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AboutCourse By: Read Course | Complete Survey | Claim Credit ➀ Read and LearnThe following course content Introduction to Nursing Interventions for Acute Pain ManagementPain is one of the most common reasons why people seek care in a hospital, and it is one of the most distressing symptoms of hospitalized patients. It is also directly linked to a patient’s satisfaction with their care: people are more likely to report being unhappy with their care if they had unrelieved pain during their stay. Most importantly, it is our job as nurses and healthcare providers to relieve the pain and suffering of the people in our care. There are legitimate concerns about the overuse and addictive nature of opioid pain relievers, and thankfully there are many alternative options. These non-opioid nursing interventions for acute pain management include non-opioid pain relievers, complementary techniques, and non-medication strategies. Nurses must regularly assess pain and collaborate with both the patient and provider to ensure that timely access to adequate pain relief is a priority of their care. This course will discuss the pathophysiology of acute pain, the classification of different types of pain, strategies for a comprehensive pain assessment, guidelines for treatment, and the different types of nursing interventions for acute pain management. Prevalence of Acute PainAcute pain is a major problem for hospitalized patients and has been identified as a priority in the provision of quality and effective care. In addition, pain management has been identified by the Quality and Safety Education for Nurses (QSEN) project for nurses as a core competency under Patient-Centered Care (1). This is important because if not properly treated, pain can cause anxiety, depression, reduced healing, fatigue, non-compliance with treatment, and longer hospital stays (2). Pain is also costly in other ways: causing decreased productivity, income, and quality of life. Despite knowing the potential consequences of poor pain relief and having multiple modalities available as nursing interventions for acute pain, many patients are still inadequately managed for pain during hospitalization. A 2016 study of hospitalized patients in the UK found that between 38-84% of patients experienced pain, while 9-36% of patients experienced severe pain (3). In their R3 report published in 2017, the Joint Commission also acknowledges that under-treatment of pain still occurs in the hospital setting (4). This is because many barriers still exist that prevent patients from being treated appropriately for their pain. These potential barriers include (5):
While all healthcare providers should aim to reduce a patient’s pain, nurses are in the unique position to make a difference with individual patients, as well as system-wide pain management protocols.
Pathophysiology of PainThere is no set definition of pain, but it is commonly defined as an unpleasant experience, usually related to underlying tissue damage or injury. Pain is a subjective experience and one that very much depends on the person experiencing it. What one person experiences as pain, another person may as a minor discomfort, and another may consider intolerable. It is a complex sensation, the experience of which involves the interaction of three different systems: Sensory/Discriminative SystemThe actual sensation of and reaction to pain through sensory and afferent nerves, spinal cord, and brain stem. This system causes the body to try and remove itself from the source of the pain. Motivational/Affective SystemA person’s learned approach/avoidance behavior concerning pain, which occurs through the interaction of the brain stem, the reticular formation, and the limbic system. Cognitive/Evaluative SystemA person’s learned behavior towards the pain experience, including appropriate (and inappropriate) pain behaviors. This learned behavior can block or increase a person’s perception of their pain (6). Anatomy and Physiology of PainThe nervous system is the primary body system responsible for the experience and interpretation of pain. The four main steps involved in this process are transduction, transmission, perception, and modulation. Step 1: TransductionThe process of transduction begins with the afferent pathway, which is responsible for the actual detection of pain. Nociceptors are pain receptors found at the end of small afferent neurons that detect noxious stimuli, which include changes in temperature, pressure, and other mechanical or chemical stimuli. These nociceptors are found deep in the skin, muscles, tendons, and subcutaneous tissue and produce a large variety of different – and not all unpleasant – sensations. These can range from a cool breeze to a pleasant massage to cutting, crushing, and burning sensations. When these receptors are activated, they cause the release of chemical mediators, such as prostaglandins, substance P, serotonin, histamine, bradykinin, and potassium. Among other functions, these mediators generate an action potential by exchanging sodium and potassium at the cell membrane and activating and sensitizing the nociceptors to further stimulation by the stimuli. Step 2: TransmissionThe sensation travels along A- and C-nerve fibers to the dorsal horn of the spinal cord. A-nerve fibers are lightly myelinated (insulated in a protein and fatty acid substance known as myelin, which allows nerve impulses to travel faster), while C-nerve fibers are unmyelinated. The thicker the nerve fiber (and myelin coating), the quicker that nerve impulses will travel. The table below shows the different types of these fibers and the sensations they detect. Nerve impulses travel the fastest along the A-alpha and A-beta fibers and slowest along the A-delta and C-nerve fibers.
