History of Pain Experience

Nonverbal Observations.

Note the patient’s general body position during an episode of pain. Look for subtle clues such as facial grimaces, immobility of a particular part, and holding or resisting movement of an extremity. With pediatric patients, facial expressions, squinting, grimacing, and crying may also be used as indicators of pain level and pain relief.

Developmental differences influence the pain experience and how children in different age-groups express pain. Realize that just because infants cannot speak does not mean that they do not have pain. Infants may express pain through continual inconsolable crying, irritability, poor oral intake, and alterations in sleep pattern. Preschool children may verbalize pain; exhibit lack of cooperation; be “clingy” to parents, nurses, or significant others; and not want the site of the pain touched—they may actually push you away as you approach the painful area. Older children may deny pain in the presence of peers and display regressive behaviors in the presence of support personnel. In the older adult, it is useful to perform the Katz Activities of Daily Living Measurement and the “get up and go” test to determine the individual’s functional status.

Pain Relief.

What specific measures relieve the pain? What has already been tried for pain relief, and what, if anything, has been beneficial?

Physical Data.

In the presence of pain, always examine the affected part for any alterations in appearance, change in sensation, or limitation in mobility or range of motion. In older adults, it is particularly important to evaluate the musculoskeletal and neurologic systems during the physical examination.

Behavioral Responses.

What coping mechanisms does the patient use to manage the pain experience—crying, anger, withdrawal, depression, anxiety, fear, or hopelessness? Is the individual introspective and self-focusing? Does the individual continue to perform activities of daily living (ADLs) despite the pain? Does the individual alter lifestyle patterns appropriately to enhance pain relief measures prescribed? Is the individual able to continue to work? Is the individual socially withdrawn? Is the person seeing more than one health care provider to try to obtain an answer about the origin of the pain or to obtain more pain medication from a different health care provider?

Comfort Measures

Exercise and Activity.

Unless contraindicated, moderate exercise should be encouraged. Often, pain causes the individual not to move the affected part or to position it in a manner that provides relief. Stress the need to prevent complications by using passive range of motion.

Regularly scheduled exercise is important to prevent further deterioration of the musculoskeletal system, especially in older patients who may also have diminished capacity.

Nonpharmacologic Approaches.

Medication.

Even though pain medicine administration may be scheduled, encourage the patient to request pain medication before the pain escalates and becomes severe. Encourage open communication between the patient and the health care team regarding the effectiveness of the medications used. Although the smallest dose possible to control the pain is the goal of therapy, it is also important that the dose be sufficient to provide adequate relief. Therefore, the patient must understand the importance of expressing the degree of relief being obtained so that appropriate dosage adjustments can be made. Express understanding, provide diversional activities, and encourage frequent rest periods, especially after the administration of analgesics, antidepressants, and antianxiety medications.

The medication profile may list more than one analgesic order for the same patient. This requires the nurse to use judgment in choosing the correct medication for the patient based on pain assessment data collected.

The nurse must identify when the last dose of pain medication was administered by checking both the patient’s medication administration record (MAR) and the narcotic control record. It is common practice for analgesics to be ordered intermittently on a PRN basis. However, in the case of chronic pain or intractable pain, it has been found that administering analgesics around-the-clock, such as every 3 to 4 hours, will maintain a more constant plasma level of the drug (steady state), resulting in more effective analgesia. This approach can result in better control of the pain while using less of the analgesic ordered. Many clinical institutions have established policies for pain medications ordered on a PRN basis. These are referred to as range orders. Medication range order policies provide guidelines for the clinical staff to interpret the PRN ranges in the same way. The pain scale assessment is often used as a guideline for the purpose of pain relief range orders.

Patient-controlled analgesia (PCA) has gained acceptance in both the inpatient and ambulatory setting. Pumps are available for inpatient use and in ambulatory units for home or nursing home settings. The PCA method of administration allows the patient to control a small syringe pump containing an opiate agonist, usually morphine, which is connected to an indwelling IV catheter. When initiating the PCA pump procedure, a loading dose is often given to gain rapid blood levels necessary for analgesia. The patient then receives a slow continuous infusion from the syringe pump; this is referred to as a basal rate. Depending on the activity level and level of analgesia needed, the patient may push a button, self-administering a small bolus of analgesic to meet his or her immediate need. A timing device on the pump limits the amount and frequency of the dose that can be self-administered per hour. Additional adjustments of the dosing and frequency may be required as therapy continues. This approach allows the patient to have some control over the pain relief and eliminates the need for the patient to wait for a nurse to answer the call light, check the last dose of analgesics given, and prepare and administer the medication. After discharge from the hospital, this method of administration also allows significantly more freedom of movement for the patient and caregiver.

When PCA is used, the nurse should explain the use of the PCA pump to the patient and observe the patient using it to validate understanding. (It also should be explained to the family and significant others.) Record the amount used every 4 hours and notify the pharmacy well in advance of the need for more medication so that it is available when needed. The degree of pain relief achieved should always be recorded. When pain relief is inadequate, assess for other causes and contact the prescriber to discuss a modification of the regimen.

PCA pumps are also used for chronic pain; however, the dose can be delivered intravenously or subcutaneously. For chronic pain treatment, the largest dose of the medication is given continuously with demand. Continuous subcutaneous opioid analgesia uses either a butterfly-type needle (25- to 27-gauge) or a special needle device placed subcutaneously into the subclavicular tissue under the clavicle or in the abdomen. The needle should be inserted in the body’s trunk, usually the abdomen, because of diminished circulation in the extremities.

Transdermal opioid analgesia uses fentanyl (Duragesic) for relief of chronic pain. It takes approximately 12 to 24 hours for the initial patch of medication to reach a steady blood level, so other analgesics must be used during this time. Once placed, the patch provides relief for up to 72 hours. Intermittent “rescue” dosing may still be needed during the patch use. When terminated, the patient still needs to be monitored for an additional 24 hours because the drug may still be present in body tissues.

Pain Control.

Some patients will not ask for pain medication, so it is important to intervene and anticipate their needs. Do not make the patient wait unnecessarily for pain medication.

Nutritional Aspects.

The patient should eat a well-balanced diet high in B-complex vitamins and limit or eliminate sugar, nicotine, caffeine, and alcoholic intake. Drinking eight to ten 8-ounce glasses of water daily helps maintain normal elimination patterns. To minimize or avoid the constipating effects of opiates, the patient should increase intake of fiber and fluids. If long-term use of opiates is planned, stool softeners may be necessary.

Fostering Health Maintenance.

Throughout the course of treatment, discuss medication information and how it will benefit the patient. Drug therapy for the management of pain should be coupled with comfort measures, relaxation techniques, meditation, stress management, and meeting the total care needs of the individual to ensure maintenance of ADLs. Provide the patient and significant others with important information contained in the specific drug monograph for the medicines prescribed. Additional health teaching and nursing interventions for adverse effects are described in the drug monographs that follow.

Seek cooperation and understanding of the following points so that medication adherence is increased: name of medications; dosage, route, and times of administration; and common and serious adverse effects.

Written Record.

Enlist the patient’s aid in developing and maintaining a written record of monitoring parameters (e.g., frequency of pain attacks, activity performed when pain occurs, techniques used to control pain, degree of pain relief, exercise tolerance; see Patient Self-Assessment Form for Analgesics on the Companion CD or the Evolve Web site). Complete the Premedication Data column for use as a baseline to track response to drug therapy. Ensure that the patient understands how to use the form and instruct the patient to bring the completed form to follow-up visits. During follow-up visits, focus on issues that will foster adherence with the therapeutic interventions prescribed.