||Acute Pain Management
Guidelines For Nurses From The University Of Iowa And The National Guideline Clearinghouse
Baseline pain Assessment
The baseline pain assessment can be completed prior to a known painful event
such as surgery or a diagnostic procedure to best help health care professionals
manage the patient's pain in a proactive manner. The following activities
comprise a baseline assessment.
- While pain is the standard term used in the protocol, it is commonly
recognized that many individuals use other terms (e.g., 'ache,' 'discomfort').
Use of preferred terminology will enhance understanding
and participation by patients in their pain management program.
pain terminology typically used by the patient and use this term throughout
the implementation of protocol.
Provide opportunity for individualized
patient/family and nurse interaction. Involve family in all aspects of
assessment and planning for pain management. Assess patient/family's
current knowledge of pain management strategies that may be implemented
- Using a standard mental status tool, such as
the Mini Mental State or the Short Portable Mental Status Questionnaire
assess the patient's cognitive ability. Also assess functional
status using the Katz ADL Scale or an institutional measure of
functional abilities remembering to include sensory assessment. Obtain
family assistance as needed.
- Complete a thorough assessment of patient pain
levels with the assistance of the patient and/or the family, which includes
the following: (A pain Assessment Inventory is available in the full
Assess patient and family attitudes and beliefs regarding: pain
and analgesics, prior successes/failures with analgesics, expectations regarding pain and
stress during hospitalization. Fear of addiction and analgesic side effects, beliefs
related to ageism, passivity of patient role, and stoicism function as barriers to patient's
report of pain.
Assess sociocultural variables
(e.g., ethnicity; acculturation) which may influence pain behavior and expression.
history of other chronic disorders which may also cause pain and interfere
with accurate assessment of acute pain.
- Investigate medication use for
chronic conditions that may interact or interfere with analgesic use.
Assess patient for depression and/or anxiety which may alter pain perception
and enhance intensity of pain.
- Investigate methods
commonly used by the patient to relieve pain (e.g., folk/home remedies) and
methods used to cope with pain (e.g., distraction, prayer).
- If the
patient is noncommunicative, try to elicit from the family the patient's
usual pain behaviors such as withdrawal, agitation, facial grimacing,
Assess pain intensity by selecting a tool based on the
patient's preferences and cognitive/functional abilities. The Verbal Descriptor Scale, pain Thermometer, Numeric
Rating Scale and Faces Scale have an acceptable accuracy, are preferred
by persons and can often be used by individuals with
Examples of pain Scales that have been used with patients:
- Verbal Descriptor Scale (VDS)
- pain Thermometer (PT)
- Numeric Rating Scales (NRS)
- Faces pain Scale (ES)
Please note: Mildly to moderately cognitively
impaired individuals are often able to rate pain using these
instruments, however individual patient ability to do so should be
Educate Patient and Family about pain Management
demonstrated that implementing an educational program for pain management for the
patient and family helps promote effective pain management.
Although this program was developed for patients with cancer pain at home
the overall structure of the program can also be adapted for patients with
acute pain. The following activities can be included in this
- General information about pain
- Provide information regarding planned procedure
and associated painful sensations to the patient and family prior to
the upcoming procedure or surgery.Then
offer opportunities for patient and family to discuss fears/concerns
regarding the diagnostic procedure or surgery.
- Provide patient and family with a brochure, such
as the brochure offered through the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency
for Health Care Policy and Research [AHCPR]) publication titled "pain Control
After Surgery: A Patient's Guide".
This brochure (AHCPR
Publication No. 92-0021) is available for sale from:
AHRQ Publications Clearinghouse
PO Box 8547
Silver Spring, MD
Call 800 358-9295 (in the US) or (410) 381-3150 (outside the
US). Information is also available at the AHRQ Web site.
to patient and family that pain can be managed and/or relieved
and the importance of reporting pain and pain control
in the recovery process (e.g., facilitation of post-op exercises to
prevent complications). Coach the patient in accurately reporting pain.
- Explain to the patient and
family the importance of preventing rather than 'chasing' pain
in effective pain management.
- pain Assessment
- Explain the pain assessment schedule and method of
pain assessment utilizing selected assessment tool(s). Assess the
patient's and family's understanding and accurate use of
- Communicate with the patient and set an acceptable
level of pain control that is based on pain rating criteria.
- Explain the need to differentiate pain related to procedure and pain
related to other chronic disorders.
- Pharmacologic Management
- Allay common fears/misconceptions regarding opiate
use, such as addiction and respiratory depression.
- Negotiate pain rating criterion for analgesic
administration (i.e., a rating on pain assessment tool.
- Explain common side effects of analgesics (e.g.,
constipation) and planned interventions for any side effects experienced.
