CHAPTER 11 PAIN AND COMFORT MANAGEMENT A. General Pain Management Principles A.1 Pain Management – Assessment A.2 Pain Management – Interventions A.3 Pain Management – PCA A.4 Pain Management – Epidural Analgesia A.5 Complex Regional Pain Syndrome A.6 Equianalgesic Dosing

Linda Wilson, PhD, RN, CPAN, CAPA, BC, CNE H. Lynn Kane, MSN, RN, MBA, CCRN H. Marie Barmore Wiegert, BSN, MAN, RN, CPAN, CAPA Linda J. Webb, MSN, RN, CPAN

B. Advanced Comfort Management Katherine Kolcaba, PhD, RN, BC

C. Pediatric Pain Management Dolly Ireland, MSN, RN, CAPA, CPN

D. Geriatric Pain Management Jane Coyle, MS, RN, CNA, CNOR, CPAN

E. Interventional Pain Therapies Linda Wilson, PhD, RN, CPAN, CAPA, BC, CNE H. Lynn Kane, MSN, RN, MBA, CCRN H. Marie Barmore Wiegert, BSN, MAN, RN, CPAN, CAPA Linda J. Webb, MSN, RN, CPAN

CHAPTER 11 A.1 PAIN MANAGEMENT: ASSESSMENT Purpose: The orientee will be able to complete a pain assessment using interview techniques and physical exam. Competency Statement: Perform a pain assessment. Criteria: 1. Assess location of pain. Pain will be assessed on the initial history taking interview and at regular intervals. The nurse should examine the site of the pain and assess physical findings. Assessment will at least include: • Intensity of pain • Quality of pain (location, description, duration, frequency, and characteristics) • Response following treatment interventions including effectiveness and any adverse side effects Subjective data of who, what, where, why and when provides the first clues of pain assessment. Objective data of observation of facial grimace, frowning, teeth clenching, crying, moaning, are noted by the healthcare practitioner. Physiologic changes such as rising heart rate, increasing BP, increasing respiratory rate, are the physiologic signs that support the patient’s subjective pain response. Physiological signs of pain may include: • Dilatation of the pupils and/or wide opening of the eyelids • Changes in blood pressure and heart rate • Increased respiration rate and/or depth • Piloerection • Change in skin and body temperature • Increased muscle tone • Sweating 2. Assess pain intensity using a pain scale. Numerous reliable and valid age-appropriate, condition-appropriate and language-appropriate pain scales are available for use. The tools must be easy to use, allow for fast assessment, allow for easy documentation and be multicultural and multilingual. Some of these assessment tools include: • Poker chip • Oucher scale • Simple verbal descriptive scale • Visual Analog Scale • Numeric Rating Scale • Wong Baker faces pain rating scale • Behavioral rating scale • Body Diagram • Daily Diary • FLACC Scale These scales evaluate the patient’s pain level with established criteria, eliminate bias, standardize care, increase patient comfort and satisfaction, and develop and implement a dependable pain management program. Pain scales that are age and cognitively appropriate should be used to identify pain intensity. Measurement and evaluation of pain varies depending on the scale utilized and the interpretation of scale criteria by the patient.

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CHAPTER 11 3. Obtain a description of the quality of pain. Quality of pain can be described according to the character, frequency and duration the patient is experiencing the pain. The nurse should ask the patient or parent of the pediatric patients to describe, in their own words, what pain feels like. The patient may describe the pain achy, pulling, throbbing, burning, sharp, crampy, hurting, dull, prickling, etc. The child may use words such as ‘boo-boo’ or ‘owie.’ Pain types include somatic, visceral and neuropathic pain. Assessing when the pain started, variations according to the time of day or activity, related patterns and duration will assist the healthcare provider in assessing the quality of the patient’s pain. 4. Seek a description of the onset and duration of the pain. The individual’s self report is the most reliable indicator of the existence and intensity of pain. Asking the following questions will assist the nurse in assessing the patient’s pain: • Where is the pain? • How much pain does one have in an average day? • What time of the day is the pain the worst? • What gets the pain started and does the pain stay or come and go? • What do you think causes the pain? 5. Obtain information on the pain aggravating and alleviating factors. By asking the questions of which pharmacological and non-pharmacological methods help, one can assess any aggravating and alleviating factors. Identify contributing factors to pain level, e.g. anxiety, fear, family problems, etc. [These previous sentences have nothing to do with the aggravating/alleviating factors] • What makes your pain worse? • What makes your pain better? • What other things have you tried to make the pain better that worked and did not work? 6. Seek information on the impact of pain on activities of daily living. The impact of pain such as daily function, sleep, appetite, emotion, concentration and other factors should be assessed. Assessing the effects may indicate that pain creates fear, suffering, and hopelessness. Patients should have established an individual pain goal and expectations should be established in terms of achieving the pain goal. • Does the pain cause problems with your activities of daily living? • How upsetting is the pain? 7. Describe pain behavior indicators. Pain behavior indicators may include crying, moaning, groaning, screaming, whimpering, facial expressions, reluctance to move or be moved, being quiet and withdrawn, anxious, restless, desperate, highly motivated to get help, using the PCA frequently or frequently requesting pain medication. The patient may exhibit few or no behavioral signs of pain. A disadvantage of relying on the behavioral indicators of pain is that the patient’s self-report of pain they are experiencing may be dismissed. 8. Assess causes for multiple causes of pain. Patients may have pre-existing conditions which affect their comfort level, such as chronic back/neck pain. Bladder distention can be extremely uncomfortable. Postoperative complications such as myocardial or pulmonary ischemia, hemorrhage, or rupture of viscus may cause pain. The nausea and vomiting cycle is also affected by pain.

