, and evaluate a patient’s response critically. Home care Consider home conditions such as type of bed, stairs, and environmental stimuli. A supportive bed and a quiet environment enhance sleep and promote pain management. Family caregivers are the main support for older people. Educate them about causes of painful conditions, common misconceptions about use of analgesics, type of pain medicines appropriate for patient, and how to support medication adherence.
- Patient-controlled analgesia (PCA) is an interactive method of pain management that permits a patient control over pain through self-administration of opioids (usually morphine, hydromorphone, or fentanyl) with minimal risk of overdose. It is a safe method of analgesic administration for acute and chronic pain, including conditions such as postoperative pain, cancer, and end-of-life pain. The goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing. Systemic PCA traditionally involves IV or subcutaneous drug administration. PCA devices are individually programmed to automatically deliver a specific health care provider–prescribed continuous infusion (basal rate) of medication, a bolus dose (patient initiated), or both. PCA prevents overdosing in two ways: having control limits for the total dose that can be administered each hour and having a timing control (lockout period) that regulates the minimum interval (e.g., 10 minutes between doses). It is crucial that candidates for PCA be able to understand how, why, and when to self-administer a medication. Oversedation is a risk in patients with sleep apnea and in obese patients with short, thick necks, who commonly have undiagnosed sleep apnea. Assessment of patient sedation levels is critical. [Ask students: what do you think the advantages of patient-controlled analgesia would be? Discuss: more constant serum levels of an opioid and avoidance of peaks and troughs of a large bolus, better pain relief and fewer side effects from opioids because blood levels are maintained at a level of minimum effective analgesia concentration, increased patient control and independence. Because PCA provides medication on demand, the total amount of opioid use can be reduced.] Patient errors in PCA are often related to misunderstanding the system, mistaking the PCA button for a nurse call button, or letting family members operate the demand button. Incorrect programming is the most common type of error among health care providers.
- [Ask students: what is the harm in administering a PCA dose for the patient? Discuss.] The nurse directs the NAP to: Notify the nurse if the patient complains of change in status, including unrelieved pain or oversedation, to the nurse. Notify the nurse if the patient has questions about the PCA process or equipment. Never administer a PCA dose for the patient, and notify the nurse if anyone, other than the patient, is observed administering a dose for the patient.
- [Ask students: what would be included in the regular assessment of patient response to analgesia? Discuss: vital signs, oximetry or capnography, sedation status, pain rating, status of vascular access site.]
- Inform patient and family that patient will not overdose with PCA if only the patient pushes the button. Explain regimen to family so they can support and help the patient (but not push the button for the patient).
- Pediatric PCA is an effective means of pain control in children who can understand the concept. When selecting children for PCA use, consider a patient’s developmental level, cognitive level, and motor skills. Ordinarily, PCA use is safe and effective for patients as young as 5 years old. From a developmental perspective, use of PCA is particularly effective with adolescents because it leads to feelings of control. Although controversial, some agencies have provided specific guidelines and training to allow parents and nurses to push the button for children too young or unable to use the device on their own. When this is allowed, the concept of patient control is negated, and the inherent safety of PCA needs to be monitored. [Ask students: when is it all right for someone other than the patient to push the PCA button? Discuss: some agencies have provided specific guidelines and training to allow parents to push the button for children too young or unable to use the device on their own.] Pharmacological pain support is safe and effective in pediatric patients when dose is calibrated according to child’s weight. Gerontological considerations Older patients sometimes appear more sensitive to analgesics and experience more opioid side effects. Older adults’ reduced renal and liver function slows opioid metabolism and excretion. This causes a faster peak effect and a longer duration of action of the opioid. Dosages should be started low and titrated upward slowly until pain relief is achieved. If patient confusion occurs while PCA is used, call to get orders to lower the dose, lengthen the lockout, or add a nonopioid analgesic to reduce the opioid dose; nurse-activated around-the-clock dosing is another alternative; refusing to medicate is not the answer; confusion may be caused by pain rather than by the medications.
- Correct answer: B Rationale: The nurse is always responsible for the initial pain assessment and administration of medications. The pain scale cannot be changed by NAP; however, NAP can assess the patient using the same scale that was decided upon by the nurse and the patient. Turning and positioning the patient as ordered can be delegated to NAP; the nurse will instruct NAP as to the time frame for repositioning and will instruct NAP to report to the nurse immediately any issues (such as increased pain or development of ulcers).