Once these nerve signals reach the spinal cord, excitatory neurotransmitters cross the synaptic cleft with the nociceptive dorsal horn neurons (NDHN). The neurotransmitters involved in this process include:
From here, the nerve impulse travels up the spinal cord to the thalamus, where they are sent to different areas in the brain for processing. Step 3: PerceptionPain perception translates all this nerve activity into a conscious and actual experience for the patient. This is facilitated by several different areas of the brain and central nervous system. Reticular Formation TractsReticular formation tracts are responsible for the recognition of and response to pain. For example, if you step on a tack, the reticular formation track recognizes the painful stimulation and causes you to move your foot quickly. This area is also responsible for the alert and attentive feeling that comes with pain. Limbic SystemThe limbic system also plays a key role in the unpleasant emotional and behavioral response to pain and actions taken to reduce it. ThalamusThe thalamus acts as a switchboard of sorts, helping to direct the pain signal to the different locations in the brain. Some parts of the thalamus also direct the motor, behavioral, and emotional responses that come with the presence of painful stimuli. Somatosensory CortexThe somatosensory cortex comprises two distinct regions in the parietal lobe of the brain that are responsible for receiving and processing sensory information from all over the body. This region receives information about painful stimuli and identifies the location, intensity, and type of pain. It also connects the current pain sensation with previous experiences with pain. Step 4: ModulationModulation is the final step in the pain pathway. This process is the changing of pain impulse transmission in the spinal cord and is due to the descending modulatory pain pathways (DMPP). Endogenous hormones and substances are found within this pathway and help to either block pain signal transmission or increase it. Inhibitory neurotransmitters help to block the transmission of pain nerve impulses to relieve pain and include:
Excitatory neurotransmitters increase the transmission of pain to the brain and are usually responsible for the increased mental alertness and cognition associated with a painful event. The Gate Control Theory is one of the most familiar theories of pain modulation. Under this theory, there are a series of gates found throughout the spinal cord. When these gates are open, pain messages are able to get through to the central nervous system, making the pain feel worse. Factors like stress, tension, anxiety, boredom, and lack of physical activity can all help to open those gates and worsen pain sensations. On the other hand, when those gates are closed, fewer pain messages get through to the central nervous system, reducing the pain experience. Factors that help to close the gates include feeling relaxed, regular exercise, distraction, certain medications, and other types of stimulation (such as massage, heat, ice, or acupuncture). This theory is often used to explain why non-medication nursing interventions for acute pain can be so effective.
Classification of PainPain can be classified based on its duration, location, quality, and intensity. Understanding these different types of pain can help the medical and nursing team plan appropriate nursing interventions for acute pain management. The figure below shows the organization and classification of these different types of pain.
Duration of PainOne of the most common and important distinctions of pain is its duration. There are two classifications of pain based on duration: acute and chronic. AcuteAcute pain is short-term pain that lasts less than six months. It is usually associated with a specific insult or injury, such as a broken leg, a ruptured appendix, or even childbirth. In most cases, once the cause is addressed and treated, the pain subsides. Acute pain is often described as sharp, stabbing, or burning. There are many effective nursing interventions for acute pain. ChronicChronic pain, however, is far more complex. Chronic pain is pain that has lasted longer than 6 months and is not usually associated with a specific cause or injury. Headaches, fibromyalgia, and arthritis are all examples of this type of pain. Chronic pain can be described as sharp or intense, but it can also be described as dull, aching, or burning. In addition, chronic pain often has a psychological or emotional component, causing anxiety, insomnia, depression, and a decrease in a person’s ability to perform everyday tasks. This type of pain is much more difficult to treat and can severely interfere with a patient’s quality of life. LocationPain can also be classified