As already established in Part One of the Pain Series (Titled – Overcoming The Barriers Of Effective Pain Management), pain is not an entirely physiological experience but has spiritual, emotional and psychosocial dimensions. The goal of pain management is to address the dimensions of pain and to provide maximum pain relief with minimal side effects. It focuses on Patient’s Priorities not the Professional’s Priorities
The standard of care in pain management is Continuous Pain Assessment and Implementation of Client-Specific Pain Interventions(pharmacological and non-pharmacological).
Pain is considered the fifth vital sign yet most institutions do not include pain assessment in their routine vital signs assessment protocol despite the fact that pain is the commonest reason why people seek for health care. Assessment of pain plays a very significant role in pain management. It forms the basis for specific interventions and evaluation.
Provision of optimal pain managements calls for the need for continuous and accurate pain assessments. It must be done before, during and after initiation of pain management. The clinician must use validated pain assessment tools to track responses to pain treatments and adjust treatment plans accordingly. Examples of pain assessment tools include Numeric Rating Scale, Verbal Rating Scale, Faces Rating Scales and Visual Analogue Scale.
For those incapable of self-reporting, standardized pain assessment tools should include behavioural observations with or without physiologic measures. Though physiologic signs such as tachycardia, hypertension, diaphoresis and pallor may accompany pain, they are non-specific to pain. Sole reliance on these physiologic signs to assess pain may be inappropriate.
Also, placebos should not be utilized to assess if pain exists or to treat pain. Remember, pain is subjective and it’s whatever the person says it is, existing whenever the person says it does. The clinician must accept the patient’s report of pain.
PERIOPERATIVE PAIN ASSESSMENT
Effective post-operative pain management starts preoperatively. The clinician must provide client centered education to the patient including information on treatment options for management of postoperative pain. There must be a written plan and goals for postoperative pain management.
This must be preceded with a thorough history and physical examination to develop an individually tailored pain management plan through a shared decision-making approach. Data must be collected on patient medical history and psychiatric comorbidities, previous postoperative treatment regimens and responses, concomitant medications, history of chronic pain and substance abuse.
Adequate preoperative pain assessment helps to reduced postoperative opioid consumption, less preoperative anxiety, fewer requests for sedative medications, and reduced length of stay after surgery.
In the post-operative stage, there must be ongoing reassessments to determine the adequacy of pain relief, detect adverse events early, and help monitor progress toward functional goals.
PAIN MANAGEMENT INTERVENTIONS
Pain management plan must be done through a shared decision-making approach. Both pharmacologicand non-pharmacologic interventions can be harnessed for adequate pain treatment. It must be tailored to meet client’s specific needs.
Pharmacologic interventions may involve the use of variety of analgesic medications – including NSAIDs, Opioids, Non-NSAIDS and Non-Opiods analgesics. It may also include adjuvants such as antidepressants, anti-seizure medications, sedatives or anti-anxiety medications and muscle relaxants.
Clinicians must use Oral over intravenous (i.v.) administration of opioids in patients who can use the oral route. Intramuscular route for the administration of analgesics must be avoided since intramuscular administration can cause significant pain and is associated with unreliable absorption, resulting in inconsistent analgesia.
There must be continuous monitoring of side effects especially in patient receiving opioids. Such monitoring should include assessments of alertness and signs or symptoms of hypoventilation or hypoxia.
When Non-pharmacological interventions are combined with pharmacological interventions, they contribute immensely for adequate pain relief. They include
Massage:- generalized cutaneous stimulation of the body, often concentrates on the back and shoulders.
Thermal therapy– Ice and Heat Therapy
Distractions– may range from simple activities, such as watching TV or listening to music, to highly complex physical and mental exercises.
Relaxation techniques:- A simple relaxation technique consists of abdominal breathing at a slow, rhythmic rate
Guided imagery:- is using one’s imagination to achieve a specific positive effect
Transcutaneous electrical nerve stimulation (TENS):-uses a battery-operated unit with electrodes applied to the skin to produce a tingling, vibrating, or buzzing sensation in the area of pain.
Accurate pain assessment and the use of appropriate interventions (both pharmacological and non-pharmacological) can contribute to adequate pain relief.
Written By Prince Assandoh-Mensah (RN, BSN- CHN, Clinical Nurse)
American Pain Society.(2016) Guidelines on the management of post-operative pain. The Journal of Pain, Vol 17, No 2 (February), 2016: pp 131-157 retrieved on 18th October, 2017 from http://www.jpain.org/article/S1526-5900(15)00995-5/fulltext
Human Right Watch.(2016). Global State of Pain Treatment, Access to Palliative Care as a Human Right.retrieved on 20th October, 2017 from https://www.hrw.org/sites/default/files/reports/hhr0511W.pdf
Maryland Board of Nursing. Pain Management Nursing Role/Core Competency A Guide for Nurses. http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/MD_nursing.pdf
Hinkle, J. L. (2014). Brunner &Suddarth’s textbook of medical-surgical nursing (Edition 13.). Philadelphia: Wolters Kluwer Health/Lippincott