 This
tool depicts 6 faces ranging from a happy face to a crying grimace. The
nurse reads a statement about how each face correlates to pain and then
the patient points to the face that best represents how he is feeling.
Besides
severity, the "S" in the pneumonic PQRST stands for symptoms. Assess the
patient for other symptoms that accompany the pain. Common ones include
nausea, vomiting, dizziness, and restlessness. Many times when the patient
is given treatment for pain, these symptoms subside or are eradicated;
but other times, adjuvant treatments are needed.
The
questions to ask in determining timing include: "How long does the pain
usually last?" and "When and how does it usually lessen or stop?" The
answers to these questions help the nurse to understand the precise nature
of the patient's pain experience and allow the nurse to support the patient's
methods of pain relief, unless they are harmful.
Besides
using the PQRST mnemonic, the nurse must be alert for various physical
and behavioral signs and symptoms associated with pain or those that may
accompany pain. The nurse may observe some of these behavioral indicators,
such as restlessness, moaning, crying, clenched teeth, or protecting /guarding
body parts. Or the patient may need to state their presence, such as when
he is feeling anxious or nauseous. Vital sign changes can also indicate
pain, such as an elevation in pulse rate, blood pressure, and respirations.
However, this is more accurate for the presence of acute, not chronic,
pain. Also, elevated vital signs are not always seen in every acute pain
situation, nor are they a reliable indicator of pain intensity. Therefore,
the absence of behavioral indicators or vital sign elevations does not
mean the patient is not experiencing pain. For example, it is unclear
whether a comatose person experiences pain; just because a person cannot
respond to a noxious stimulus may not mean that he cannot feel it. Conversely,
these other signs and symptoms may be the only clue the nurse has that
the patient is in pain. This is particularly significant when the patient
has difficulty expressing pain due to factors such as socioculturally
learned behaviors, immaturity, neurologic damage, or mental or physical
handicap.
Another
area for the nurse to observe is how the patient's pain is affecting activities
of daily living (ADLs). When a patient is in pain, ADLs are often either
neglected or altered. Sleep can become erratic, sexual activity may decline,
exercise programs can cease, playtime or hobbies are neglected and the
patient may miss more hours at work. Simply asking patients, "How does
pain limit your daily activities?" or "What can you no longer do because
of your pain?" may elicit useful information.
Another
important area for the nurse to consider when assessing the patient's
pain is neurological status. When deficits are present in the central
nervous system, such as dementia, mental handicap, or even immaturity,
the nonverbal cues of pain become most important. Though it is more difficult
to assess a patient with cognitive impairment, it is not impossible; every
person deserves a thorough pain assessment. Behaviors that can indicate
pain include flinching, guarding, grimacing, whimpering, and restlessness.
Additionally, further investigation is warranted when a patient refuses
to move or eat, pulls at equipment such as tubing, or has a change in
continence. When the patient has a peripheral nervous system deficit,
such as the diabetic with peripheral neuropathy, the sensation of pain
in certain parts of the body is altered. Teaching the patient with peripheral
nervous system deficits to visually inspect his body on a daily basis
is important; injuries can occur without the sensation of pain as a warning.
Also, careful application of certain treatments, for example hot or cold
packs, is essential.
Pharmacologic Interventions
Once
a complete assessment has been done, the patient needs to receive treatment
in a timely manner. The key to any treatment plan is individualization,
for each patient and sometimes each pain episode. Often a variety of resources
are needed for pain control. Certainly the goal is pain eradication, but
sometimes bringing pain to an acceptable level of tolerance is more realistic.
Pharmacological intervention is usually a good place to start. The three
main categories of pharmacologic pain relief medications are non-opioids,
opioids, and adjuvants.
Specific
examples of commonly used non-opioid pain medications, often called non-narcotics,
include acetaminophen, aspirin, nonsteroidal anti-inflammatories (NSAIDs),
choline magnesium trisalicylate (Trilisate), and diflunisal (Dolobid).
Acetaminophen's analgesic properties appear to involve central mechanisms
associated with nitric oxide and N-methyl-D-aspartate receptors. Aspirin,
other salicylates, and NSAIDs inhibit prostaglandin synthesis to produce
analgesia.
Common
opioid medications, sometimes referred to as narcotics, are typically
characterized as either weak or strong. Weak opioids include codeine,
oxycodone, Vicodin, and oxycodone combined with either acetaminophen or
aspirin. Morphine, hydromorphone, fentanyl, and meperidine are examples
of strong narcotic medications. The opioids can also be classified by
two subtypes: agonists and agonist-antagonists. Both types of opioids
provide analgesia through mu, delta, and kappa receptors found in the
central and peripheral nervous systems. The agonists attach to mu, delta,
and kappa sites; however, the agonist-antagonists bind to the mu and kappa
receptors, producing effects at the kappa sites but blocking effects at
the mu sites.