- Epidural analgesia is effective during labor and does not result in any adverse effects or increased frequency of cesarean delivery. Patient-controlled epidural analgesia (PCEA) has been shown to provide excellent control of labor and postoperative pain when compared with intravenous (IV) patient-controlled analgesia (PCA). Epidural opioids reduce the total amount of opioid medication required to control pain and thus produce fewer opioid-related side effects. Safe and effective management requires a coordinated interprofessional approach. The epidural space is a potential space that contains a network of vessels, nerves, and fat; it is located between the vertebral column and the dura mater—the outermost meninges covering the spinal cord. Analgesic is distributed by diffusion through the dura mater into the cerebrospinal fluid, by blood vessels in the epidural space, or by systemic delivery, or it may be absorbed by fat in the epidural space. Analgesic acts by binding to opiate receptors in the dorsal horn of the spinal column, thus blocking transmission of the pain impulse to the cerebral cortex. [Shown is Figure 16-1: Anatomic drawing of epidural space. (Reprinted from www.netterimages.com © Elsevier, Inc. All rights reserved.)]
- Opioids and local anesthetics, separately or in combination, are used in epidural analgesia. Opioids are delivered close to their site of action (central nervous system) and thus require much smaller doses to achieve the same pain relief. Common opioids given epidurally include morphine, hydromorphone, fentanyl, and sufentanil. These opioids differ by their lipophilic “fat-loving” and hydrophilic “water-loving” properties, which affect absorption rate and duration of action. An anesthesia provider places a catheter into the epidural space below the second lumbar vertebra, where the spinal cord ends. Epidurals may also be placed at the thoracic level of the spinal cord. [Image is Figure 16-2: Placement of epidural catheter.]
- Temporary or short-term catheters are not sutured in place and exit from the insertion site on the back. A catheter intended for permanent or long-term use is “tunneled” subcutaneously and exits out on the side of the body or on the abdomen. Tunneling reduces infection and catheter dislodgement. A sterile occlusive dressing covers the catheter exit site and is secured to the patient. An x-ray film confirms epidural catheter placement. [Image is Figure 16-3: Epidural catheter attached to ambulatory infusion pump. (Image courtesy Astra Zeneca Pharmaceuticals, Wilmington, Del. All rights reserved.)]
- A health care provider administers epidural medication intermittently via a bolus injection, or a patient can inject on demand (patient-controlled epidural analgesia [PCEA]) through a pump. An epidural infusion can also be given continuously via a controlled delivery system such as an implanted infusion pump. The use of epidural opioids requires astute nursing observation and care. The catheter poses a threat to patient safety because of its anatomic location, its potential for migration through the dura, and its proximity to spinal nerves and vessels. Catheter migration into the subarachnoid space can produce dangerously high medication levels. Frequent complications include hypotension, respiratory depression, motor block, urinary retention, pruritus, and superficial infection around a catheter. Do not administer other supplemental opioids or sedatives when patients are on an epidural; the combined effect may cause respiratory depression. In many health care agencies, anesthesiologists and nurse anesthetists are the only health care providers who may initiate epidural opioid infusions or administer a medication bolus. [Discuss local requirements with students.]
- The skill of epidural analgesia administration cannot be delegated to nursing assistive personnel (NAP). The nurse directs the NAP to: Observe the dressing over the insertion site when repositioning or ambulating patients to prevent catheter disruption. Avoid pulling patient up in bed while he or she is lying flat on the back, which can dislodge the epidural catheter. Report any catheter disconnection or leakage from dressing immediately. Immediately report to the nurse any change in patient status, comfort level, or loss of sensation or movement to nurse immediately.
- Record drug, dose, method of administration (bolus, demand, or continuous), and time given (if injection) or time begun and ended (if demand or continuous) on appropriate medication record in the electronic health record (EHR) or chart. Specify concentration and diluent. With continuous or demand infusion, obtain and record pump readout hourly for first 24 hours after infusion begins and then every 4 hours. Review pump settings and usage together with staff coming on the next shift.
- Record regular periodic assessments of patient’s status in nurses’ notes in electronic health record (EHR), and/or on appropriate flow sheet, including vital signs, pulse oximetry/capnography, intake and output (I&O), sedation level, pain severity score, neurological status, appearance of epidural site, presence or absence of adverse reactions to medication, and presence or absence of complications resulting from placement and maintenance of epidural catheter. Report any adverse reactions or complications to health care provider immediately. Document evaluation of patient learning.
