What is the most appropriate method to ensure adequate pain relief in the immediate postoperative period from an opioid drug?

Assessment of pain is a critical step to providing good pain management. In a sample of physicians and nurses, Anderson and colleagues21 found lack of pain assessment was one of the most problematic barriers to achieving good pain control. There are many recommendations and guidelines for what constitutes an adequate pain assessment; however, many recommendations seem impractical in acute care practice. Nurses working with hospitalized patients with acute pain must select the appropriate elements of assessment for the current clinical situation. The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format.5 The assessment parameters should be explicitly directed by hospital or unit policies and procedures.5, 22, 23 To meet the patients’ needs, pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. The time frame for reassessment also should be directed by hospital or unit policies and procedures.5

An early Clinical Practice Guideline on Acute Pain Management released by the Agency for Health Care Policy and Research addressed assessment and management of acute pain.22 This guideline outlines a comprehensive pain evaluation that would be most useful when obtained prior to the surgical procedure. In the pain history, the nurse identifies the patient’s attitudes, beliefs, level of knowledge, and previous experiences with pain. Expectations of patient and family members for pain control postsurgically will uncover unrealistic expectations that can be addressed before surgery. This comprehensive pain history lays the foundation for the plan for pain management following surgery, which is completed collaboratively by the clinicians (physician and nurse), the patient, and his or her family.

The pain history should include the following:

• Significant previous and/or ongoing instances of pain and its effect on the patient

• Previously used methods for pain control that the patient has found either helpful or unhelpful

• The patient's attitude toward and use of opioids, anxiolytics, or other medications, including any history of substance abuse

• The patient's typical coping response for stress or pain, including the presence or absence of psychiatric disorders such as depression, anxiety, or psychosis

• Family expectations and beliefs concerning pain, stress, and postoperative course

• Ways the patient describes or shows pain

• The patient's knowledge of, expectations about, and preferences for pain management methods and for receiving information about pain management22 (p. 7–8)

During the postsurgical period, pain assessment must be brief and simple to complete.22 Because choice of intervention, including type of analgesic and dosing, is made based upon intensity, every pain assessment should include this type of measure. Numerous pain intensity measures have been developed and validated. Several tools provide a numeric rating of pain intensity (e.g., visual analogue scale, numeric rating scale (NRS)). Simpler tools such as the verbal rating scale, which classifies pain as mild, moderate or severe, also are commonly used. For patients with limited cognitive ability, scales with drawings or pictures are available (e.g., the Wong-Baker FACES scale). Patients with advanced dementia require behavioral observation to determine the presence of pain; tools such as the PAIN-AD are available for this patient population. (For more detail, go to section “Tools to Assess Pain Intensity in Cognitively Intact and Impaired Adults,” below.)

The Joint Commission developed pain standards for assessment and treatment based upon the recommendations in the Acute Pain Clinical Practice Guideline. The Joint Commission requires that hospitals select and use the same pain assessment tools across all departments. This standard suggests providing options among scales such as the NRS, the Wong-Baker FACES scale, and a verbal descriptor scale.

Selecting the pain assessment tool should be a collaborative decision between patient and health care provider. When this is done during the preoperative period, it ensures the patient is familiar with the scale. If the nurse selects the tool, he or she should consider the age of the patient; his or her physical, emotional, and cognitive status; and preference.22 We tend to think of these intensity scales as verbal, but patients who are alert but unable to talk (e.g., intubated, aphasic) may be able to point to a number or a face to report their pain. The pain tool selected should be used on a regular basis to assess pain and the effect of interventions. It should not, however, be used as the sole measure of pain perception.24

Location and quality of pain are additional assessment elements useful in selecting interventions to manage pain. Since patients may experience pain in areas other than the surgical site, location of pain using a body drawing or verbal report provides useful information. The pain experienced may be chronic (e.g., headache, low-back pain) or it may be related to the positioning and padding used during the procedure. The quality of pain varies depending upon the underlying etiology. Instruments such as the McGill Pain Questionnaire25, 26 contain a variety of verbal descriptors that help to distinguish between musculoskeletal and nerve-related pain. Typically, patients describe deep tissue pain as dull, aching, and cramping, while nerve-related pain tends to be more sporadic, shooting, or burning.27, 28

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.24 The ability to resume activity, maintain a positive affect or mood, and sleep are relevant functions for patients following surgery. The Brief Pain Inventory10, 29 includes four items that may be useful in assessing this aspect of the pain experience. Using an NRS format, assessment of interference with ability to walk, general activity, mood, and sleep during the recovery period will assist in selecting interventions to enhance function and quality of life.

The final elements of pain perceptions involve determining current aggravating and alleviating factors.22, 24 Aggravating factors may be as simple as patient position, a full bladder, or temperature of the room. Alleviating factors include the interventions used (e.g., analgesics) and cognitive strategies used to control pain. Examples of such strategies are distraction, positive self-talk, and pleasant imagery. The pain history will provide insight into the coping strategies previously used by the patient and their effectiveness with previous painful episodes.

In addition to self-reported pain perceptions, a comprehensive assessment of pain following surgery includes both physiological responses and behavioral responses to pain22 (p. 11). Physiological responses of sympathetic activation (tachycardia, increased respiratory rate, and hypertension) may indicate pain is present. Behaviors that may indicate pain include splinting, grimacing, moaning or grunting, distorted posture, and reluctance to move. While these nonverbal methods of assessment provide useful information, self-report of pain is the most accurate. A lack of physiological responses or an absence of behaviors indicating pain may not mean the patient is not experiencing pain. (Go to section “Tools to Assess Pain Intensity in the Cognitively Impaired,” below, for more detail.)

Adequate pain management requires an interdisciplinary approach.22, 24 Documentation of pain assessment and the effect of interventions are essential to allow communication among clinicians about the current status of the patient’s pain and responses to the plan of care. The Joint Commission requires documentation of pain to facilitate reassessment and followup. The American Pain Society suggests that pain be the fifth vital sign as a means of prompting nurses to reassess and document pain whenever vital signs are obtained.30 Documentation also is important as a means of monitoring the quality of pain management within the institution.

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Sample multimodality pain management