Pain Management: It is a Focus of Care and a Focus of Auditors Part 2
Agencies need to identify, through policy or definitive tool, the questions to be asked. Some, but certainly not all questions, include:
What initiates or triggers the pain?
How and when did the injury occur or when was the disease been defined?
What treatments and interventions have been utilized? Repositioning used?
Assess if Heat/Cold was used? Homeopathic remedies used? Hypnosis or self relaxation exercises tried? Is Reflexology or Acupuncture used?
What medications have been prescribed? What frequency have medications been used?
What treatments have been effective?
Where is the pain located? Does it radiate?
Please describe the pain?
Is the pain present at this time?
How would you rate the pain?
How has the pain impacted your life? As to work? As to socialization? As to sports? As to family? As to finances? As to image?
Does the pain awaken you from sleep?
How frequently does this pain occur each day?
Do you still have pain despite having pain medication?
Let’s discuss your pain medications and other techniques you are using to manage this pain.
Rosdaqhl, 2010 describes a Description of Pain: COLDSPA:
COLDSPA provides a cueing chart of terms to assess pain by clinicians. It is quick and easy to remember.
The Joint Commission and other accrediting bodies expect the clinician to adequately explain the rights of the patient to have an appropriate assessment, and to have clinicians who are educated in pain assessment and pain management.
Pain Measurement Tools
Though clinicians are usually aware of the Wong Baker Faces Scale which has facial expressions that correlate to an analog 0-10 rating scale, they may not be as accustomed to other scales such as the:
FLACC scale is an observational scale for preverbal children to assess specific body parts as pain indicators.
NPS is a neonatal pain observational scale to assess the child’s facial expressions, their cries, breathing, and state of arousal.
In addition, the McGill-Melzack Scale provides an assessment of word groupings from Group 1-Flickering, pulsing quivering, throbbing, pounding or Group 4- Sharp, gritting, lacerating, to Group 12- Sickening, suffocating to Group 20-Nauseating, agonizing, dreadful, and torturing.
Each scale offers pain assessment for a specific population.
Pharmacological Therapy (in general)
Pharmacologic interventions are used to not only reduce pain but assist the patient’s mood, affect, and ability to increase socialization as well as providing a sense of hope. Controlled pain tremendously impacts the view of the world by the patient.
In general, the comfort and pain management medications can be divided into three analgesic classifications:
Nonsteroidal anti-inflammatory (NSAIDS) are used for mild to moderate pain. These drugs include Aspirin, ibuprofen (Motrin), and Naproxen (Aleve). Tylenol may also be used but with caution as Tylenol is frequently used in so many products including cough syrup. The NSAIDS require lab monitoring of the liver and stomach.
Opioid narcotic analgesics are used for moderate to severe visceral and somatic pain as well as Cancer and chronic pain. There are a variety of opioid types of analgesics which may be used together at staggered times to prevent breakthrough pain and manage intractable pain and to prevent tolerance to a specific single drug.
Examples of these drugs include:
Morphine: available in quick and slow release. Constipation is common as is initial nausea.
Dilaudid: considered to be 6-7 times more powerful than Morphine. Available in short acting doses.
Oxycodone: usually coupled with acetaminophen (Tylenol) or Ibuprofen. Short acting lasting usually only 6 hours or longer acting is also available.
Hydrocodone: usually coupled with Tylenol as Vicodin. Short acting for about 4 hours.
Fentanyl: provided in patch form providing various strengths of this systemic drug.
Adjuvant drugs are drugs that support NSAIDS and Opiods. These anti-epileptic drugs are usually used for neuopathic pain.
Neuotin: commonly used with patients demonstrating numbness, tingling, and burning pain. This may be seen with patients post chemotherapy use who exhibit peripheral neuropathy.
Antidepressants are utilized to combat depression and improving the quality of life of chronic pain sufferers. Some research supports the fact that over 60% of chronic pain suffers also have a psychiatric diagnosis.
Patient Controlled Analgesia: PCA
In the 1970s, PCA pumps became popular to allow patients to have a set dose of medication with almost immediate medication delivery. Patients were given autonomy with safe dosage, less sedation, and improved patient and physician satisfaction. PCAs are now routinely available post-op and available for cancer patients and select chronic pain patients.
Patients are frequently concerned with potential addiction. They worry about the type of meds and the short and long term effects. If the patient does not have a terminal illness with less than six months expected lifespan, the clinician is overtly monitoring the patient for addiction.
Addiction is defined by the 4 Cs: Compulsive use, quantity Control, Craving the effects and feeling of the drugs, and Continued use even with significant drug adverse effects.
Non Pharmacologic Interventions
Nurses have been taught to utilize non pharmacologic interventions for pain management. These include:
- Skin and Ortho comfort from a clean comfortable bed
- Restful calm music or music of patient choice
- Warm comfortably lit room
- Tasty visually appealing food
- Reduction of strong odors
- Prevention of constipation and diarrhea
- Proper hydration
- Diversion activities
- Positional changes as necessary
- Warm baths (sponge or tub)
- Therapeutic massage
- Application of heat or cold
- Visual imagery
- Spiritual support
- TENS Units stimulation/Biofeedback
- Chiropractic Care
- Family support and contact
- Planning for future…having a plan….having hope.
Do you have other suggestions for pain management that have provided relief? Research continues in this area. Know that clinicians must document pain management carefully. Know that the surveyors and auditors are focusing on pain and management of that pain.