Our principles are: first, identify patients at risk for poor pain management.
If you can’t do that, you’re really setting populations away that
are going to fail. How are you assessing for patients who can’t tell
you? What is your technique? Maybe it’s looking for grimacing, a furrow
over the eyebrow. With infants, it may be palmar sweating. How you assess for
pain should be the way the nurses in front of you on your shift and the nurses
after you do it so there is continuity. Everyone is using the same thing versus
different tools, different perceptions. Maybe it’s believing the family.
Families are actually better at assessing their loved one’s
pain than we are. They will be more accurate. I always ask, “how
do you think we’re doing?” If they don’t think
we are doing good my assessments change because they know how they
act when they are in pain especially if they are noncommunicative.
If they have something that would hurt you or me, the assumption
should be it’s hurting them until you can prove it’s
not and therefore, you are treating them. As you treat them, and
you address the treatment to their needs, look for the response.
Does the heart rate go from 110 to 90. Does their breathing go
from 18 to 16. Does that furrow on the eyebrow go away. Does the
agitation get better. When in doubt, you always have to rule out
pain and if you can’t be sure, think about a trial of analgesics
and note the response. Once again, if it would hurt you or me,
you’ve to prove that it’s not hurting them, which is
a major way of thinking from the way most of us were taught.
We know some patients are going to give up after a few days of
having pain, may never say they are in pain. They may just look
apathetic and listless, which really drives us crazy when we are
trying to treat pain. We want people to look like they are in pain.
We really do. We want them curled up in a ball crying. With chronic
pain, it takes too much energy. It really isn’t going to
happen. It is belief in the patient and belief in the etiology
and going in there and treating it, really careful assessments.
Maybe it’s a sharp, stabbing pain. Sharp and stabbing, there
is some interesting research coming out about neuropathic pain
and cancer.
One study demonstrates between 60% to 70% of these patients have
a neuropathic component which may not be responsive to opiates
or may need aggressive treatment. That’s not saying don’t
use opioids but are you aggressively treating them. You need
a good pain history. When did this start, what makes it better,
what makes it worse. Where is this pain located. Remember what
I said in the beginning, 10% of your cancer patients are going
to have 7 or more sites of pain. If you don’t know the
location, you may not know what you’re treating which Coumadin
be vital.
What’s the intensity on 0 to 10. It drives me crazy when
a pain assessment is 0 to 10 and nothing else because it’s
never going to tell you if it’s a new pain. It’s never
going to tell you if is neuropathic.
There are a lot of pain assessment tools out there. Remember
this is only one part of a pain assessment. Zero to ten is what
most people use but for some patients, it will not work so then
you have to find something you can use for that patient throughout
the course of their illness, their hospitalization. The elderly
may do better on a 0 to 5 scale. I’ll tell you, boys never
pick the crying face. We have some cultural issues too.
What are the components that are in your pain assessment, what
are you looking for. Does it come and go. What’s the quality
of the pain. Does it have a pattern, “it’s worse after
I eat.” What makes it better, what makes it worse. One of
my favorite stories was I had a gentleman with prostate cancer
and he came to our pain clinic. He said every morning my pain is
a 9 out of 10 and I sit down at the kitchen table for an hour and
it goes back down to a 3 and that’s tolerable. Every night
before I fall asleep at night, it’s back to that same pain
score. We were adjusting his medications and we actually did a
pain diary and he came back to us a day later and he said, I figured
it out. Okay, tell me, and he is writing this pain diary.
Every morning this guy wakes up, gets out of bed and walks down
three flights of stairs. At the bottom stairs he starts to feel
his back hurting and every night he goes back up those three flights
of stairs and those stairs bother his back. The rest of the day
he is downstairs and feels fine. He figured out a great strategy.
He just rolled over in the morning. He took two pain pills, waited
45 minutes, did the stairs. Before he went up, he took two before
he went up the stairs. He figured out everything just by looking
at how it was working. Sometimes things are simple, sometimes they
are not. Figuring out what is aggravating is really important.
What is their medication history. What has worked in the past,
what hasn’t worked in the past so that you don’t start
off with something that has failed or something that may them exceedingly
sick. A real important question is what does pain mean to this
patient. If it means disease progression, how they are going to
tell you about it may be very different so it’s real important
to ask those questions.
Look for pain behaviors. If they are not communicating to you from
the facial grimacing, are they saying things in-between, calling
out screaming if they can’t tell you. Are they getting
aggressive. This is a big one nursing homes use a lot for pain
assessment. What are their body movements. How are they changing
their activity.
I had an 11-year-old with a hepatocellular cancer. They cut him
open, very large incision, and I’m going to see him 12 hours
postoperative. He is back in the room and I’m asking how
is your pain, “I don’t have any pain.”
Okay, I’m looking at this huge incision going I can’t
believe he is not having pain but he is denying it. We want to
get him out of bed, just move him a little bit, get him to sit
and he wont move. “Lets just roll you over. Don’t want
to move. Are you in pain? No pain, I just don’t want to move
now, come back.”
He was pretty strong in his beliefs. We talked a little bit and
we ended up giving him a small dose of morphine through his IV.
Twenty minutes later he is moving around in bed, and saying “Can
I get out of bed and get up in the chair?”
Can I play Nintendo was really what he was saying.
We are sitting there talking to him, and said, “We gave
you some pain medicine.” He says, “I know, it really
helped a lot.” I said, “I thought you weren’t
haven’t pain.”
He says, “Well, the last time I was in the hospital everyone
kept sticking a needle in my butt. I didn’t want anyone sticking
any needles in me so I denied pain.”