based upon the location where the pain is occurring. Both acute and chronic pain can be classified by any of these categories. Visceral PainVisceral pain arises from the internal organs in the abdomen and pelvis, such as the intestines, female reproductive organs, kidneys, and liver. This type of pain is often described as diffuse, and it is often difficult to isolate where it is actually coming from. One reason for this is the phenomenon of referred pain, where the pain is actually experienced in a location different from the actual injury. Think about having left arm and shoulder pain during a heart attack. While the internal organs are mostly immune from injuries like lacerations or burning (short of a catastrophic injury), they are more likely to cause pain by inflammation, ischemia (death of tissue), and stretch (like overdistended intestines). Visceral pain is often described as pressure, dull, throbbing, or aching. Somatic PainSomatic pain, on the other hand, is pain that is experienced in the skin, muscles, bones, and joints. While visceral pain is diffuse, somatic pain is usually well-localized and easy to determine where it is coming from. It is usually described as sharp, stabbing, aching, or burning. Somatic pain can result from an injury, such as a papercut, or an illness, such as arthritis or bone cancer. Somatic pain can be further categorized as deep or superficial, depending on where the injury occurs. Deep PainDeep somatic pain comes from structures deep within the body. Think of bones, muscles, tendons, and joints. Superficial PainSuperficial somatic pain comes from structures closer to the surface of the body, like the skin and mucus membranes. PathophysiologyThe last main way to classify pain is based upon its cause or pathophysiology. There are three types of pain in this category: nociceptic, neuropathic, and psychogenic. Nociceptic PainNociceptic pain comes from an injury to the body tissues and is the type of pain that most people are familiar with. It can be acute, chronic, visceral, or deep pain. It covers many kinds of injuries or illnesses, from the simple paper cut or stubbing a toe to arthritis or cancer pain. Nociceptic pain is usually responsive to changes in the environment: shifting position, applying ice or a heat pack, or elevating the injured site. Neuropathic PainNeuropathic pain arises from damage to the neurons in the peripheral or central nervous system itself. Familiar with the tingling associated with hitting your funny bone? That’s neuropathy: you’ve hit and temporarily injured the large nerve that runs through the elbow. Other common causes of neuropathies include multiple sclerosis, diabetic neuropathy, and even phantom limb pain. Unfortunately, neuropathic pain doesn’t respond well to changes in the environment and is more likely to develop into chronic pain. Damaged neurons or nervous tissue don’t heal quickly or easily. Psychogenic PainPsychogenic pain is pain for which no underlying cause can be found and is attributed to psychological factors. It is no longer an official diagnosis and the term is not frequently used anymore, simply because we have a greater understanding of neuropathic and chronic pain disorders. The correct term is Persistent Somatoform Pain Disorder (PSPD), which is defined by the ICD-10 as:
However, the ICD-10 is being phased out and replaced by the ICD-11 in early 2022, which no longer acknowledges Persistent Somatoform Pain Disorder. Instead, this type of pain is referred to as Bodily Distress Disorder, and defined as:
Despite this changing definition, we do know that depression, anxiety, and other psychological problems can interact with pain, particularly chronic pain. Depression (anxiety, etc.) can worsen pain, and ongoing pain can significantly worsen associated psychological symptoms. As nurses, we should be mindful of and sensitive to these types of issues.
Performing a Pain AssessmentOne of the most important nursing interventions for acute pain management is regular assessment of the patient’s pain and the effectiveness of their pain management plan. There are two main components of a pain assessment: health history/interview and a physical exam. Health History and InterviewAssuming that you are working with an established patient, you don’t need to complete a full history or patient interview, but you should touch upon the relevant clinical factors about their pain. If this is a new admission or a new patient, you will need to perform the comprehensive initial history and assessment first. The PQRSTU mnemonic can help you remember all the different points you should hit during the interview to assess the characteristics of their pain. The table below shows the important questions that you should ask about a patient’s pain.