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CHAPTER 11 9. Perform re-assessment to examine the response to medication intervention for pain. Asking the following questions allows the healthcare provider to assess the patient’s response to medications: • What analgesia has the patient received? • How effective was it in relieving their pain? • How is it affecting their vital signs? • Is the patients level of alertness affected by the analgesia and if so, to what extent? • Were there any changes in the dosage of medication? • Was any additional medication needed for breakthrough pain? Document the level of pain (using a consistent pain scale tool) which the patient has identified as acceptable. 10. Communicate and document all pertinent information per facility/unit specific policy/protocol.

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CHAPTER 11 A.2 PAIN MANAGEMENT: INTERVENTIONS Purpose: The perianesthesia nurse needs a body of knowledge to establish a foundation from which the pain experience can be managed. Pain management involves applying pharmacologic and nonpharmacologic techniques for pain. The orientee will be able to safely apply pharmacologic and nonpharmacologic interventions for pain management. Competency Statement: Provide care for the patient experiencing pain. Criteria: 1. Define pain-related terms. Acute Pain: Pain of short duration, the cause of which may or may not be known. Intensity ranges from mild to severe; duration is usually thought to be less than six months. Addiction: A pattern of compulsive drug use characterized by a continued craving for an opioid and the need to use the opioid for effects other than pain relief. Analgesia: Absence of normal sense of pain. Breakthrough Pain: Pain that increases above the pain addressed by the ongoing analgesics. Chronic pain: Prolonged pain, usually lasting more than six months; cause may not be known; has not responded to treatment and or pain does not subside after injury heals; intensity may range from mild to severe. Discomfort: The condition of being uncomfortable in body or mind; mild distress (comfort means to soothe in time of grief or fear, to console, to ease physically, to relieve as in pain; a state of well being). Drug tolerance: After repeated administration of a narcotic, a given dosage begins to lose its effectiveness (decreased duration of relief, then decreased level of relief); need for a higher dose of drug to maintain an effect. Neuropathic pain: arises from the nervous system itself, either the peripheral nerves or the central nervous system. Noxious stimulus: Stimulus that is damaging or potentially damaging to normal tissue. Nociceptor: Receptor preferentially sensitive to a noxious stimulus or to a stimulus that would be noxious if prolonged. Pain threshold: Point at which increasing intensity of stimuli is felt as painful; perception of pain sensation. Pain tolerance: That duration of intensity which a person is willing to endure (involuntary behavior based on physiological changes). Physical dependence: After repeated administration of a narcotic, withdrawal symptoms occur when it is not taken (involuntary behavior, based on physiological changes). Somatic pain: often known as musculo-skeletal pain, usually sharp and well localized. Suffering: To feel pain or distress; to sustain harm; injury pain or death; to tolerate or endure pain, evil, injury or death. Visceral pain: involves internal organs of the body, often poorly localized and vague crampy/ache.

