2 Pain
Nursing diagnoses:
Chronic pain
related to disease process, injury, or surgical procedure
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Obtain history about ongoing/previous pain experiences and previously used methods of pain control. Elicit what was/was not effective. Consider whether pain is acute, chronic, or acute with an underlying chronic component. | A pain history enables development of a systematic approach to pain management for each patient, using information gathered from pain history and the hierarchy of pain measurement (self-report, pathologic conditions or procedures that usually cause pain, behavioral indicators, report of family, and physiologic indicators). Agency for Health Care Policy and Research (AHCPR) and American Pain Society (APS) state self-report of pain is the single most reliable indicator of pain. |
| Use a formal patient-specific method of assessing self-reported pain when possible, including description, location, intensity, and aggravating/alleviating factors. | The first step of effective pain management is accurate assessment of pain. A numerical rating scale (NRS) of 0 (no pain) to 10 (worst possible pain), descriptive scales, and visual analog scale (VAS) are commonly used to assess intensity in adults who are cognitively intact. Pain intensity scales are available in many different languages when language barriers are present. The Wong-Baker FACES scale may be useful to measure pain in children (Wong & Baker, 2001). Consider using the Faces Pain Scale (Bieri et al., 1990) in older adults (Taylor & Herr, 2001). |
| Assess for behavioral and physiologic indicators of pain at frequent intervals (e.g., during scheduled vital signs [VS] assessments). Document responses. | Behavioral and physiologic responses are potential indicators of pain in patients who are unable to self-report. This assessment optimizes reassessment and treatment intervals. Note: Not all patients demonstrate the same response to pain, nor does the lack of response negate the presence of pain. Behavioral responses: Examples include facial expression (grimacing, facial tension), vocalization (moaning, groaning, sighing, crying), verbalization (praying, counting), body action (rocking, rubbing, restlessness), and behaviors (massaging, guarding, short-attention span, irritability, sleep disturbance). Behavioral examples may be seen in patients with impaired communication, including those who are cognitively impaired, unconscious, or conscious but unable to communicate. |
| Physiologic responses: Examples include diaphoresis, vasoconstriction, increased or decreased blood pressure (15% or more from baseline), increased pulse rate (15% or more from baseline), pupillary dilation, change in respiratory rate (RR) (usually increased to greater than 20 breaths/min), muscle tension or spasm, and decreased intestinal motility (evidenced by nausea, vomiting). Physiologic indicators may reflect pain as a result of autonomic stimulation of the sympathetic and parasympathetic responses. | |
| Teach patients that pain assessment and management are not only a part of their treatment but also their right. | Patients have the right to appropriate assessment and management of their pain (TJC, 2003). |
| Evaluate patient’s health history for alcohol and drug (prescribed and nonprescribed) use, which could affect effective doses of analgesics (i.e., patient may require more or less). Ensure that surgeon, anesthesiologist, and other health care providers are aware of any significant findings. Consult a pain management team if available. | Other drug use could alter effective doses of analgesics or lead to undertreatment. All care providers must be consistent in setting limits while providing effective pain control through pharmacologic and nonpharmacologic methods. Psychiatric or clinical pharmacology consultation may be necessary. |
| Develop a systematic and collaborative approach to pain management for each patient, using information gathered from pain history and the hierarchy of pain measurement. | American Society for Pain Management and American Nurses Association (2005) identifies importance of involvement of patient, family, and other health care providers in data collection, formulation of outcomes, and development of the pain management plan. The AHCPR and APS state self-report of pain is the single most reliable indicator of pain. |
| Use at least two identifiers (e.g., patient’s name, medical record number) before administering medications. | Using two or more identifiers improves accuracy of patient identification in keeping with The Joint Commision (TJC) National Patient Safety Goals promoting the right patient receiving the right medication. |
| Use a preventive approach: administer prn pain medications before pain becomes severe as well as before painful procedures, ambulation, and bedtime. | Prolonged stimulation of pain receptors results in increased sensitivity to painful stimuli and the need to increase the amount of drug required to relieve pain. |
| Administer analgesics according to the World Health Organization (WHO, 1996) three-step analgesic ladder. | The WHO analgesic ladder focuses on selecting analgesics and adjuvants based on pain intensity. The WHO analgesic ladder has been endorsed by the AHCPR Guidelines (1994) and the APS (2003). Note: Not all patients start with the first step; the process is determined by the etiology and severity of the pain. The three steps include: |
| Recognize that choice of analgesic agent is based on three general considerations: therapeutic goal, patient’s medical condition, and drug cost. | Individualized therapeutic goal and the stage of illness/disease process are important factors in agent selection to maximize pain relief and minimize potential of adverse side effects. The difference in cost of different drugs used to accomplish the same goal may be large. Where there is no proven or expected benefit of using one drug in preference to another to accomplish a desired goal, the less costly drug should be considered. The right drug is the one that works with the fewest side effects. |
| Also consider convenience, anticipated analgesic requirements, side effects, and patient’s previous experience with a specific agent or patient’s recall of side effects experienced with a specific agent, including route. | The preferred route is the one that is least invasive while achieving adequate relief. Aversion to painful routes of delivery (e.g., subcutaneous, intramuscular [IM]) may lead to underreporting of pain by patients and to undermedication by nurses. – IM analgesia is inconsistent; less titratable; and can cause complications such as hematoma, granuloma, infection, aseptic tissue necrosis, and nerve injury. APS suggests that this route be used rarely, and the AHCPR Acute Pain Practice Guidelines suggest that it be avoided when possible. < div class='tao-gold-member'>
Only gold members can continue reading. Log In or Register to continue
 Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
|