Pain ScalesPain scales are useful tools that the nurse can use to assess and rate a patient’s pain. There are several different scales that can be used in different clinical situations, and it is up to the nurse’s judgment to determine which is the most appropriate one to use. Number Rating ScaleThis is the most common pain scale, and the one that most people are familiar with. It is appropriate for adults (or older children) who are alert, oriented, and responsive. Ask the patient to rate their pain on a scale from one to ten, with one being no pain and ten being the worst pain they’ve ever had. Wong-Baker FACESThis pain scale is very commonly used for children aged three and older. The scale uses six pictures of faces varying from a face without pain to a face with a lot of pain. To use it, the child is asked to pick which face represents how they are feeling. FLACCThe FLACC scale is used for young children from ages 0-2 years of age. It stands for Face, Legs, Activity, Cry, and Consolability. The nurse assesses each of these characteristics and assigns a score from zero to two. These scores are added together for a total score between zero and ten. The higher the number, the higher the patient’s pain is assumed to be. (10) CRIESThe CRIES scale is also used for young infants who are greater than or equal to 38 weeks of gestational age. This scale is similar to the FLACC scale in that the nurse evaluates the infant based on five characteristics, assigning a score of zero to ten. The scores are totaled, where a score greater than 6 indicates the need for analgesia. The characteristics used by this scale are the presence of high-pitched cry, the requirement of oxygen to maintain oxygen saturation above 95%, increased blood pressure and pulse, facial expression, and sleeplessness. (11) CPOTThe CPOT (Critical Care Pain Observation Tool) was developed to be used in critically ill patients who may not be able to verbalize their own pain. It is similar to the CRIES and FLACC scales: four different criteria are assessed on a scale from zero to two, with a maximum score (indicating the most pain) of eight. The domains used in this scale include facial expression, body movements, muscle tension, and compliance with mechanical ventilation (in intubated patients) or vocalization (in non-intubated patients) (12). Please note that this is not a comprehensive list of all available pain scales. You should defer to your institutional policies when appropriate. The patient should be assessed frequently, especially if they are having pain or receiving pain medication. The nurse should also ask about the presence of associated signs and symptoms: insomnia, nausea, vomiting, shortness of breath, itching, etc. Make sure to evaluate the effectiveness of the nursing interventions for acute pain by reassessing the pain level after administering analgesia or other non-pharmacological interventions. The nurse must always remember that pain is what the patient says it is, regardless of their body language. If the patient states that their pain is a level 7, but is laughing and hanging out with family members, the nurse must document and act as if the pain level is a 7.
Physical ExamThe physical exam should also be abbreviated and limited to what is actually relevant to the patient’s pain, if appropriate. Make sure to get a set of vital signs and then examine the area that is causing pain.
If the pain is new, make sure to notify the provider in case it signals a change in status.
Non-Pharmacological Nursing Interventions for Acute PainFor patients with mild pain, non-pharmacological nursing interventions for acute pain can sometimes be very effective. They can also work well in conjunction with pain medications and other nursing interventions for acute pain. AcupressureAcupressure is a traditional Chinese modality that has been used for generations. By applying pressure to certain points on the body, the belief is that you can help to restore the flow of energy and balance throughout the body. Though acupressure is mostly considered safe, there are some points that should not be stimulated in pregnant women as they might stimulate labor. Press firmly and use an up-and-down or circular movement for several minutes. Make sure to stop or ease up pressure if the motion causes worsening pain or discomfort. AcupunctureAcupuncture is also a traditional Chinese modality that has recently gained popularity in the United States and other Western countries. It is believed that the insertion of small needles into the skin at specific points helps to stimulate endorphin release and trigger other pain-relieving changes in the brain. The needles are left in place for 10 to 30 minutes at a time so the patient can rest. The needles are then removed, and the treatment is repeated several times. Acupuncture is quite safe but should only be performed by a licensed practitioner. Research about effectiveness is mixed, but it may be worth a try for patients with complicated or chronic pain. AromatherapyThe use of essential oils is an ancient therapeutic modality that dates back hundreds of years and has gained popularity in recent years. It involves the absorption of essential oils through the skin or olfactory system to reduce pain, nausea, muscle tension, anxiety, and depression. Studies on the effectiveness of aromatherapy vary. One review of nine randomized controlled trials was split nearly 50/50: Five studies found that aromatherapy could be effective for postoperative pain, and four found no statistical difference associated with aromatherapy use (13). DistractionDistraction is quite an effective and simple nursing intervention for acute pain. Remember the gate theory of pain? Distraction is one of those factors that can help to close the pain gates, which reduces the experience of pain. In fact, the presence of strong sensory input can help a person be unaware of their pain. MusicMusic therapy works similarly to distraction. It gives the person something else to focus on apart from their discomfort. When using this nursing intervention for acute pain, the nurse must remember to let the patient select the type of music that they prefer to listen to. HeatThe application of a heating pad or hot water bottle may stimulate the closure of the pain gates, reducing pain and discomfort. It may also stimulate the release of endorphins, which also reduce pain. The patient should be reminded to not lie directly on the heat source due to the risk of burns. If the nurse applies the heating pad, the site should be reassessed frequently to reduce the possibility of injury. ColdApplying a cold or ice pack works similarly. Cold can relieve inflammation and pain, and promotes healing. It works best over inflamed joints. Like applying heat, the nurse must carefully and frequently assess the patient’s skin to ensure that injury does not occur and remove the ice if the patient feels numbness, aching, or burning. Ice can be particularly effective before a needle puncture or injection. Guided ImageryThis nursing intervention for acute pain involves the nurse sitting close to the patient and helping them to create a calming and relaxing image in their mind. The nurse speaks quietly, helping the patient to concentrate on the image and relax. MassageMassage is a great technique to soothe tense muscles and promote relaxation and sleep. This touch stimulation may trigger the release of endorphins or help to close the pain gates responsible for pain transmission. BiofeedbackBiofeedback is a type of behavioral therapy that is taught to the patient over several weeks. It allows the patient to visualize physiological responses and eventually learn to control them. This technique is particularly beneficial for people with headaches or muscle tension. Transcutaneous Electrical Nerve Stimulation (TENS)This technique uses a special device that produces a mild electrical current through the skin via external electrodes. The machine produces a buzzing or tingling sensation, the intensity of which can be controlled by the patient in response to the pain they are feeling. This treatment does require a physician’s order, and the nurse should help the patient with hair removal if needed before applying the electrodes.