Adjuvant
medications can also be used to supplement non-opioid and opioid medications.
Adjuvant analgesics are medications whose primary indication is not for
pain management but which have demonstrated analgesic effects. Examples
of adjuvant medications used to treat pain include tricyclic antidepressants
and anticonvulsants. Tricyclic antidepressants help to improve mood and
increase pain threshold. The analgesic action of tricyclic antidepressants
is not certain; however, it has been theorized that they enhance the descending
pain inhibitory system through prevention of serotonin and norepinephrine
re-uptake. They have been found to be particularly useful for treating
some types of migraines and burning types of pain. Examples of tricyclic
antidepressants include amitriptyline and nortriptyline. The anticonvulsants'
mechanism for pain control is also uncertain; however, they have been
found to be particularly useful in treating lancinating and neuropathic
pain. Carbamazepine, valproate, and gabapentin are three examples of anticonvulsants
used to treat pain.
The
medication chosen to treat pain is often based on practitioner's
preference; however, certain restrictions apply. Generally, a patient
should not be taking two analgesics from the same class at the same time,
unless one is sustained release used on a round-the-clock basis and the
other is instant release for breakthrough pain. When a patient needs to
switch from one narcotic to another, due to ineffectiveness or intolerable
side effects, health practitioners should consult an equianalgesic guide.
An equianalgesic chart shows practitioners the equivalent potency regarding
dosage and route between narcotics, helping to eliminate the possibility
of under or overdosing. Educate patients to ask for pain medication when
the pain begins, not when it becomes unbearable. Pain control methods
work best when they are administered at the onset of pain. Also remember
to check patients' allergies before administering any medication.
In
addition to administering medications, nurses are also responsible to
know the potential side effects of each medication. Every medication has
the potential for side effects, even if the patient has had the medicine
before and not experienced a particular side effect. Also, be aware that
side effects may occur at lower doses among the older adult population.
With the exception of acetaminophen and Trilisate, the non-opioids have
antiplatelet effects that can lead to bleeding, particularly in the gastrointestinal
tract. Nausea and vomiting have also been associated with the non-opioids.
Acetaminophen may cause hepatotoxicity, but this is rarely seen except
for overdose or when used with people who have a compromised liver. Be
aware that for each non-opioid there is a ceiling dose. The ceiling dose
is the highest level of analgesia that can be achieved without significant
side effects or toxicity.
The
most troublesome side effect of the opioids is constipation. Fortunately,
concurrently instituting a bowel regimen usually helps to eliminate this
side effect. A good bowel regimen includes the daily use of a stool softener
plus a laxative, increasing fiber and fluid intake, and instituting routine
aerobic exercises. Opioids can also cause sedation, nausea, and vomiting.
As with any sedating medication, caution must be instituted when performing
physical activities. An antiemetic can be prescribed for relief of nausea
and vomiting. Fortunately, tolerance generally develops to sedation, nausea,
and vomiting. Respiratory depression is a potentially serious side effect
of opioids but fortunately not a very common one. If respiratory depression
does occur, it tends to be a short-lived phenomenon. Additionally, using
the antagonist medication naloxone can reverse respiratory depression.
However, because the half-life of naloxone is shorter than most opioids,
the patient must be monitored closely for recurrence of respiratory depression.
Also, using naloxone can reverse the analgesic effects of the opioid;
therefore, the patient may need further treatment to control his pain.
Besides
the choice of medication, the way a medication is administered is also
important. Options include enteral and parenteral medications. Enteral
medications are those that use the gastrointestinal (GI) tract, while
parenteral medications bypass the GI system. If the GI system is intact,
this is usually the best choice. When parenteral medication is preferred
there are several notable options: local pain relief, epidurals, rectal
administration, and patient controlled analgesia.
Local
pain relief can involve a topical application to the skin or mucous membranes.
One popular use of topical pain relief, particularly among the pediatric
population, has been the use of a cream mixture of prilocaine and lidocaine
applied to the skin before an intravenous insertion is performed.