- Describe as well as demonstrate typical analgesic regimen (e.g., PCA).
- Nonpharmacologic Management
- Describe cognitive/behavioral pain management
options (e.g., relaxation strategies, imagery) and cutaneous stimulation
options (heat/cold; Transcutaneous Electrical Nerve Stimulation (TENS)) and
select options based on patient preference and cognitive/functional
- Explain/demonstrate routine post-procedure exercises/activities (e.g.,
coughing) and methods to decrease discomfort from these (e.g., splinting).
Monitoring The Acute pain Experience
- Be aware that older individuals often suffer from
chronic pain in addition to acute pain and implement strategies to relieve
pain from chronic disorders as much as possible.
- Assess and document characteristics, intensity, duration, and effects of
pain: Use selected assessment tool.
Assess pain at least every two
hours and during rest, during activity, and through the nighttime when
pain is often heightened. Ability to sleep does not indicate absence of pain.
Observe for nonverbal cues of pain (e.g., grimacing, guarding)
and behavioral changes (e.g., new onset of confusion, agitation and/or withdrawal;
Elicit pain statements from communicative, cognitively impaired patients and use
a selected assessment tool. Try several tools to evaluate which one is
most easily used by the cognitively impaired individual. Many cognitively impaired subjects
can complete at least one of the pain scales included in
In noncommunicative, cognitively impaired patients, observe for change in usual
behavior (e.g., withdrawal, increased confusion, agitation), facial expressions of pain (e.g.,
grimacing), bodily tension, fidgeting, and vocalization. Research indicates that failure to assess and
treat pain in these individuals is often due to an
unfounded belief by healthcare providers that pain sensations are diminished
in individuals with cognitive impairments.
- Assess for
autonomic responses typically associated with acute pain (e.g., increased heart rate and
blood pressure; increased or decreased respiratory rate; diaphoresis).
Assess pulmonary function (e.g., respiratory rate, lung sounds, signs of hypoxia)
for pain-related complications every four to eight hours.
- Differentiate procedural pain from pain
due to chronic disorders or complications of procedure (e.g., new
pain, increased intensity of pain, pain not relieved by previously
- Assess the patient for atypical presentation of
complications commonly seen in . For example:
- Shortness of breath
and confusion with MI and absence of or delayed chest pain.
- Absence of pain
during intra-abdominal emergencies.
- pain of various conditions often referred from
the site of origin.
- Document pain assessment findings on a flowsheet that includes: date,
time, pain rating, use of analgesics, other pain intervention, vital signs
and side effects.
- Use the following guidelines for analgesic
significantly less analgesic medication than younger adults experiencing similar
painful conditions/procedures, therefore leading to inadequate pain relief in these older patients. This tendency
may be due to a belief on the part of
healthcare providers that, in general, pain sensation decreases with age. There is
no research base to support this misguided belief.
- Ethnic minorities receive
significantly less narcotic analgesics for similar painful events secondary
to ethnic influences on the part of the patient (e.g., reluctance
to request medication) and/or the caregiver (e.g., misinterpretation
of ethnic-based pain behavior). Formal caregivers must assess for ethnic influences
in order to provide appropriate pharmacological interventions.
Cognitively impaired individuals receive significantly less analgesics
then cognitively intact patients with similar painful events. There is no
empirical evidence to support that cognitive impairment is associated with
decreased pain sensation.
Safe analgesic administration in
the is complicated by interactions with multiple chronic
disorders, multiple drugs to treat these disorders, nutritional alterations
(e.g., protein deficiency) and altered pharmacokinetics. The incidence of acute confusion
and other adverse reactions increases with the number of prescription
individuals generally receive greater peak and longer duration of action from
analgesics than younger individuals, thus dosing should be initiated at lower doses
(1/4-1/2 adult dose) and titrated carefully.
Use patient-controlled analgesia for intravenous analgesics particularly
during immediate post-procedure period (e.g., 48 hours), but monitor and titrate
cautiously due to increased potential for toxicity.
- Recognize that cognitively impaired
patients may require nurse assisted use of PCA.
- Administer oral analgesics on an
around-the-clock (ATC) basis. Administer on PRN basis later in course as
indicated by patient's pain status. If given on PRN basis,
administer 30 minutes prior to activities (e.g., PT) and postoperative exercises. Assess
for breakthrough pain and need for supplemental doses.
- If acute confusion develops, assess for other
contributing factors prior to altering the prescription or discontinuing
analgesic use. Confusion in postoperative patients has been found to be
associated with unrelieved pain rather than opiate use.
- Assess bowel function daily
and initiate patient's home protocol or the Constipation Management
research-based protocol to prevent the constipating effects of analgesic use. Assess
for signs of ileus related to narcotic analgesics.
- Measure intake and output and assess for signs
of urinary retention/suppression.