Analgesics as Nursing Interventions for Acute PainFor patients with pain that does not respond to non-pharmacological measures, analgesics may be more effective. There are three types of pain medication:
Non-Opioid AnalgesicsNon-opioid analgesics can be used to treat mild to moderate pain and are often combined with opioid pain relievers to enhance their effectiveness. The two main types of drugs in this category are cyclooxygenase inhibitors and acetaminophen. Cyclooxygenase InhibitorsCyclooxygenase inhibitors are mostly made up of nonsteroidal anti-inflammatory drugs and aspirin. Cyclooxygenase, or COX, is an enzyme in the pathway to synthesize prostaglandin, a key inflammatory hormone-like substance, from arachidonic acid. When produced, prostaglandins have several different effects on their target organs and are known to contribute to nociceptic pain. There are two types of COX enzymes: COX-1 and COX-2. COX-1 is found primarily on the gastric mucosa, kidneys, and blood vessels. Inhibition of this enzyme is believed to contribute to renal toxicity and gastrointestinal effects. COX-2 enzymes are activated by the processes causing pain, fever, and inflammation. Selective COX-2 inhibitors were introduced as an alternative to non-selective COX-1/COX-2 inhibitors with the goal of reducing the gastric side effects linked to COX-1 inhibition. However, the drugs were quickly linked with some potentially serious cardiovascular safety concerns, including myocardial infarction, cerebrovascular accident, and other thromboembolic diseases (14). Most of these medications were removed from the market, and the FDA recommended limiting the use of celecoxib (Celebrex), the remaining selective COX-2 inhibitor. Salicylates, like aspirin, are non-selective COX inhibitors, and they also inhibit platelet aggregation, block pain impulses, and may act on the hypothalamus to reduce fever and pain. The table below shows selected medications belonging to the COX inhibitor class of drugs.
AcetaminophenAcetaminophen is thought to inhibit prostaglandin synthesis in the central nervous system. It also reduces fever and inflammation, though less effectively than the COX inhibitors. It is used to treat mild to moderate pain and can also be used as a fever reducer. Dosing in children depends on their age and weight, but in adults, the dose is typically 650mg q4 hours or 1,000mg q6 hours, with the maximum daily dose to not exceed 4g per day. Patients with a history of liver failure should not exceed 2g per day. Acetaminophen is metabolized in the liver, but larger doses can cause the accumulation of a hepatotoxic metabolite that can build up and cause liver damage. Hepatotoxicity is the primary adverse effect of acetaminophen, and the nurse should carefully counsel patients to be aware of hidden sources of the drug in cold medicine and other combination products. Acetaminophen overdose is a medical emergency and is often fatal secondary to hepatotoxicity. There are four phases of acetaminophen overdose: Phase 1 – Occurs within the first 2 to 24 hours after ingestion. The treatment for acetaminophen overdose includes gastric lavage, administration of activated charcoal, and acetylcysteine every 4 hours (started within the first 8 hours after ingestion) for 18 doses. Acetylcysteine interferes with the formation of hepatotoxic metabolites. In addition to administering medication and providing supportive care, the nurse will need to follow plasma acetaminophen levels.
Opioid Pain ManagementOpioid pain relievers are a nursing intervention for acute pain that is usually reserved for cases of severe pain, such as cancer or post-surgical pain, or moderate pain that is not well-controlled with other types of drugs. This class of medication acts directly on receptors in the central nervous system in a few different ways: they block transmission of nociception from the peripheral nerves to the spinal cord, change the activity of the limbic system in the brain, and modulate the descending inhibitory pathways in the spinal column to prevent transmission of pain signals. There are three types of opioid receptors: mu, kappa, and delta, and drugs are classified based on their response at these receptors.
