Learning Scope #317
2 contact hours
Expires Oct. 12, 2011

The goal of this CE is to provide the most current information about pharmaceutical pain management in acute care that nurses can apply to practice. After you have completed reading this article, you will be able to:

1. Develop strategies for pain management based on pharmacodynamics and nursing implications for selected drugs.
2. Utilize Joint Commission standards for assessment, implementation and documentation of pain management.
3. Compare and contrast uses, mechanism of action, onset and duration of selected drugs.
4. Discuss pain management in the substance abuser.

You can earn 2 contact hours of continuing education credit in three ways: 1) For im­mediate results and certificate, take the test online; grade and certificate are available immediately after taking the test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

Pain is a subjective experience. Nurses have been taught pain is what the patient says it is and exists when the patient says it does. We have also been taught lack of objective signs does not always mean lack of pain or lack of an obvious physiologic cause. Yet, studies continue to demonstrate healthcare providers undertreat pain.¹

While the patient's first concern about pain management is comfort, pain relief encompasses more than relieving discomfort. Improper pain relief prolongs the stress response, delays wound healing and causes immunosuppression. Pain may increase oxygen demand, promote coagulation and decrease gastric and intestinal motility. Further, the vicious cycle of pain-muscle tension-anxiety and increased pain-decreased mobility can result in deep vein thrombosis, pulmonary embolism, atelectasis and pneumonia.

Acute pain differs from chronic pain in that with acute pain the onset tends to be sudden and the pain may be attributed to a specific cause. It usually signifies underlying trauma or disease and may be easily localized.² This type of pain may result from trauma such as fractures or burns, ischemia, inflammation or surgery. Acute pain is usually self-limiting, perhaps making it easier to cope with than chronic pain. Nonetheless, it must be addressed effectively.

Pain Assessment Tools

There are many assessment tools available, such as the simple 1-10 numerical scale or visual analog scale (VAS). Typically, a horizontal line is drawn and the number 1 placed to show a very little pain. The number 10 is placed at the opposite end of the scale with the cue the worst pain possible. The patient is then asked to point to or to state the amount of pain he has which corresponds to the scale. Asking the patient to rate his pain on an imaginary scale from 1-10 is not considered a tool.³

The Wong-Baker FACES scale is used with children or non-verbal adults, those who are cognitively impaired or those who don't speak English.¹ The patient can point to a face representing their level of pain; for example the face representing "comfortable" shows a smiling face. Each subsequent rating the faces appear more and more distressed until the face exhibiting "unbearable pain" is shown crying.

The McGill-Melzack questionnaire assesses not only location and quality of pain but psychosocial factors as well. Questions regarding how the pain feels, how the pain changes with time as well as a section to evaluate response to treatment are included in this full-page tool.³

While written instructions for assessment tools and pain management materials are appropriate, many narcotics lead to blurred vision as well as poor concentration or confusion impeding understanding. Because patients receiving narcotic analgesic may develop sedation, explanations may need to be given many times. Patients should have their eyeglasses and hearing aids in place during assessments to maximize understanding of the questions.

Many nurses, patients and their families believe pain is a part of growing old. This misconception may lead to incomplete assessment and improper analgesia. An elderly patient may be anxious, temporarily disoriented from a new environment or have dementia or cognitive impairments that make pain assessment difficult. The nurse may need to rely on non-verbal or behavioral changes such as grimacing or guarding, restlessness or agitation, hostility or combativeness to assist with pain assessment. This does not mean elderly patients or patients with dementia should not be medicated for pain or receive narcotic analgesics. Rather, the rule of thumb is to "start low, go slow," initiating treatment with a dose that is 25-50 percent of the usual adult dose and titrating for comfort, function and safety.⁴