Pain Management in the Surgical/Trauma Patient



Pain Management in the Surgical/Trauma PatientAntoinette McNeil, BSN, RN, CCRNWashington Adventist UniversityAnalysis of Evidence-Based PracticeNURS 535Chioma Nwachukwu, DNP, RNOctober 18, 2012Pain Management in the Surgical/Trauma PatientIntroductionThere are over 77 million people who suffer from pain. Pain has been defined as whatever the patient states it is and it occurs whenever the patient states it does (Bernhofer, 2012). Often time’s pain is what the healthcare worker says it is and it occurs when they say it does. Many individuals have pain due to surgery or from a trauma that they have sustained. Pain is a nasty sensory and emotional experience that is associated with actual or potential tissue damage (Dihle, Bjolseth, & Helseth, 2006). No one can escape the effects of pain. Pain is always what the patient says it is and not what the healthcare worker says it is for the client. Patients’ being in pain is unacceptable and hospitals are realizing that their patient satisfaction scores are being based on how an institution treat or minimizes a patient pain .Too many patients are left in pain and their pain is not addressed properly. This paper will look at the inadequacies of pain management and what can be done to improve itMany healthcare workers underestimate the need to ensure that their patient’s pain is under control. Patients have the right to have their pain under control. Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) conducted a survey which revealed that only 63-74% of hospitalized patients stated that their pain was controlled. With the knowledge of pain research and treatments for pain management, patients who were hospitalized, satisfaction regarding pain management has not increased it has remained the same (Bernhofer, 2012). If acute post-operative pain is not managed efficiently for some patients, then their pain can potentially last for months or even years after the surgery (Reimer-Kent, 2004). One must remember that the goal of pain management is to control pain and to improve the quality of life for patients (Vega-Stromberg, Holmes, Gorski, & Johnson, 2002).When pain is not managed properly there are complications that can occur. Some of the complications that can occur when pain is not managed effectively are pneumonia, deep vein thrombosis (DVT), pulmonary emboli, myocardial infarction, confusion and chronic pain which can increase morbidity and mortality (Reimer-Kent, 2004). When a patient is in pain they are less likely to move or cooperate with their care than those who pain is managed or controlled effectively. Pain affects also ones emotion and responses like anxiety or fear of pain can cause the perception of pain to be greater than what is actually is (D’Arcy, 2011).Nursing Theory/ModelWhen looking at pain management Leininger’s Theory regarding culture, care diversity and universality (CCDU) is something to look at when addressing pain management. Leininger’s theory states that care is the essence and focus of nursing, culture care expression may be diverse among cultures but then they do have commonalities that exist (Sagar, 2012). Nurses must be knowledgeable regarding the client’s culture and various factors that influence a patient’s need (Sagar, 2012). Knowing a patient’s culture can help in regard to pain management, there are some cultures that think it is wrong to take pain medication (Leegaard et al., 2011).Nurses must also look at their beliefs and or values as it relates to caring for patients who have unrelieved pain. Many nurses may not believe a patient is in pain, they may be insensitive to the patient’s sign, they may believe that a patient is not to be totally free of pain, and they may feel patients are to tolerate some pain (Dihle et al., 2006). Caring is finding out what your patient needs to be comfortable and help in managing their pain to their comfort.Impact of the ProblemUncontrolled pain can lead to an increase risk of post-operative mortality and morbidity from complications such as pneumonia, deep vein thrombosis (DVT), pulmonary emboli, myocardial infarction, confusion and chronic pain (Reimer-Kent, 2004). These complications are to be taken seriously. When a patient has bilateral or multiple rib fractures, that individual has the potential to develop pneumonia due to shallow breathing, pulmonary emboli from a DVT and confusion. When pain is left unmanageable and at least 6 months has passed the pain is classified then as chronic pain. Chronic pain has been defined at pain that last for 6 months and longer (Goodman, 2003). When a patient stays on pain medication for several months or more they are looked as being addicted. When an addicted patient has acute pain, their pain management is compromised and leads to an unsatisfactory experience managing their pain (McCreaddie et al., 2010).Chronic pain is debilitating and it affects more that one’s health, it also affects one’s employment. The cost of unmanageable pain is astounding. The estimated cost for lost workdays exceeds $100 billion yearly (Woodward, 2005). Medicare cost as it relates to pain treatment and disability cost as it relates to chronic pain cost $124 million or more yearly (Goodman, 2003). Pain is costly and is not cheap. When patients are hospitalized due to chronic pain and then they have surgical intervention for their pain, unmanageable pain can lead to prolong hospitalization. In fact when a patient is a trauma or surgical patient and they have complications due to ineffective pain management that also leads to prolong hospitalization.Patients have had their pain mismanaged for years that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is holding healthcare institutions