Morphine sulfate is the prototype opioid prescribed for pain and the drug against which the other opioids are compared. It is the drug of choice for cancer patients and is often used for other types of moderate to severe pain. In addition to producing analgesia, morphine has several other clinically useful effects, including reduction of the emotional response to pain, suppression of the cough reflex, reduction of cardiac workload, and reduction of anxiety. Because of this, morphine is an effective nursing intervention for acute pain management. In addition to morphine, there are many other options for opioid pain relievers. The table below shows some common drugs in this class of medication.
Opioid medications do carry the risk of some serious side effects, which the nurse must monitor for. Side effects include:
Due to their similar nature, many of the opioids produce similar effects in varying degrees. However, opioid antagonists are the exception and cause very different side effects, which can include:
There is also a risk of allergy, which can occur with any of the major opioid drugs, including morphine. The nurse must be especially careful of this risk and other adverse effects when administering opioids to an opioid-naïve patient.
Adjunct AnalgesicsAdjunct, or adjuvant drugs are the final type of medications that are used for analgesia. These drugs are often combined with analgesics to enhance pain relief. Sometimes, these drugs are used on their own to manage specific types of pain. There are many different types of adjuvants, depending on the patient’s needs and clinical situation. CorticosteroidsCorticosteroids are primarily used to manage acute and chronic cancer pain, pain due to spinal compression, and pain affecting the musculoskeletal system. Though the exact mechanism is unknown, corticosteroids are known to reduce swelling, inflammation, and edema. However, corticosteroids do cause some serious side effects, including hyperglycemia, increased susceptibility to infection, reduced immune system function, and suppression of adrenal function. Dexamethasone, prednisone, and methylprednisolone are the three most prescribed corticosteroids. Corticosteroid injections are one of the most common nursing interventions for acute pain management of arthritis and joint pain. AntidepressantsA class of antidepressants, known as tricyclic antidepressants (TCAs) can be used with opioid or non-opioid pain relievers to help relieve pain. They are most effective for neuropathic pain and may work by increasing the levels of serotonin and norepinephrine in the synaptic cleft, preventing the transmission of pain signals. Doses for TCAs tend to be lower when used to treat pain than the dose used to manage depression. The most common side effects are weight gain, loss of sexual desire, dry mouth, orthostatic hypotension, and urinary retention. Antiepileptic DrugsAntiepileptic or antiseizure drugs affect the central nervous system in several different ways that can reduce neuropathic pain. They modulate amino acids and neurotransmitters in a way that reduces the transmission of pain signals between the periphery and central nervous system. These drugs tend to be used for chronic pain disorders, such as diabetic neuropathy and fibromyalgia. AntihistaminesSome antihistamines, particularly hydroxyzine, have been found to have analgesic, anxiolytic, and sedative properties that can be useful in patients with acute or chronic pain. Local AnestheticsLocal anesthetics are a great option for well-localized pain, usually in the skin or superficial structures. Topical EMLA creams work well to minimize the pain due to venipuncture, intravenous line insertion, or other simple procedures. Lidocaine or prilocaine can be injected into the tissue to help with pain associated with invasive procedures, while patches can be used to manage post-herpetic lesions and neuropathies. Alpha-2 Adrenergic AgonistsAlpha-2 adrenergic agonists may decrease the release of peripheral norepinephrine and work on the central alpha-2 adrenergic receptors, both of which may help to reduce chronic headache and neuropathic pain. The drugs from this class that are most commonly prescribed for pain are clonidine (Catapres) and zanidine (Zanaflex). Side effects are mild, but may include dry mouth, orthostatic hypotension, and sedation. GABA Receptor AgonistsMore commonly known as muscle relaxants, GABA receptor agonists work best on neuropathic pain and muscle spasms. These drugs block the transmission of pain impulses and can decrease spasticity. It may take time and trial and error to find a regimen that works. The nurse’s role in the assessment and evaluation of different nursing interventions for acute pain plays a crucial role in helping patients be as comfortable as possible. Most importantly, the nurse must advocate for patients who are struggling with pain management in the acute care setting.
