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The first step to solving this problem is to recognize pain. Assume that all critically ill patients are in pain or are at high risk for pain. Pain can be triggered by many medical conditions including ischemia, infections, inflammation, edema, and distention. Immobilization, incisions, wounds, and the use of invasive and noninvasive medical devices can also cause pain. In addition, many commonly performed nursing procedures such as suctioning, turning, dressing changes, and insertion and removal of catheters may be a source of pain. Some patients are particularly at high risk for poor pain management, specifically those who are unable to vocally communicate because of intubation, those who are chemically paralyzed, and those who are unable to clearly communicate their needs because of sedation or an altered mental status. The very young and the very old frequently fall into these high-risk groups.
Q: Quality improvement data show that patients are not very satisfied with their pain management. How can we do better?
Make pain management a priority. Establish unit standards related to pain assessment and management just as your unit has standards for frequency of vital signs, intake and output, changing intravenous tubing, positioning, and checking the crash cart. As a unit, choose a method for measuring and documenting pain and include pain assessment as a fifth vital sign to be recorded on flowsheets. Continue to monitor outcomes related to pain management.
Emphasize pain prevention. It is easier to control pain when you prevent it from gaining a foothold in the first place. Ask physicians and nurse practitioners who admit patients to your unit to write orders for regularly scheduled analgesic doses or patient-controlled analgesia, rather than as-needed doses, for any patient expected to have pain. This around-the-clock dosing will allow you to prevent the onset of pain. If pain is not expected but occurs anyway, begin analgesic therapy as soon as possible after the pain begins.
Ensure that all patients have at least as-needed analgesic orders so you can immediately begin to treat pain if it occurs. Once initial pain is controlled, remember to use non-pharmacological pain-relief methods such as positioning, relaxation, applications of heat and cold, and guided imagery. Many of these methods fall within nursing’s scope of practice (Table 1
).
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Q: What is the best way to assess pain in critically ill and injured patients?
Ask the patient. Pain is a highly individualized and subjective experience. We have no objective method of quantifying pain; you just have to believe the patient. If a patient cannot vocally tell you about pain, body language and physiological status may provide clues to its presence. However, these nonverbal behaviors should never be used instead of or to refute a patient’s verbal complaint of pain.
A basic assessment must include at least the intensity and location of the pain. You may want to obtain a more comprehensive assessment for patients whose pain is particularly difficult to control.
Pain intensity is easily measured using a numerical rating scale. To use a numerical rating scale ask the patient, "On a scale of zero to 10, with zero being no pain and 10 being the worst possible pain, which number represents the amount of pain you are having right now?" The number selected by the patient is the pain score. Numerical rating scales may also be depicted as a horizontal or vertical line printed on paper (Figure 1). In this case the patient points to or circles the number representing their pain. This method could be used with a patient who is intubated. Alternatively, intubated patients can also tap the side rail of the bed to represent the number between zero and 10 that corresponds to their pain.
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). In addition to analog scales, other methods of quantifying pain include the use of poker chips to represent pain intensity.4,5 Adults or children are presented with 4 poker chips and told that these 4 chips represent "pieces of hurt." They are then instructed to select the number of chips that represent the amount of hurt (or pain) that they are experiencing. The number of chips selected is the pain score. A number of pain scales with pictures of faces in various levels of pain are also available for use with children6–8 (Figure 2).
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Assess pain on a regular schedule around the clock, for example, every 2 hours in critical care settings, and before and after procedures. Pain scores should also be obtained at an appropriate time after administering an analgesic, eg, recheck pain status 10 minutes after giving an intravenous dose of morphine. If pain is still present, another dose can then be administered.
Q: How should analgesic medications be administered?
Ideally, analgesic therapy should be started before pain begins (preemptive analgesia) or as soon as possible after pain begins. When possible, use both opioid and nonopioid medications to manage pain.9 Medications such as acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDS) work in the peripheral nervous system to control pain. Opioids such as morphine, hydromorphone hydrochloride (Dilaudid), and fentanyl work within the dorsal horn of the spinal column and in higher areas of the central nervous system to control pain. Opioid and nonopioid medications have complementary effects.
The World Health Organization recommends the use of a stepped approach to the use of analgesics10 (Figure 3). For mild pain, acetaminophen or nonsteroidal anti-inflammatory drugs should be the first therapy. For moderate to severe pain, opioid analgesics are the initial therapy. For patients with chronic neuropathic pain, anticonvulsants such as gabapentin, and antidepressants such as nortriptyline are frequently prescribed.
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For chronic pain and pain associated with cancer, analgesic treatments should cover the entire 24-hour period. Oral or topical preparations of longer-acting analgesics (morphine sulfate [MS Contin], oxycodone hydrochloride [Oxycontin], or a fentanyl patch) should be supplemented by as-needed doses or treatments for breakthrough pain. Dosing should be individualized to manage the pain and minimize side effects. If side effects such as nausea occur, antiemetics should be provided along with the analgesic.
Patients who are receiving adequate medications will report very low pain scores. When this occurs, your pain management plan is working and you should continue the medications as scheduled. Continue to assess the patient for breakthrough pain and side effects. Remember, the goal is to prevent pain from recurring.
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This article is based on the protocol "Pain Management in the Acutely Ill" by Julie Stanik-Hutt, from the Creating a Healing Environment series of AACN’s Protocols for Practice. Protocols can be obtained from AACN, 101 Columbia, Aliso Viejo, CA 92656-1491, (800) 899-AACN, (949) 362-2000. $11.00, AACN members; $14.00, nonmembers
Note:
This article was first published in Critical Care Nurse October 1998.
Acknowledgment
"Pain Management in the Acutely Ill" by Julie Stanik-Hutt, one of AACN’s Protocols for Practice, was sponsored by Hewlett-Packard.
References
This article has been cited by other articles:
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  J. E. Helms and C. P. Barone Physiology and Treatment of Pain Crit. Care Nurse, December 1, 2008; 28(6): 38 - 49. [Full Text] [PDF]
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