accountable for patient’s pain. JCAHO has pain standards that states patient’s have the right to appropriate assessment and management of their pain (Vega-Stromberg et al., 2002). JCAHO has four main components of care which are the following: assessing the patients need; planning care, treatment and services; providing care, treatment and services; and finally coordinating care treatment and services (D’Arcy, 2011).The American Pain Society (APS) in 1995 stated that the first step in improving the treatment of pain is assessing and recording the patient’s report of pain (Mularski et al., 2006). Both the APS and JCAHO refer to patient satisfaction as a standard patient outcome and point of evaluation (Vega-Stromberg et al., 2002). Since 2001 JACHO has held acute care hospitals accountable for the assessment, documentation, and management of patient’s pain (Dusek, Finch, Plotnikoff, & Knutson, 2010).Congress created the Decade of Pain from 2000 to 2010 which focuses on how to improve pain management in patients (D’Arcy, 2011).Multidisciplinary ApproachPain management is not a one discipline approach to patient satisfaction regarding pain management and quality practice. The development of ongoing resources and having support is essential to maintain quality practice (Vega-Stromberg et al., 2002). Having buy-in by physicians to ensure that patients pain is manage appropriately is a must, because they can assist in improving practices (Vega-Stromberg et al., 2002). It has been suggested that the Anesthesiologist should be responsible for pain management for the first 24 hours post-operatively, prescribing all analgesics including analgesic for break-through pain (Megens, Van Der Werff, & Knape, 2008).Nursing has a role in assessing pain in the patient and administrating the treatment that is prescribed for the patient and assess its effectiveness. Nurses must administer the patient’s pain medication around the clock after surgery and if non-opioids are ordered then it is to be given around the clock also even if the patient denies having pain (Reimer-Kent, 2004). Nurses must evaluate and re-evaluate the patient for pain and the effectiveness of the pain medication.For a pain management plan to work leadership and administration are responsible to provide administrative and financial support for pain management plan. Having institutional support and accountability is the answer for success (Vega-Stromberg et al., 2002). If administration does not stand behind the changes to ensure that patient safety as it relates to pain management progress then it will fail. Also patient satisfaction scores are tied into the management of pain for the patient.Evidence-Based Practice for Pain ReliefA study revealed that patients receiving an intrathecal injection before a total knee arthroplasty has better immediate postoperative pain management than those receiving general anesthesia (Napier & Bass, 2007). Studies have shown that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors are useful analgesic adjuncts that can improve pain relief while reducing the need for opioids postoperatively, these medications have a combination of analgesic, anti-inflammatory and anti-pyretic effects (Layzell, 2008).The use of acetaminophen and/or NSAIDs before surgery was given to achieve minimal pain perception (Megens et al., 2008). The World Health Organization (WHO) developed an analgesic ladder to guide providers in prescribing choice of pain medication (D’Arcy, 2011). Looking at Level 1 where the patient is having mild to moderate pain use NSAIDs. Looking at Level 2 where the patient is having moderate to severe pain use a combination of opioid and acetaminophen. Looking at Level 3 where the patient is having severe pain a strong opioid should be used (D’Arcy, 2011).There are other therapies that are used also for pain management. Patient-controlled analgesia (PCAs) would be successful if the patient was reasonably comfortable when it is begun; therefore pre-loading with opioids is a must (Layzell, 2008). Epidural analgesia is one of the most effective methods available for the management of pain the surgical patient with sever acute pain (Layzell, 2008). There are bupivacaine collagen sponges where the sponge is placed directly over the surgical site. The medication is released were it is needed and the sponges biodegrades over a few days (Layzell, 2008). Elastomeric pumps are disposable infusion pumps which have medication placed in its reservoir. The pressure generated by the filled reservoir and the flow restrictor set a fixed flow rate to dispense the medication. A catheter is placed near a nerve or in the wound incision at the end of the operation, which is connected to the pump that has the medication which is an anesthetic. The medication usually flows for at least 48 hour period. With this pump is allows the patient to mobilize early which leads to an early discharge from the hospital (Layzell, 2008).There also is the transdermal iontophoresis which is a process that allows a delivery of charged molecule across intact skin using a very small electrical current. Fentanyl has an iontophoretic transdermal system (IONSYS), which is totally patient controlled. A patch is placed on the skin the chest or the upper arm, which holds 80 doses of Fentanyl. The medication last either for 24 hours or until the 80 doses is gone. The patient can activate the delivery system and there is a 10min lock-out time. The dose that is delivered is only 40 mcg of Fentanyl. This is only for short term use and is not a system to be used for all patients (Layzell, 2008).Methods to Improve Pain ManagementPatient education regarding pain management is vital especially before the surgical intervention, but this