Give staff this guide to pain management
Give staff this guide to pain management
Lack of knowledge can leave patients in pain
Too often, patients with chronic pain are undertreated because patients and health care professionals alike fear the possibility of addiction, says Mary O’Donnell, RN, MHM, consultant educator for Catholic Home Health Services of Broward in Lauderdale Lakes, FL.
Teaching home health nurses and aides about pain management can help them overcome those fears and provide more consistent relief for patients who suffer from chronic pain. O’Donnell quotes the Department of Health and Human Services, which notes that up to 70% of patients with cancer in the United States do not receive adequate pain treatment. She says that in her experience, addiction from pain medication is truly rare among patients with chronic pain.
"I’ve been nursing for over 40 years, and in that time I’ve only seen two people addicted through their pain," she says. "Both were back pain, which can be excruciatingly agonizing."
O’Donnell says all health workers, not just nurses, should be taught about pain and its management and to be alert for signs that a patient needs stronger intervention.
"I think everybody who recognizes somebody who’s in pain should feel comfortable about taking that message to whoever has the power to do something about it," she says. "I am a hospice person from way back, and some of my biggest helpers, particularly in an institutional setting, were the housekeeping staff, who would come and tell me that somebody doesn’t seem to be doing too well."
In her introduction to effective pain management, she covers the difference between acute and chronic pain, and the concept of "total pain" as explained by Cicely Saunders, a British physician and founder of the modern hospice movement. "Total pain" considers not only the effects of physical pain, but also other components such as mental, psychosocial, and spiritual pain.
O’Donnell says it’s important that health professionals listen nonjudgmentally to their patients’ descriptions of pain. "Pain is whatever the patient says it is, which we always seem to get hung up on," she says. Even when a patient is reluctant to discuss pain, nurses should be alert for clues that it is there.
"When you find somebody, particularly in a physical assessment, who’s telling you they’re not in pain but when you ask them to stand up, it is a major event. You say, Wait a minute. What’s going on here?’" O’Donnell says. "Older people will often call their pain uncomfortable.’ Uncom fortable doesn’t ring a bell with all of us."
A detailed assessment of a patient’s pain — its history, character, intensity, how long it lasts — is the first step. She suggests simple pain scales that are easy for patients to understand. One she uses is color-coded, starting with peaceful blues at the lower end to represent an absence of pain, and violent orange and red at the top end to represent excruciating pain.
"When people cannot describe their pain, they very often can look at that chart, which is on a scale of 1 to 10 and say, That’s how I feel,’" she says. "They can point to what that meaning is."
Another chart, which shows faces that range from smiling and happy to teary and upset, is especially useful with pediatric patients.
The usefulness of pain scales comes with repeated assessment over time, showing when pain peaks and lessens and giving clues as to what exacerbates or relieves it.
"The only key to pain assessment is continuous assessment," O’Donnell says, relating a recent conversation she had about a patient being treated for pain. "I asked when [the nurse] thought she’d reassess again and she said a week. I said that’s not going to work. You need to be doing this in 12 or 24 or 48 hours. People don’t have time for you to mess around with their pain management. This is their life you’re dealing with, you know?"
Sometimes the factors that make pain worse or better are not immediately apparent. O’Donnell says she worked with one patient who lived at home with his wife and four daughters. His pain kept peaking at 3 p.m., "at a time when my perception was that he should be feeling pretty comfortable."
Some investigation showed that at 3 p.m. his daughters all came home from school, loudly and boisterously making their entrance. No one was associating that with his pain, but it only took a few changes — asking the girls to come in more quietly and go to another part of the house — to ease the situation.
"His pain at 3 o’clock started to diminish," O’Donnell says. "What relieved him was actually a whole family dynamic, first of all recognizing the pain and what was happening. He was very sensitive to noise.
"We looked at some behavioral things for the kids, recognizing that children do need their own noisy place," O’Donnell says. "They recognized that the house was large enough that they could actually go somewhere and not have to be noisy around him, which they were all happy to do."
A patient’s pain can have a devastating effect on family members, who don’t understand why the pain is continuing, who may feel guilty for not understanding it, and who may fear that the situation will never get better.
A ladder of treatments
In her inservice, O’Donnell introduces staff to the World Health Organization’s pain ladder, which guides physicians in managing pain by introducing stronger medications step by step as pain increases or persists. This is a description of that three-step pain ladder:
• At the first indication of pain, doctors prescribe non-opioid drugs (acetaminophen or nonsteroidal anti-inflammatory drugs such as aspirin) plus adjuvant or auxiliary drugs that help enhance the painkiller’s effectiveness.