- Slowed intramuscular absorption of analgesics
in patients may result in delayed/prolonged effect of IM
injections, altered analgesic serum levels and possible toxicity with
repeated injections. This is more common with IM meperidine than IM morphine. Use IV or intraspinal analgesia for rapid
control of severe pain.
- Antiemetics for analgesic-induced nausea may
result in problems in patients due to anticholinergic effects
(bowel and bladder dysfunction, confusion, movement disorders).
- The following analgesics and adjuvants may produce increased confusion
levels in patients:
NSAIDS (greatest risk during initial use).
- Pentazocine (Talwin).
- Anticholinergics (Antihistamines, e.g.,
- Drug interactions occur
more frequently in the .
The analgesic effects of NSAIDS supplement
the analgesic effects of prescribed opioids, therefore reducing the dose of
opioid that is required for effective pain management. Thus,
they may reduce the incidence of opioid-induced respiratory depression in patients.
The following NSAID complications are common among patients and must
be carefully monitored:
GI bleeding especially with initiation of drug or higher doses of
a drug. Therefore, avoid use, if patient has a history of peptic ulcers.
A meta-analysis of the variability and risk of GI complications of NSAIDS
found that low dose ibuprofen (under 1,600 mg/day) was associated with
the lowest relative risk. Initiate antacid regimen and administer with food.
Monitor for signs of GI bleeding.
- Nephrotoxicity. Avoid use if
patient has a history of renal impairment, congestive heart failure,
concurrent volume depletion or diuretic use.
Bleeding disorders. Avoid use if patient has a history of bleeding disorders
or a concurrent use of anticoagulants, or use platelet-sparing
agent (e.g., Salsalte, Diflunisal).
Confusion. Monitor patient for new onset or increased
confusion in demented patients during initial use. Long-term use has been found to
have a protective effect on cognitive decline.
- Other (e.g., constipation, headaches,
- Age-associated physiologic changes
(e.g., reduced renal and/or liver function) result in increased toxicity with
- ACETAMINOPHEN is an effective analgesic in the and does not
produce the gastric and bleeding complications seen with NSAIDS. Other
complications that may be associated with acetaminophen usage include:
- Increased risk of end-stage
renal disease with long-term use.
- Toxicity due
to reduced hepatic metabolism.
- Over coagulation with warfarin in the outpatient
- OPIATES produce greater analgesic effect
and have a higher serum peak and duration in patients.
Assist patient to enhance his/her sense of personal control over pain (e.g.,
allow movement at preferred pace).
in patient's comfort level and willingness to implement/alter strategies
as needed to facilitate pain relief; frequently reinforce availability
of pain relief measures; encourage verbalization regarding pain concerns.
- Support usual pain coping methods.
(e.g., prayer, meditation).
- Facilitate use of
home/folk pain remedies, unless contraindicated.
Use relaxation strategies and distraction (e.g.,
breathing, massage, touch, music, imagery) to complement analgesics. Avoid imagery in-patients with
severe cognitive impairment or psychoses.
- TENS has
been used successfully in for postoperative pain.
- The can benefit from multimodal
pain treatment that includes pharmacologic and non pharmacologic
Assessing Effectiveness of pain Management
For each individual patient:
pain relief from interventions (30 minutes after parenteral, 60
minutes after oral) using patient-based feedback through one of the pain
intensity scales described herein.
Document all pharmacologic and nonpharmacologic pain interventions on a pain flowsheet
(Document pain assessment findings on a flowsheet that includes: date, time,
pain rating, use of analgesics, other pain intervention, vital signs and
side effects. A pain flowsheet is included in the full protocol).
Monitor each patient's pain flowsheet for patterns, in order to identify
the efficacy of the pain intervention activities chosen and to determine any need
for revision in the pain plan.
The pain Level Outcome
from the Nursing Outcomes Classification (NOC) can also be used to assess
the effectiveness of pain management for each individual patient
- If pain management is not adequate, revise the plan
based on consultation among the patient's physician, nursing staff,
and the pharmacy department.
- In collaboration with the patient and his/her family,
develop a discharge plan for pain management and provide written
instructions, which include drug dosage, interval, drug interactions, and prevention
of common side effects (e.g., constipation). Review routine medications
for possible interactions. Assess patient and family member's ability
to obtain analgesics and intervene accordingly.
For quality improvement of nursing care:
Acute pain management for patients should be evaluated at the
organizational level (unit, hospital, nursing home, etc.) to evaluate whether
the staff is using the pain management guidelines in a consistent and effective
manner. Therefore it is important to monitor the use of the pain management
guidelines in a structured manner.
This guideline was excerpted from the National Guideline Clearinghouse Brief Summary of the original University of Iowa Guideline.
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