is not feasible when the patient is a fresh trauma. If the trauma patient is coherent and understands all that is being said then patient teaching regarding pain management is to be done. The patient is to be included in their care which includes pain management. Many times a patient knows what pain medication works best for their pain thus healthcare providers should listen and not ignore the patient.Physicians need more education regarding pain management. The physicians have a committee that looks at educational topics and they should have topics that relate to pain management. Pharmacist education looks at the advantages and disadvantages of opioids that are used. Physical and Occupational therapy looks at education on the impact of pain on goals and develop strategies on improving pain management (Vega-Stromberg et al., 2002).Nurses first of all need to recognize their need to for information to better care for their patients of different ages and cultures and understand better about pain management (Leegaard et al., 2011). The acute care settings need to have in-services regarding pain management that will educate nurses on pain and how to better care for their patient in pain. Nurses must recognize that they are the first line of intervention for the patient, thus by assessing and reassign the patient for pain is paramount. Nurses need to attend conferences regarding pain management.EvaluationTo determine if changes the institution made regarding to pain management is working, they can do a survey before the patient leaves the hospital or when the patient has gone home. The survey that most hospitals participate in is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). One of the questions that are asked is pain control. All institutions want their patient satisfaction scores to be higher that what it is now. Patient scores hospitals low when their pain has not been managed well. Look at a patient’s length of stay for certain surgical diagnosis. Evaluating pain for a certain surgical diagnosis and the pain is managed properly there should be a drop in patient’s length of stay. By early teaching regarding pain management, promoting using the incentive spirometer, coughing and deep breathing and allowing the use of sequential compression devices for DVT prophylaxis will lead to a decrease of the complications that can occur from unmanaged pain.ConclusionPain management is vital for patient comfort and safety. There is much to be learned regarding how to best treat post-surgical or pain due to physical trauma. Healthcare providers must be proactive in attending in-services or conferences regarding pain management. With changes with CMS as it relates to payment to healthcare facilities pain management will be a factor on how well a patient’s pain was managed. JACHO has standards regarding pain management thus acute care institutions must be in compliance. Having the Anesthesiologist involved in pain management is beneficial for the patient. All disciplines must work together for the betterment of the patient.ReferencesBernhofer, E. (2012, January). Ethics: Ethics and Pain Management in Hospitalized Patients. The Online Journal of Issues in Nursing, 17. , A., Bjolseth, G., & Helseth, S. (2006). The gap between saying and doing in postoperative pain management. Journal of Clinical Nursing, 15(), 469-479.Dusek, J. A., Finch, M., Plotnikoff, G., & Knutson, L. (2010, March). The Impact of Integrative Medicine on Pain Management in a Tertiary Care Hospital. Journal of Patient Safety, 6(1), 48-51.D’Arcy, Y. (2011). Compact Clinical Guide to Acute Pain Management An Evidence-Based Approach for Nurses. New York, NY: Springer.Goodman, G. R. (2003, April-June). Outcomes Measurement in Pain Management Issues of Disease Complexity and Uncertain Outcomes. Journal of Nursing Care Quality, 18(2), 105-111.Layzell, M. (2008, April 10). Current interventions and approaches to postoperative pain management. British Journal of Nursing, 17(7), 414-419.Leegaard, M., Watt-Watson, J., McGillion, M., Costello, J., Elgie-Watson, J., & Partridge, K. (2011, July/August). Nurses’ Educational Needs for Pain Management of Post-Cardiac Surgery Patients A Qualitative Study. Journal of Cardiovascular Nursing, 26(4), 312-320.McCreaddie, M., Lyons, I., Watt, D., Ewing, E., Croft, J., Smith, M., & Tocher, J. (2010). Routines and rituals: a grounded theory of the pain management of drug users in acute care settings. Journal of Clinical Nursing, 19(), 2730-2740.Megens, J. H., Van Der Werff, D. B., & Knape, J. T. (2008, July). Quality improvement: implementation of a pain management policy in a university pediatric hospital. Pediatric Anesthesia, 18(7), 620-627.Mularski, R. A., White-Chu, F., Overbay, D., Miller, L., Asch, S. M., & Ganzini, L. (2006, June). Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management. Journal of General and Internal Medicine, 21(6), 607-612.Napier, D. E., & Bass, S. S. (2007, November/December). Postoperative Benefits of Intrathecal Injection for Patients Undergoing Total Knee Arthroplasty. Orthopaedic Nursing, 26(6), 374-378.Reimer-Kent, J. (2004, October). Improving Post-oprative Pain Management by Focusing on Prevention. Nursing BC, 20-24.Sagar, P. L. (2012). Transcultural Nursing Theory and Models. New York, NY: Springer .Vega-Stromberg, T., Holmes, S. B., Gorski, L. A., & Johnson, B. P. (2002, October). Road to Excellence in Pain Management: Research, Outcomes and Direction (ROAD). Journal of Nursing Care Quality, 17(1), 15-26.Woodward, D. (2005, July-September). Developing a Pain Management Program Through Continuous Improvement Strategies. Journal of Nursing Care Quality, 20(3), 261-267. ................
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