Nursing Care of Patients Receiving AnalgesiaThe nursing care plan is an invaluable tool when caring for a patient with acute pain. AssessmentThe nurse should start with an assessment, as described earlier in this module. For a new complaint of pain, the nurse should perform a more comprehensive assessment: determine if there are other symptoms, ask about the characteristics of their pain (PQRSTU questions), and perform a physical examination as needed. When caring for someone with known or expected pain, such as a post-surgical patient or after a broken ankle, the assessment could be more focused on the patient’s current pain level. Even in these situations, you should continue to perform a complete assessment at least once per shift or according to your institutional policies. Make sure to report any new or unexpected complaints of pain or abnormal assessment findings to the provider and document them in the patient’s chart. Identifying Goals and PlanningBased on the data identified during the assessment, the nurse will formulate goals and objectives to meet the patient’s needs. The primary goal for someone with acute pain is relief from that pain, but there may be other goals that are also appropriate. They may include:
Creating a concept map can be a useful tool to help identify potential problem statements and the relationship between them, as pain is often interrelated with other health problems. Once goals are set, it is important to establish criteria against which the goals are measured. For example, you may identify that your patient will have a tolerable amount of pain upon discharge from the hospital. Your expected outcome may be that their pain level is consistently reported to be at a 4 or below. A comprehensive pain management plan must consider the entire interdisciplinary care team. Did the medical provider enter orders for pain management medications? Are they appropriate? (For example, a simple acetaminophen order after a surgical procedure may not be sufficient to deal with post-surgical pain). Is the physical therapist planning to start mobility exercises to get the patient back on their feet? Does the patient want to speak with a clergy member to help focus on spiritual health? Is a pain management specialist needed? Having the appropriate team members in place makes it more likely that the patient will achieve the planned outcomes. ImplementationDepending on the extent of the patient’s pain, you’ll use your nursing judgment to select and implement nursing interventions for acute pain to address it. For mild pain, non-pharmacological measures may suffice; for severe pain, regular administration of opioid pain relievers (as ordered) may be the best course of action. For these patients, it is important to stick with the scheduled doses as closely as possible because the pain becomes much harder to treat once it becomes severe. Once you get their pain under control, it is important to begin teaching and involving the patient in their own care. Non-pharmacological comfort measures, wellness strategies, what to expect during the healing period are all important for the nurse to teach the patient. This information helps them become more capable of caring for themselves and promotes both physical and emotional healing. EvaluationRemember those expected outcome statements you created earlier in the planning stage? Well, now is when you’ll put them to use by comparing those expected outcomes to the actual outcomes experienced by the patient. The best way to evaluate patient outcomes is to ask the patient themself. Key questions could include:
If the patient is unable to communicate, the family could also be a useful source of information. It is important for the nurse to explicitly ask these questions: some patients may not readily volunteer this information or be afraid to mention that they are still in pain or having side effects. In addition to speaking with the patient (or family) directly, objective data can also provide useful information, particularly about potential side effects, such as oversedation or respiratory depression. The nurse should collect data, such as:
If the data suggests that the patient’s pain is under control and there are no bothersome side effects, then great! In this situation, you’ll continue to care for the patient according to the care plan and periodically evaluate the patient to ensure continued success. If, however, the patient is still experiencing unacceptable amounts of pain or having side effects (whether they are dangerous or just uncomfortable), then the nurse will need to immediately make changes to the plan. This may include administering a second dose of medication, speaking to the provider about adding additional pain medication, adding in alternative methods of pain management, or discontinuing a medication that is causing side effects, and obtaining an order for a different option. The nurse must continue to check in with the patient and provide reassurance and education about pain management. For example, if the patient complains that intravenous pain medication is not working 5 minutes after administration, the nurse should reassure the patient that the medication will have peak effectiveness at about 15 to 30 minutes, and they’ll check back then.