- Teaching Describe catheter placement and use to the patient as appropriate. Drawing or showing pictures often helps. Teach patient and family members the purpose and action of opioid or local anesthetic, as well as signs and symptoms of adverse reactions. Teach when and which signs and symptoms should be reported to the nurse. Teach patient to report pain level with an acceptable (to patient) pain scale. Inform patient of other pain-management strategies that supplement or enhance pharmacological intervention. [Ask students: what are some examples of nonpharmaceutical pain-management strategies? Discuss: imagery, distraction, relaxation, massage, etc.] Some patients may attempt to ambulate without assistance or may overdo other activities. Caution them to begin slowly to avoid injury, and to always call for the nurse to assist with any activity. Explain that the first attempt to ambulate may feel strange secondary to decreased sensation, but motor (leg) function should be unaffected. Pediatric Apply EMLA cream to the epidural site a minimum of 60 minutes before catheter insertion. Dosing regimens for children must be adapted for age and weight with maximum dosage clearly defined to minimize cumulative local anesthetic toxicity. Hourly assessments are recommended, especially in the first 12 hours. There should be regular review of need for infusion especially after 48 hours.
- Gerontological Older adults are at the same risk for complications and medication adverse effects as other adult patients. Home care Patients needing long-term therapy are discharged with a tunneled catheter. Before considering catheter placement and care in the home, assess patient’s fine-motor skills, cognitive ability, and stage of disease and prognosis, as well as the degree of involvement of family caregiver. Teach patient and caregiver proper dosage and administration of medication. Evaluating patient’s technique for catheter care, administering medication, and reinforcing instructions are priorities. Teach patient and caregiver aseptic technique for medication administration as needed and for all catheter care procedures, including dressing changes. Instruct patient to change dressing every week (policy varies with home care agency). Teach signs and symptoms of infection and instruct patient to report to nurse or health care provider immediately should signs and symptoms appear. Teach patient and caregiver about signs and symptoms of adverse reactions to medication being used and interventions used to alleviate mild side effects in the home. Give patient and family phone numbers of health care providers to contact in an emergency and information on resources in the community.
- During surgery for joint replacement, some surgeons insert a one-way catheter into the surgical site and attach it to an infusion pump. The pump delivers a local anesthetic (e.g., bupivacaine and ropivacaine, or mepivacaine) directly into the wound bed to constantly “bathe” the specific nerve or nerve plexus responsible for pain at the surgical site, thus maintaining analgesia during and after surgery. Even if the patient still requires oral analgesics, the total dosage of medication is often reduced. [Image is Figure 16-4: Local anesthetic infusion pump in use after shoulder surgery. (Image courtesy Breg, Inc, Vista, CA. All rights reserved.)] The pump has a demand rate (4 to 6 mL/bolus) and a continuous (basal) rate (2 to 4 mL/hr) feature. Continuous flow reservoirs hold 100 mL, whereas patient-controlled units have a 60-mL reservoir. The device remains in place for about 48 hours and is rarely removed during hospitalization; patients learn how to remove the catheter at home. Patients regain their mobility quickly, thus reducing the risk of developing postsurgical complications. Nursing care focuses on assessment of catheter site and connections, evaluation of local anesthetic side effects, and patient teaching.
- The task of managing local anesthetic infusion pump analgesia cannot be delegated to NAP.
- [Ask students how they will remember the factors that need to be recorded. Discuss.]
- [Ask students how they will remember the factors that need to be recorded. Discuss.]
- Teaching Provide preoperative teaching because device is placed in operating room. If device is on demand (not continuous), instruct patient to depress button every 6 hours. Instruct patient to inform nurse if pain exceeds pain intensity goal because additional oral and/or intravenous analgesics are available for breakthrough pain. Pediatric Local continuous infusion pumps have been used for children undergoing orthopedic surgery. Instruct parents and the child as described under Home Care Considerations. Explain special precautions that can help to avoid dislodgement of the catheter.
- Gerontological Continuous dosing is sometimes administered, but demand doses require a mentally competent adult. In addition, special precautions can be taken to protect the catheter. Home care Instruct patient to notify health care provider if excessive fluid or bleeding on the dressing occurs; if patient has signs of anesthetic reaction, including arrhythmias, weakness or numbness of affected area, seizure, confusion, drowsiness, ringing in the ears; or if sings of infection develop (redness and tenderness at catheter site, drainage or fever). Provide written copy of instructions. Provide verbal and written instructions regarding how and when to discontinue the device when at home. Remind patient to place catheter in a plastic bag and bring it to first follow-up visit with health care provider. Provide instructions regarding extremity movement. Home health nurse may be ordered to remove pump via surgeon’s order.