• If pain persists or increases, a weak opioid such as codeine can be added to the non-opioid.
• If necessary, the painkiller can be upgraded to a stronger opioid such as morphine, while still administering a non-opioid drug.
It is at these higher levels of pain management that patients worry about the possibility of addiction. O’Donnell says she tries to calm those fears by explaining the difference between a pain patient’s use of a drug and an addict’s.
"Those people have two different goals," she says. "The addict has the goal of getting high, as high as possible, while the person who’s in pain, their only goal is to get out of that pain or to relieve it as much as possible. [A pain patient’s] incremental dosages in taking more pain medication are usually very, very slow. They take these very long, shallow steps upwards. Whereas the addict will generally have a very sharp sort of step up, up, up, as he or she becomes addicted. You’ll see a totally different pattern."
One key to keeping control of pain management is to continually reassess, using pain scales, so that patient, family, and nurse all know how the pain is being affected by medication. O’Donnell stresses that medication for chronic pain should be given as antibiotics are, around the clock, so its effects are not given a chance to wear off and subject the patient to more pain.
"People should not have to wait for their pain medication; they shouldn’t have to ask for it when they’re in severe pain," she says. "Once it’s worn off and that person is back in pain again, you have a whole lot of issues. You’ve encouraged the person perhaps to think they can get out of pain, and if they’re not adequately medicated, they go back into pain, and then they really lose that trust level."
She describes a common scenario that occurs when medication isn’t allowed to work continuously. "Somebody hasn’t been sleeping soundly for weeks. They get out of their pain, they start to sleep, and at two o’clock in the morning, when their medication is due, they’re not given it — We didn’t want to disturb him.’ At 6 o’clock or 7 o’clock in the morning, they wake up and they’re in agony and the reason is they weren’t woken up at 2 o’clock to be given their pain medication."
Getting on schedule
Nurses must set up a system of documenting medication so families can chart when drugs are given and what the pain scale was throughout the day and night. "You get a 24-hour-a-day picture of how much is being given, how it’s affecting sleep, so you can have a look and see what has happened in the previous 48 hours to a week," she says.
After the first 72 hours, in which medication must be given strictly on schedule, a more forgiving schedule can be worked out that doesn’t require family members to get up in the middle of the night to administer medication.
"A family that is tired out is an irritable, not-coping-very-well family," O’Donnell says.
It’s important that families know they can call to ask questions, particularly at the beginning of a pain management regimen. "If you’re starting this on a Friday, you really need to ask the on-call people to see that this is happening over the weekend," she says. "That’s when you have the most questions. Very often, we all need repetition [of instructions]. When somebody’s in a lot of pain, they’re not hearing too well, and if the family is very anxious, they’re not hearing too well, either."
If they’re in doubt, they’re likely to give less rather than more medication, she says.
Intramuscular administration of medication isn’t always the best route to take, O’Donnell warns, particularly if someone has been ill for some time and is quite thin. "There’s not much muscle, it hurts going in, and you’re liable to get a necrotic area there, eventually," she says. "Every nurse has seen an area where the material you’ve put in just oozes back out, so you have no effect at all."
She advises giving pain medication by mouth, when possible, and rectally. "I don’t think we use rectal medications as much as we could," she explains. "You’ve got this nice big blood supply down in the anal area that’s going to take it right back into the system very rapidly; absorption happens very rapidly."
Because constipation is a common side effect of opioid use, medication to treat that symptom should be given from the start, O’Donnell says.
She prefers Senekot to other laxatives and, as a general rule, suggests one Senokot per 15 mg of morphine. But she also asks patients what has worked for them in the past, and increases that treatment to a point where bowel movements are at a frequency the patient is used to.
"You’ve got a lot of people who don’t have regular bowel movements for four to five days; that’s their norm," O’Donnell says. "But if that gets out of hand with the pain medication, you really do have the possibility of impaction."
Other side effects often seen with medication include drowsiness in the first 72 hours, nausea, and a decrease in vital signs.
While pain is being treated with medication, O’Donnell also suggests adjunctive therapies such as relaxation exercises, massage therapy, gentle exercise, balanced nutrition, and music therapy. The type of music that works for one patient may be totally different from the type that works for another, she says.
"It’s a matter of finding out what they like," she says. "For the last 20 years, I’ve worked with people with HIV and AIDS. Their music will be very different from mine, but I also found it worked great with them. It was whatever they needed. Not just soothing classical, but maybe very stimulating music."
These adjunctive therapies "aren’t going to take their pain away, but it’s probably going to make them feel a whole lot better."
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