Nursing Interventions for Acute Pain in Special PopulationsPain management strategies may need to be adjusted when caring for certain populations. Three populations that will always need special consideration are infants and children, older adults, and people with a history of addiction. Infants and ChildrenHealthcare providers used to believe that infants did not feel pain and would not provide pain medication for certain invasive procedures, such as circumcision (15). Thankfully, we now know that this is not correct, or ethical for that matter, and medicate infants appropriately for painful procedures. While the process is the same as with adult patients, assessment tools and treatments must be modified to work for the developmental ages of the young kids they are caring for. Pain scales like the FACES, FLACC, and other scales specifically designed for use in pediatric patients should be used when assessing for pain, and the nurse can also rely on input from the parents. As discussed earlier, these scales rely on the nurse’s own observations of the child to determine pain level, rather than asking the child to describe their pain, which they may not be able to do. Older children and adolescents are more likely to be able to verbalize their pain, making it more appropriate for the nurse to ask these kids directly. When administering pain medication to children, especially infants or very young children, the nurse must be extremely careful when drawing up and administering intravenous medications. Some institutions may even require that a second nurse be present to review the order, medication label, prepared medication, and patient ID band before a narcotic is administered. Frequent assessments should be performed to reduce the risk of serious adverse reactions. Older AdultsAge-related changes can influence not only a patient’s experience of pain but also how they metabolize pain medication. Older adults are more likely to suffer from multiple health conditions, which can make the assessment process a bit more confusing. This would require the nurse to perform a more in-depth or comprehensive assessment to determine the source and type of pain that a patient is experiencing. In addition, the nurse must take a careful medication history, as they are at higher risk for side effects and drug interactions. Other factors that could increase a person’s risk for adverse effects include (16, 17):
The nurse must be careful to take these factors into account when administering narcotics or other pain medications to an older adult, and monitor them closely for side effects, adverse reactions, or drug interactions. In addition, older adults may be more likely to suffer from cognitive impairments, like Alzheimer’s disease or dementia, which could impact their ability to accurately communicate or report their pain. Again, the nurse must be aware of these limitations and use the appropriate tools when working with these patients. Safety is a major concern for this population as well, particularly when administering medications that can increase drowsiness, dizziness, or the risk for falling. The nurse must be careful to check on the patient frequently, provide assistance with ambulation and place the call bell or other needed items within easy reach of the patient. People with a History of AddictionPeople with a history of addiction pose a unique challenge to the implementation of pain management strategies. Patients in recovery are often concerned about the risk of relapse, whether they were addicted to opioids, alcohol, or other substances. And patients who are actively using may be concerned about withdrawal while being in the hospital, or even whether their pain will be taken seriously given their history. Healthcare providers may also struggle with providing opioids for patients with a history of substance abuse: they may be worried about diversion or overtreatment of pain or be distrustful of a patient’s report of pain (18). When treating opioid-dependent patients with narcotics for pain, they will likely need higher doses to achieve pain relief. The nurse must carefully monitor patients in this situation due to the risk of toxicity. The addition of adjuvants may also be particularly useful in this population. (18). Patients who refuse opioid treatment due to the risk of relapse should be respected; this may mean finding other viable alternatives, such as non-opioid adjuvants, local or regional medications (like an epidural or spinal block), and non-pharmacological methods of pain relief.
ConclusionAcute pain is a public health emergency. If left untreated, pain can lead to depression, anxiety, reduced healing, non-compliance with medical treatment, longer hospital stays, poor quality of life, and even reduced patient satisfaction with the healthcare facility. However, treating pain is not simple. It is a complex phenomenon that is experienced differently by everyone and influenced by many different factors. The nurse plays a vital role in identifying patients with unrelieved pain and advocating for better pain management strategies. References + Disclaimer
Disclaimer:Use of Course Content. The courses provided by NCC are based on industry knowledge and input from professional nurses, experts, practitioners, and other individuals and institutions. The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NCC. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Knowledge, procedures or insight gained from the Student in the course of taking classes provided by NCC may be used at the Student’s discretion during their course of work or otherwise in a professional capacity. The Student understands and agrees that NCC shall not be held liable for any acts, errors, advice or omissions provided by the Student based on knowledge or advice acquired by NCC. The Student is solely responsible for his/her own actions, even if information and/or education was acquired from a NCC course pertaining to that action or actions. By clicking “complete” you are agreeing to these terms of use. ➁ Complete SurveyGive us your thoughts and feedback ➂ Click CompleteTo receive your certificate Want to earn credit for this course? Sign up (new users) or Log in (existing users) to complete this course for credit and receive your certificate instantly. What are the goals of acute pain management?The primary aim of acute pain management is to provide treatment that reduces the patient's pain, with minimal adverse effects, while allowing them to maintain function. A secondary aim is to prevent acute pain from progressing to chronic pain.
What is the goal of treatment for acute pain versus chronic pain?The therapy of acute pain is aimed at treating the underlying cause and interrupting the nociceptive signals. The therapy of chronic pain must rely on a multidisciplinary approach and should involve more than one therapeutic modality.
What are the goals of pain management therapy in a patient experiencing chronic pain?Restoring a sense of order in a chronic pain patient's life is one of the main goals of pain management. Being able to set realistic goals can help with this, along with making practical changes in work, recreation and social activity.
How many goals does pain management have?[35] Goal-specific agreement was measured separately for each of the five ranked goals (intensity, function, side effects, enjoyment, and diagnosis) by calculating the difference between the patient and physician ranking for each goal.
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