- Some of these nonpharmacological pain-management interventions are also classified as complementary or alternative therapies, and evidence supports pain relief. Distraction, relaxation, guided imagery, and cutaneous stimulation such as massage and acupressure are a few examples of effective nonpharmacological measures. Many nonpharmacological techniques trigger a relaxation response by stimulating the parasympathetic nervous system (PNS). Because pain often causes muscle tension and anxiety, PNS stimulation relieves these disturbing responses. [Review with students Box 16-5, Nonpharmacological Strategies for Pain Management.] Nonpharmacological interventions are appropriate for patients who find such interventions appealing, express anxiety or fear, may benefit from avoiding or reducing drug therapy, and have incomplete pain relief with pharmacological interventions alone.
- Relaxation A patient’s full participation and cooperation are necessary for relaxation techniques to be effective. These techniques are particularly useful for chronic pain, labor pain, and relief of procedure-related pain. Relaxation interventions involve progressive muscle relaxation, massage, quiet breathing, deep breathing, guided imagery, or a combination. Guided imagery The goal of imagery is to have a patient use one or several of the senses to create an image of a desired result. Focusing the imagination helps patients change their perceptions about their disease, treatment, and healing ability, which helps to relieve pain, tension, or stress. [Ask students: will the same imagery work for all patients? Discuss: choosing images that patients find pleasant requires careful assessment. Otherwise you may mistakenly describe images of objects or things that a patient fears or dislikes. For example, a scene of rolling waves at the seashore is restful for one patient but may be frightening to another.]
- Massage Blocks perception of pain impulses and helps relax muscle tension and spasm that otherwise might increase pain. Hastens the elimination of wastes stored in muscles, improves oxygenation of tissues, and stimulates the relaxation response in the nervous system. Massage after a bath or before a patient prepares for sleep promotes relaxation and comfort. Do not perform massage over bruised, swollen, or inflamed areas or on bones of the spine. Heat and cold The selection of heat versus cold varies with a patient’s preference and condition. Application of heat or cold in a health care agency or a home health environment requires a health care provider’s order. Although physiological responses to heat and cold differ, superficial heat or cold applications provide comfort in similar conditions such as muscle spasms, strains, and localized joint pain (see Chapter 42 for a review of warm and cold therapy). Distraction There are internal and external distraction techniques. Internal techniques include having patients count, sing to themselves, pray or repeat statements in their head such as “I can cope.” External distractions include changing a patient’s activity, needlework, listening to music, reading, walking, playing a musical instrument, or watching a comedy program. When the distraction is removed, a patient may have a heightened awareness of pain.
- Assessment of a patient’s pain cannot be delegated to NAP.
- [Ask students why responses to nonpharmacological interventions are reported to the staff or in a care plan meeting.]
- Teaching Provide patient information about each nonpharmacological therapy, including purpose, rationale for how pain is relieved, and how patient can maximize benefits. If NAP performs massage, you still need to provide patient education. Some techniques require more practice before patients achieve results. Pharmacological intervention is sometimes required to lessen pain so patient can relax. Teach patient to rest between periods of activity at home and in hospital because fatigue increases pain perception. Teach family member how to perform massage (if not contraindicated) as part of home care. Pediatric considerations You can use nonpharmacological pain-management therapies successfully with children. Adapt distraction and relaxation strategies to the developmental level of the child (e.g., use a pacifier for an infant, offer to read or play a recording of a favorite story for a preschooler, encourage a teenager to listen to music with headphones). Play therapists are usually available at large pediatric hospitals and are good resources for appropriate distraction techniques. Because children usually have an active imagination, relaxation is often a powerful adjuvant in pain control. Parents are very helpful in providing pain relief. For example, they provide comfort by their presence or conversation, and by holding and cuddling their child.
- Gerontological Visual, hearing, cognitive, and motor impairments make it difficult for older adults to be able to effectively use procedures such as distraction, relaxation, or guided imagery. Make certain that glasses, hearing aids, and other assistive devices are in place. An evidence-based practice protocol for pain management in older adults recommends these guidelines for nonpharmacological therapies. Tailor nonpharmacological techniques to the individual. Cognitive behavioral strategies may not be appropriate for the cognitively impaired. Physical pain-relief strategies focus on promoting comfort and altering physiological responses to pain and are generally safe and effective. Home care Family members need to collaborate on planning time to reduce noise and other stimuli in the home to promote patient relaxation.