Another
way to administer parenteral medication is through an epidural. An anesthesiologist
or anesthetist places a catheter into the epidural space in the spine,
securing it with a sterile dressing and tape. Medication is either administered
continuously through a pump or intermittently by the anesthesiologist
or anesthetist. Usually the catheter placement is temporary and exits
out the back; however, long-term epidurals can be performed and they often
exit through the abdomen. The nurse's responsibility to a patient
who has an epidural includes making sure the catheter is securely in place,
usually taped to the skin, and informing the anesthesiologist or anesthetist
when the patient on intermittent dosing needs more medication to be injected
into the catheter. Advantages of the epidural route include site-specific,
rapid and prolonged pain relief with less severe systemic adverse side
effects.
An
often-neglected route is rectal administration. Advantages of the rectal
route include simplicity of administration and lower cost than most other
parenteral methods. To administer, position the patient on his left side
with top leg flexed, while aiming toward the patient's umbilicus
insert a moistened suppository against the rectal wall approximately a
finger's length into the rectum, and after withdrawing your finger
ask the patient to relax and not bear down. Briefly holding the patient's
buttocks together may aid in eliminating expulsion. While suppositories
are most often the products given rectally, solutions, injectable medications,
and even tablets have been used with little or no alteration. Contraindications
of the rectal route include neutropenia (low white blood cell count),
thrombocytopenia (low platelets), and rectal bleeding.
Another
very effective method of parenteral pain medication administration entails
the use of patient controlled anesthesia (PCA). The effectiveness of PCA
is based on its individualization, a primary component of pain management.
With PCA the patient receives either intravenous or subcutaneous medication
when he presses a button on the PCA machine to which he is attached. The
nurse, following prescriptive order, presets the medication, dosage, and
timing before the patient is attached to the machine. The machine can
be set to include a lockout time. This is when the patient can push the
button to deliver medication but no medicine is released until a certain
time elapses, thus preventing overdose. However, it is very important
to monitor patients who are on PCAs, particularly in the initial stage
of operation. Areas for potential problems include machinery malfunction,
a too strong prescribed dosage, or a too short or too long lockout time.
Additionally, patients must be educated on how to use a PCA machine. When
a patient is on PCA a nurse should include, as part of the pain assessment,
whether the patient understands how PCA works and how to use it to obtain
medication. Luckily, PCA machines are easy to use and have the advantage
of giving the patient control of his own pain relief. An additional advantage
is that patient's serum drug levels can remain constant since the
moment he feels pain, he can push a button to receive medication. When
patients rely on nurses for pain medication, relief takes longer since
the patient must notify the nurse he is feeling pain, the nurse must check
the medication order, then pour the medication, before she can finally
give it. An exciting new development is the use of PCA for treating pain
in children and adolescents.
A
simple, widely used, and effective approach to pharmacotherapy for cancer
and other pain has been devised by the World Health Organization (WHO).
The five essential concepts in the WHO approach to drug therapy of pain
are:
- By the mouth.
- By the clock.
- By the ladder.
- For the individual.
- With attention to detail.
It
has been shown to be effective in relieving pain for approximately 90
percent of patients with cancer and over 75 percent of cancer patients
who are terminally ill. Called the WHO Pain Ladder, this approach incorporates
the concept of an analgesic ladder, a rational, stepwise approach to pain
management.
The
first step in the ladder is the use of acetaminophen, aspirin, or another
NSAID for mild to moderate pain. Adjuvant drugs to enhance analgesic efficacy,
treat concurrent symptoms that exacerbate pain, and provide independent
analgesic activity for specific types of pain may be used at any step.
When
pain persists or increases, an opioid such as codeine or hydrocodone should
be added (not substituted) to the NSAID. Opioids at this step are often
administered in fixed dose combinations with acetaminophen or aspirin,
because this combination provides additive analgesia. Fixed-combination
products may be limited by the content of acetaminophen or NSAID, which
may produce dose-related toxicity. When higher doses of opioid are necessary,
the third step is used. At this step separate dosage forms of the opioid
and nonopioid analgesic should be used to avoid exceeding maximally recommended
doses of acetaminophen or NSAID.
Pain
that is persistent, or moderate to severe at the outset, should be treated
by increasing opioid potency or using higher dosages. Drugs such as codeine
or hydrocodone are replaced with the more potent opioids (usually morphine,
hydromorphone, methadone, fentanyl, or levorphanol), as described above.
Medications for persistent cancer-related pain should be administered
on an around-the-clock basis, with additional "as-needed" doses,
because regularly scheduled dosing maintains a constant level of drug
in the body and helps to prevent a recurrence of pain. Patients who have
moderate to severe pain when first seen by the clinician should be started
at the second or third step of the ladder.
