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AssessmentNurses play an essential role in performing comprehensive pain assessment. Assessments include asking questions about the presence of pain, as well as observing for nonverbal indicators of pain, such as grimacing, moaning, and touching the painful area. It is especially important to observe for nonverbal indicators of pain in patients unable to self-report their pain, such as infants, children, patients who have a cognitive disorder, patients at end of life, non-English speaking patients, or patients who tend to be stoic due to cultural beliefs. See Figure 11.14[1] for an image of a patient who is expressing pain nonverbally. Figure 11.14 Nonverbal Expression of PainRecall that pain is defined as whatever the person experiencing it says it is. Subjective assessment includes asking questions regarding the severity rating, as well as obtaining comprehensive information by using the “PQRSTU” or “OLDCARTES” methods for assessing a chief complaint. For some patients who are unable to quantify the severity of their pain, a visual scale like the FACES scale is the best way to perform subjective assessment regarding the severity of pain. Objective data includes observations of nonverbal indications of pain, such as restlessness, facial grimacing and wincing, moaning, and rubbing or guarding painful areas. For patients who cannot verbalize their pain, using a scale like the FLACC, COMFORT, or PAINAD is helpful to standardize observations across different staff members. Keep in mind that patients experiencing acute pain will also likely have vital signs changes, such as increased blood pressure, increased heart rate, and increased respiratory rate. It is important to assess the impact of pain on a patient’s daily functioning. This can be accomplished by asking what effect the pain has on their ability to bathe, dress, prepare food, eat, walk, and complete other daily activities. Assessing the impact of pain on daily functioning is a new standard of care that assists the interdisciplinary team in tailoring treatment goals and interventions that are customized to the patient’s situation. For example, for some patients, chronic pain affects their ability to be employed, so effective pain management is vital so they can return to work. For other patients receiving palliative care, the ability to sit up and eat a meal with loved ones without pain is an important goal.[2] When performing a patient assessment, any new complaints of pain or pain that is unresponsive to the current treatment plan should be reported to the health care provider. Instances of sudden, severe pain or chest pain require immediate notification or contact of emergency services. DiagnosesCommonly used NANDA-I nursing diagnoses for pain include Acute Pain (duration less than 3 months) and Chronic Pain. See Table 11.5 for more information regarding these diagnoses.[3]For more information about defining characteristics and related factors for other NANDA-I nursing diagnoses, refer to a current nursing diagnosis resource. Table 11.5 Pain NANDA-I Nursing Diagnoses[4]
Outcome IdentificationAn overall goal when providing pain management is, “The patient will report that the pain management treatment plan achieves their comfort-function goals.”[5] SMART outcomes are customized to the patient’s unique situation. An example of a SMART goal is, “The patient will notify the nurse promptly for pain intensity level that is greater than their comfort-function goal throughout shift.”[6] Planning InterventionsSeveral pharmacological and nonpharmacological interventions have been described throughout this chapter. See the following box for a summarized list of interventions for acute pain management. Acute Pain Management[7]
See the following box for a summarized list of interventions for chronic pain management. Chronic Pain Management[8]
Implementing Pharmacological InterventionsPatients should be involved and engaged in their plan of care to treat pain. By demonstrating empathy and collaborating with patients and the interdisciplinary team, it is more likely the treatment plan will be effective based on the patient’s goals. When administering analgesic medication, holistic nursing care is important. Begin by considering the patient’s goals for pain relief and ask if they have been met effectively by previously administered medications. If they have not been met, it may be necessary to advocate for additional or alternative medication with the health care provider. It is also important to consider if the patient is experiencing any side effects that may impact the patient’s desire to take additional pain medication. When administering medications that have been ordered on an “as-needed” basis, it is vital for the nurse to verify the amount of medication the patient received in the past 24 hours and if any dosage limits have been met to ensure patient safety. Prior to administration, consider the best route of administration for this patient at this particular time. For example, if the patient is nauseated and vomiting, then an oral route may not be effective. On the other hand, if a patient’s pain has improved when receiving intravenous medications during the recovery process, it may be possible for the patient to begin taking oral pain medications in preparation for discharge home. Keep the WHO ladder in mind when selecting medications to reach patient goals while also avoiding potential adverse effects when possible. When preparing opioid medications, it is important to remember that these medications are controlled substances with special regulations regarding storage, count auditing, and disposal/wasting of medication. Follow agency policy regarding these issues. It is also important to assess the patient’s level of sedation and respiratory status before administering additional doses of opioids and withhold the medication if the patient is oversedated or their respiratory rate is less than 12/minute. However, when providing pain management during end-of-life care, these parameters no longer apply because the emphasis is on providing comfort according to the patient’s preferences. Read more about end-of-life care in the “Grief and Loss” chapter. EvaluationIt is vital for the nurse to regularly evaluate if the established interventions are effectively meeting the pain management and function goals established collaboratively with the patient. Additionally, when administering analgesics, the patient should be reassessed in an hour (or other time frame based on the onset and peak of the medication) to determine if the medication was effective. If interventions are not effective, then follow-up interventions are required, which may include contacting the health care provider. For patients living with chronic pain, it can be helpful for them or their caregiver to maintain a pain journal. In the journal they can document activities that precipitated pain, medications taken to manage the pain, and whether these medications were effective in helping them to meet their functional goals. This journal is shared with the health care provider during follow-up visits to enhance the treatment plan.[9] The nurse must continually monitor for potential adverse effects of pain medications. For example, if a patient is receiving acetaminophen daily for chronic osteoarthritis pain, signs of liver dysfunction, such as jaundice and elevated liver function bloodwork, should be monitored. For older adults receiving NSAIDs, it is important to watch for early signs of gastrointestinal bleeding, such as melena. Patients receiving opioids should be continually monitored for oversedation, respiratory depression, constipation, nausea and vomiting, urinary retention, and pruritus. Side effects should be reported to the health care provider and orders received for treatment. Which principle should a nurse consider when administering pain medication to a client?The principle of beneficence is upheld when the appropriate amount of medication or other treatment is administered to the patient in a timely fashion resulting in the best pain control with acceptable side effects.
How should the nurse plan to manage caring for patients in pain?The following are the therapeutic nursing interventions for your acute pain care plan:. Provide measures to relieve pain before it becomes severe. ... . Acknowledge and accept the client's pain. ... . Provide nonpharmacologic pain management. ... . Provide pharmacologic pain management as ordered.. What interventions are appropriate for pain management?Key pain management strategies include:. pain medicines.. physical therapies (such as heat or cold packs, massage, hydrotherapy and exercise). psychological therapies (such as cognitive behavioural therapy, relaxation techniques and meditation). mind and body techniques (such as acupuncture). community support groups.. Why is it important to manage a patient's pain?Pain interferes with many daily activities, and one of the goals of acute pain management is to reduce the affect of pain on patient function and quality of life. The ability to resume activity, maintain a positive affect or mood, and sleep are relevant functions for patients following surgery.
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