Pain Management Outcomes: Issues For Advanced Practice Nurses

The common complaint of unresolved pain still beleaguers caregivers. This article summarizes some of the factors in poor pain management, including knowledge/education deficiencies, lack of assessment and documentation; inappropriate drug choice, route, and scheduling; and failure to use appropriate non-pharmacological adjuncts. Best practice for general pain management is presented, including web-sites for clinical guidelines. Research-based approaches to management of acute pain have particular relevancy for advanced practice nurses in all settings. This article describes pragmatic tools such as national guidelines and educational videotapes in English and Spanish. The Pain Management Report Card, comparing desired target versus actual findings and a new tool for Formative Evaluation present two methods for determining effectiveness of pain management. The Pain Management Index (PMI) is explained as a way to quantify how well pain is managed with pharmacological intervention. Caregiver interactions with patients are a major factor in patient responses to pain management, and instructions for change are discussed. A patient was admitted to the emergency room, reporting that she had suffered a severe fall. It was obvious that she was in pain according to the Emergency Medical Technician notes, "the fracture was open and bone was showing." The nurse then conducted the standard trauma assessment, and then approached the Emergency Department physician for an order for pain. The physician inquired, "Has she had an x-ray? I do not want her to have anything for pain until we confirm that she indeed has a fracture." After the x-ray confirmed the fracture, the nurse again approached the physician for a pain medication order. At that time, he ordered Demerol 50 mg. and Phenergan 25 mg. intramuscularly (IM). The nurse suggested the intravenous route (IV); the physician said "No, the IM route would last longer". Unfortunately, this is an example of poor pain management that occurs everyday in clinical practice. In spite of the unparalleled progress in health care in the past two decades, clinicians have not been able to maintain consistent outcomes for the common complaint of pain. Advanced practice nurses (APNs) are on the front lines of care and thus in a position to assess and intervene to manage pain more effectively. Moreover, APNs need to be change agents for how pain is managed by the entire team. Influences on the health care environment are bringing renewed interest to correcting this problem, including new pain standards required in 2001 by the Joint Commission on Accreditation of Healthcare Organization which are described at this web-site: http://www.jcaho.org/standard/pm_frm.html1 Pain Management Outcomes: Issues For Advanced Practice Nurses 2 of 8 The purpose of this article is to discuss some of the factors involved in mismanagement of pain and to discuss effective tools and best practices for pain management. This topic is important because inadequate pain control results in unnecessary pain and suffering. Furthermore, mismanagement of pain has physiological, psychological, and financial consequences. Ferrell cited slowed healing, higher complication rates, anxiety, sleep disturbance and lowered quality of life as results of poorly managed pain.2 Unscheduled readmissions for pain control, delayed return to work, and longer periods of poor role function/performance compound the problem for a substantial economic impact.3 A patient was admitted to the emergency room, reporting that she had suffered a severe fall. It was obvious that she was in pain according to the Emergency Medical Technician notes, “the fracture was open and bone was showing.” The nurse then conducted the standard trauma assessment, and then approached the Emergency Department physician for an order for pain. The physician inquired, “Has she had an xray? I do not want her to have anything for pain until we confirm that she indeed has a fracture.” After the x-ray confirmed the fracture, the nurse again approached the physician for a pain medication order. At that time, he ordered Demerol 50 mg. and Phenergan 25 mg. intramuscularly (IM). The nurse suggested the intravenous route (IV); the physician said “No, the IM route would last longer”. Unfortunately, this is an example of poor pain management that occurs everyday in clinical practice. In spite of the unparalleled progress in health care in the past two decades, clinicians have not been able to maintain consistent outcomes for the common complaint of pain. Advanced practice nurses (APNs) are on the front lines of care and thus in a position to assess and intervene to manage pain more effectively. Moreover, APNs need to be change agents for how pain is managed by the entire team. Influences on the health care environment are bringing renewed interest to correcting this problem, including new pain standards required in 2001 by the Joint Commission on Accreditation of Healthcare Organization which are described at this web-site: http://www.jcaho.org/standard/pm_frm.html1 The purpose of this article is to discuss some of the factors involved in mismanagement of pain and to discuss effective tools and best practices for pain management. This topic is important because inadequate pain control results in unnecessary pain and suffering. Furthermore, mismanagement of pain has physiological, psychological, and financial consequences. Ferrell cited slowed healing, higher complication rates, anxiety, sleep disturbance and lowered quality of life as results of poorly managed pain.2 Unscheduled readmissions for pain control, delayed return to work, and longer periods of poor role function/performance compound the problem for a substantial economic impact.3 FACTORS IN MISMANAGEMENT OF PAIN There are many factors involved in the mismanagement of pain, and they involve caregivers and patients/families. Some of these factors include a general undertreatment of pain in approximately one-third to one-half of all hospitalized patients.4-7 At special risk for undertreatment are ethnic minorities4,8,9 and the elderly.5,6,10 Recent work has demonstrated that gender variations are important in pain management, with women being at risk for mismanagement.11,12 The lack of consistent and accurate documentation of assessment of the pain experience by caregivers is also problematic.13 Other problems revolve around using p.r.n. (given as needed) rather than scheduled analgesics when pain is to be expected, e.g., the first 3648 hours after surgery.15 Moreover, the type of analgesic may not be appropriate, e.g. Demerol usage is problematic because of dosage and duration.16 The continued use of intramuscular route of administration rather than the recommended oral or intravenous routes is another frequent area of mismanagement.6,16 Non-pharmacological adjuncts such as massage and relaxation, are not fully utilized in pain management, even though their effectiveness has been documented.5,6,13,17 The patient and family factors in ineffective pain management start with misunderstandings and lack of knowledge about expectations for pain relief.14,16,18 Moreover, patients/families may judge pain on the basis of false beliefs or myths.5,6,19,20 To further complicate the picture, patients may indicate satisfaction with pain management by nurses and physicians, yet still be in pain or report high intensity of pain.5,6,21,22,23 Given the interaction of all these factors, what guidance is available to assist the Pain Management Outcomes: Issues For Advanced Practice Nurses 3 of 8 APN and other caregivers? BEST PRACTICE AND TOOLS FOR PAIN MANAGEMENT Best practice for pain management includes the use of clinical guidelines, assessment tools, report cards, and Pain Management Index (PMI) scoring. Two additional significant factors in managing pain are the patient-nurse interaction and education for the patient/family throughout the treatment period.