The
topic of placebos is controversial. A placebo is any inactive substance
given to satisfy a demand for medication. Studies have been done to demonstrate
the effectiveness of placebos; however, many healthcare practitioners
deem the use of placebos as unethical. Some studies have demonstrated
that the effectiveness of placebos may be due to the body's release
of endorphins or even the presence of the healthcare worker. Essentially,
when a practitioner prescribes placebos he negates the subjectivity of
pain because he has labeled the patient's pain as not real and therefore,
not needing an active treatment. Those patients who are prescribed placebos
are often seen as liars, drug seekers, or mentally ill. Certainly, when
one prescribes or gives a placebo, there is the potential that the trust
relationship, so important within the healthcare arena, could be destroyed.
Non-Pharmacologic Interventions
Besides
medications there are also non-pharmacologic options to control pain.
Most often they are used to complement pharmacologic options. The advantages
of using non-pharmacologic methods include the fact that many of them
do not require a prescription or any special equipment. However, always
make sure an intervention is appropriate and safe for each patient situation
before implementation.
The
simplest way to eliminate or reduce pain can involve altering the environment.
Many variables within the patient's setting can cause or worsen pain
such as temperature, bedding, body alignment, equipment, and clothing.
Adjusting the air-conditioning, adding a fan, or removing or supplying
a blanket can help the patient who is uncomfortable due to temperature.
Wrinkles in sheets can cause extra friction and pressure, which can be
relieved by tightening and smoothing linens. Adding an eggcrate mattress
can improve old or unsupportive mattresses. Positioning in anatomical
alignment, providing support for limbs, and eliminating pressure points
are important ways to prevent pain from occurring in the immobilized patient.
Therapeutic beds can also relieve pressure. Encouraging active range-of-motion
exercises or providing passive range-of-motion can alleviate pain caused
from stiffness and prevent painful muscle contractures. Equipment can
cause pressure points and friction areas and therefore must be routinely
checked for proper placement, with frequent skin assessments. For example,
a nasal cannula can cause erosion of nares or ear tissue, or tubing can
become lodged underneath the patient. Also, patient clothing, whether
a gown or street clothes, can become tangled or caught on equipment, causing
constriction and pain. Wet clothing can also become an irritant.
Other
non-pharmacologic interventions are relaxation and guided imagery, often
used together. Relaxation can be as simple as focusing on one's breathing
to control tachypnea or mentally concentrating on a pleasant thought or
scene. Patients can also be taught to progressively contract and then
relax various muscle groups, usually in a sequential pattern, such as
from neck to toes. Meditation is a form of relaxation. Guided imagery
generally implies that a trained practitioner reads or speaks in soothing
tones while the patient focuses on a positive image, such as a beach scene
or a walk in the park. The key points of guided imagery involve focusing
on a repetitive thought, word, phrase, or activity and taking a positive
attitude toward intruding thoughts, eliminating them as distractions.
Relaxation and guided imagery are thought to counterbalance the "fight
or flight" response the body often activates in response to pain.
As a result of using these techniques the body often experiences a reduction
in skeletal muscle tension, a decrease in vital signs, lowered metabolic
rate, and less oxygen consumption.
Cutaneous
stimulation can be used to eliminate pain as well. The therapeutic effects
of cutaneous stimulation are based on the Gate Control Theory of pain
discussed earlier. Cutaneous stimulation focuses on non-painful peripheral
skin surfaces, thereby blocking the painful stimulation, causing a decrease
in pain. Techniques that use cutaneous stimulation are massage, acupressure,
acupuncture, hot and cold applications, and transcutaneous electrical
nerve stimulation (TENS).
Massage
involves using either the hands or a smooth hard object, such as a sandbag,
to hold, clutch, knead and rub the skin and superficial muscle layer.
Particular attention is given to areas of pain. In its simplest form,
a person may automatically massage a painful area; however, the use of
professional massage therapists is growing in popularity.
Both
acupressure and acupuncture originated in China. Acupressure entails massaging
and/or applying pressure to trigger points. Trigger points are hypersensitive
areas in connective or muscle tissue. Acupuncture also uses trigger points
but instead of massage, fine sterilized flexible needles are placed at
these sites. After the needles are inserted under the skin, the practitioner
agitates the needles in order to produce pain relief. Pain relief is based
on the belief that health is a state of constantly changing flow of energy
which, when unbalanced, causes disease and pain. Acupuncture is thought
to help regulate the body's energy flow back to a state of balance.
Though the energy flow theory has not been proven, it has been demonstrated
that acupuncture stimulates the body's endorphins and monoamines.