Really, the history is very important to figure out how he was
treated in the past. If he was treated like that, they may lie.
What are you doing physically. What non-verbal cues do you have.
Have you really examined the site of pain. I get a lot of calls
from home health and other places saying they are having severe
pain and my first question is, what does it look like the area.
We haven’t gone out there yet but they said it’s
really sore. I’ve had patients admitted with stage III
decubitus from home health and home health hadn’t seen
it. Those are the things that scare me. With our population,
is it early herpes zoster infection. Is it an impending cord
compression. I’ll say these over and over. You know, is
it an ileus because giving them a pain medication may not be
the best thing at the time.
We are doing good physical assessment and with pain management
you need great physical assessment skills.
Any time pain changes you got to go back and reassess. You got
to figure out what’s going on. What helps with the pain.
Did the medication you give helps or was it wasting everyone’s
time including the patient. Are you assessing the relief. How
good did we do when we dropped it down and always make documentation
visible.
I’m one of the believers that in acute care setting, I
want everyone documenting pain. I want everyone writing down 0
to 10. The chaplains in there, I want them asking. Physical therapist,
nurses aide, I want everyone asking because I think the more that
is asked about it makes it real. It’s important to all of
us, to the whole team. Now, if it’s intolerable, they need
to go grab the nurse but they need to make sure things are going.
Physical therapy, it’s vital. Sure, they are comfortable,
but I can’t walk them because it’s a 10. All of these
are important to your management plan. You need to bring the whole
team in.
You got to look at existential distress. You got to look if the
pain management plan is making things worse. If the constipation
is worse than the pain, the nausea, the sedation that may come
with it. How are you treating that, how are you improving their
quality of life. You’ve got to have more of the nursing.
You need the physicians, the OT, the chaplain, your social workers.
You need the family on board. Everyone has got to be part of
the plan or the plan will fall apart.
How do you communicate your assessment findings. To be effective
in managing pain as a nurse there are a few things that you have
to do to be effective. First, never call up a physician saying,
Mrs. Jones has a lot of pain. Failure. If you can get a number,
physicians respond better to a number. Dr. Smith, Mrs. Jones,
who I know you are aware of, is rating her pain as 7 out of 10.
It’s well localized in her mid abdomen. I know you are
giving her two Percocet every four hours, which presently is
taking her pain from an 8 to a 6. I know Dr. Smith you are aware
of if we change that Percocet to 15 of immediate release morphine,
that would be 3 Percocet, which is a 30% increase rated on her
pain, it would probably be a useful idea, should I put that order
for you now?
One, you have given them a pain score they can follow so when
the next nurse calls and they say versus Mrs. Jones’ pain
is really bad, is that worse than it’s really terrible, I’m
not really sure. They can tract to the intervention and do things.
Two, you gave a really good pain assessment. You never call without
a plan because they could say, two Percocet are not working,
let’s try two Tylenol #3. If you take that order you’ve
given the patient less drug. The p.o. is not working, give 2
of IV morphine, which is still less than the 2 Percocet. If you
don’t have a plan in place and you don’t know equianalgesics,
you are setting the patient up for barriers so you need to be
really good but never call without a plan, and give as much information
as you can and make it their idea. You walked them through, used
the signs. If you don’t know equianalgesics, I can’t
recommend it enough.
In one study, 70% of physicians and nurses didn’t know
how to go to one drug from another, from p.o. to IV, from one to
another. It is vital that you know equianalgesics. In the same
study, 50% of pharmacists got it wrong. So if you are counting
on the pharmacist to back your play, you may be setting yourself
up. We are going to discuss that plan. We are going to use scales.
We are always going to have a plan.
Reassessment. After you get the plan from the physician, after
you get those orders, you got to go back and document what you
did. Did it work, how helpful was it. One of the biggest problems
we have in our institution truly is we don’t reassess enough
after we do something. We have to go back and that’s our
big educational component this quarter, is reassessing when we
give pain medications, what were their impact, how useful was it.
As I mentioned, new research shows that if don’t educate
the family, you’re setting the patient up.
We can use nonopioids. They have a lot of adverse effects. No one
to this date knows how Tylenol works. More and more literature
is coming out about Tylenol toxicity to include the inpatient
setting. Patients can get a lot of Tylenol. We all know 4 grams
per day is the magic number but if they are getting two of Tylenol
before blood transfusion, two of Tylenol for fever, two Percocet
for pain, at the end of the day they can have 6 grams and not
a lot. They go home, they can be taking these one gram pills
and then at night take NyQuil with Benadryl. Going over that
is very easy to do.
When I think about nonsteroidals in cancer patients, the first
thing I think about is why can’t I use them. That should
be the first thing you think about. Have they had a GI bleed in
the last five years. Probably not a good drug. Do they have platelets.
Not a good drug. Are they over 70 or 75. Higher risk of a GI bleed.
You know there were in 1999 300,000 patients hospitalized for GI
bleed from nonsteroidals, 5000 deaths in the United States. These
are not benign drugs. You have to think about them.
How is their kidney function. Nonsteroidals cause papillary necrosis.
Do they have good kidney function that can support using nonsteroidals.
If they had plastic surgery in the last month, if they have higher
scar formation. Are they on steroids, higher risk of GI bleed.
I’m always trying to figure out why not to use them. I
think we’ve learned a lot about the COX-2 from this whole
incidence because the COX-2s were only checked for three months
and now we are learning their long-term duration when they got
FDA approval. These are all things.
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