Heat
has been found effective in soothing inflamed muscles and helping to reduce
inflammation, particularly for post-traumatic pain, rheumatic aches, and
neck and back pain. It is best used after initial inflammation has resolved,
usually twenty-four hours after injury occurs. Also, heat can be applied
before mobilization is attempted, allowing for a greater degree of movement
as well as increased comfort. When heat is applied there is increased
blood flow, decreased vasomotor tone, and increased tissue metabolism
providing overall effects of analgesia, reduced muscle spasticity, sedation,
and elevation of the pain threshold. Heat should not be used, however,
at the site of neoplasms, skin desensitization, vascular insufficiency,
active infection, or bleeding.
Cold
application can be as effective as heat and is usually the first application
in an initial acute injury. Cold reduces inflammation and swelling through
decreasing vascular flow. It is useful to lessen muscle spasticity and
may elevate pain threshold by reducing nerve conduction velocity. Contraindications
for cold therapy include vascular insufficiency and conditions directly
aggravated by cold, such as Raynaud's syndrome. Both hot and cold
are useful for analgesia, and the choice may be simply a matter of patient
preference.
A
TENS unit is a portable machine attached to the patient's skin at
specific trigger points or peripheral nerves near the site of pain. The
practitioner applies the unit and then, with patient input, adjusts the
placement, frequency, and voltage. A TENS unit can either be set for continual
or periodically delivered electrical stimulation in order to provide for
optimal pain relief. The electrical current stimulates sensory cutaneous
nerve endings that are thought to block deeper, more painful sensations.
Additionally, TENS may stimulate the release of endorphins. Patients report
that the stimulus feels like a pricking or buzzing sensation. TENS has
been found to be very effective for certain types of pain such as rheumatic
aches, back and neck pain, stump pain, postoperative pain, and neuralgia.
People with cardiac arrhythmias or pacemakers should not use a TENS
unit. Also, TENS should not be placed over an open wound nor on areas
of desensitivity.
Another non-pharmacologic treatment option is biofeedback. Biofeedback
requires the use of special equipment and trained practitioners, which
can be a costly endeavor. The patient is taught, through systematic trial
and error, to condition brain wave activity. The patient is attached to
a machine that relays information to him about body changes occurring
and thus, he learns to control or replace those associated with pain with
a more pleasant experience. Biofeedback has been found to be effective
for a variety of painful conditions including headaches and osteoarthritis.
Therapeutic
touch is based on an eastern philosophy of energy manipulation. A trained
practitioner does not actually touch the patient but rather directs the
patient's energy by moving her hands above the body part experiencing
pain. The practitioner must center herself, make an assessment of the
patient, unruffle the field, direct and modulate the energy, and also
recognize when to stop. Proponents of therapeutic touch believe it to
be a healing therapy that can also decrease pain. However, due to spiritual
conflicts, some healthcare workers and patients have declined to participate
in therapeutic touch.
Lastly,
never underestimate the value of education. A well-informed patient is
usually best able to cope with his pain. The nurse should not be the only
person in the nurse-patient relationship with the proper information on
pain and its treatment. Certainly, in today's information explosion
society, patients may present with a plethora of information; however,
a patient with a lot of information is not synonymous with an educated
patient. Beyond instructing patients about pain and treatment options,
nurses may need to clarify and correct misinformation.
Principles of Pain Treatment
Some
principles to remember when administering pain treatments include obtaining
the patient's consent before implementation, particularly for the
non-pharmacologic options. Consent can be as simple as a verbal agreement
to participate in the activity or the patient may need to sign an actual
form. Also teach the patient to inform you of his pain before it becomes
severe; pain is best treated before reaching a severe level. Likewise,
assessments should occur on a routine basis so that pain does not become
severe before it is treated. Be aware that people may not use the word
pain but call the experience an ache or discomfort. Also, do not assume
that, because the patient received adequate relief for four hours from
the last medication administration, he will get the same length of relief
from the same amount of medicine at the next administration. Too many
variables are changing throughout the day; for instance, a painful procedure
may need to be done during one time span or nighttime may occur, when
endorphins are known to be lower. It is also important to consider the
patient's willingness and ability to engage in treatment. The best
methods will not help if the patient is unwilling or unable to utilize
them.
Documentation
Certainly
another integral part of pain treatment involves documentation. Things
that need to be documented include the assessment findings, treatments
offered and utilized, and the results of the treatments. Documentation
can occur in a variety of forms, from narratives to flow charts or a combination;
however, it is most important that it is done routinely in a systematic
format. Documentation helps to facilitate regular reassessment and follow-up,
and is essential for effective pain management. Examples of documentation
forms for assessment and evaluation are included as Figures 4 and 5.
|
National Center
of Continuing Education