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CHAPTER 11 2. Describe non-pharmacologic interventions for pain. Examples of comfort measures are: • positioning/repositioning • elevating affected limbs • applying ice as ordered • covering the incision with a pillow and holding during coughing • providing music therapy or imagery • providing distraction techniques such as progressive muscle relaxation or massage • providing a non-stimulating environment • encouraging deep breathing • using of pacifiers or bottles containing glucose water • being held in a rocker • applying warm blankets • burping infants 3. Describe the rationale for administration of pharmacologic agents for pain. Pain control can be achieved by trying to target appropriate medications for the underlying problem, and trying to minimize pain with different non-narcotic as well as narcotic medications. Non-narcotic options include acetaminophen, non-steroidal anti-inflammatory medications, steroids, and newer anesthetics. For patients who have severe pain the intravenous route of administering opioids provides a fast onset and rapid reduction of pain. Bolus doses as well as continuous dosing via the Patient Control Analgesia (PCA) method can be given to patients to decrease their pain. A steady state is best maintained with a continuous infusion compared with the bolus method. Almost all opioids can be administered via the intravenous route. 4. List potential side effects of pharmacologic interventions for pain management. Opioid administration is associated with the following potential complications: • Respiratory depression • Hypotension • Sedation and mental clouding • Nausea • Pruritus • Constipation • Dry mouth • Urinary retention • Altered cognitive function • Sleep disturbances 5. List precautions and monitoring required during pharmacologic interventions for pain management. Nurses must have knowledge of all pharmacologic implications of the medications along with baseline information about the patient. Baseline information needed includes: • Any known allergies • Renal, bowel, bladder and liver function • Previous opioid use • Health habits including drug and alcohol usage • Baseline mental status • Any other medications used

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CHAPTER 11 Documentation of the patient’s pain intensity, blood pressure, pulse, respirations, side effects and evaluation of response to intervention is essential. The patient’s pain should be re-evaluated thirty minutes after an intervention for pain management has been initiated. 6. State the rationale for discontinuing pharmacologic interventions for pain management. • When pain is relieved • Adverse effects such as the following have occurred: o respiratory depression less than 8 breaths per minute o blood pressure change of 30% or more from baseline o sedation scale greater than 3 (Ramsey Sedation Scale) o oxygen saturation less than 90% o signs of an allergic reaction to the opioid 7. Communicate and document all pertinent information per facility/unit specific policy/protocol.

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CHAPTER 11 A.3 PAIN MANAGEMENT: PATIENT CONTROLLED ANALGESIA (PCA) Purpose: One aspect of pain management involves the use of patient controlled analgesia (PCA). The orientee will be able to safely set up and administer medication via the PCA pump. Competency Statement: Provide care for the patient using patient controlled analgesia (PCA). Criteria: 1. State the rationale for patient administration of PCA. • Allows the patient to titrate analgesics to their needs, bypassing the unavoidable delays that occur when analgesics are provided on request • Provides for intermittent and steady-state analgesia that is patient activated • Blood levels of analgesic medications can be maintained within an effective range • The patient takes an active role in managing their own care • Usage of PCAs in pain management avoids the peaks and valleys of analgesia, sedation and pain for patients 2. State desired outcomes of PCA therapy. • Adequate pain relief in a safe manner • The patient has control in pain relief • Keeps the serum opioid level within the therapeutic range to prevent the peaks and valleys of analgesia • The patient can breathe deeply and ambulate early • Patients are more comfortable, enhancing patient satisfaction 3. Identify who can order the administration of PCA. The RN, acting as the patient advocate, consults with the physician regarding need for PCA and parameters for use. The physician must order the administration of the PCA. 4. Identify opioids that can be administered using a PCA. Most frequently used: • Morphine • Hydromorphone • Fentanyl 5. Identify potential adverse effects of PCA administration. • Respiratory depression • Hypotension • Pruritis • Urinary retention • Constipation • Nausea

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CHAPTER 11 6. State common examples for drug concentration, incremental and basal ranges, and lockout intervals for opioids used during PCA administration. The use of an equianalgesic chart is recommended to guide one to the determination of the starting dose of a new medication. The most frequently used opioids today for PCAs are:

Opioid Morphine

Drug Concentration

Incremental(IR) Basal range (BR) interval

Lockout

1 mg/mL

IR: 0.5 – 3 mg. BR: 0 – 3 mg

6-10 minutes

Hydromorphone

0.2 mg/mL

IR: 0.1- 0.6 mg BR:0 – 0.4 mg

6–10 minutes

Fentanyl

25 mcg/kg

IR: 0 – 100 mcg BR: 0 – 50 mcg

6 – 10 minutes

PEDIATRIC IV PCA DOSING Opioid

PCA DOSE

BASAL RATE

LOCKOUT

Morphine

10-30 mcg/kg/dose

0-30 mcg/kg/hr

6 – 10 minutes

Fentanyl

0.5 – 1 mcg/kg/dose

0 – 1 mcg/kg/hr.

6 – 10 minutes

Hydromorphone

3 – 5 mcg/kg/dose

0 – 5 mcg/kg/hr

6 – 10 minutes

McCaffery M, Pasero C: Pain: Clinical manual p. 255. Mosby, Inc. 1999

7. List steps in initiating PCA administration. • Select patient: Does patient understand the relationship between pain pushing a button and pain relief? Is the patient physically able to use the equipment? • Obtain the appropriate pump, tubing and labels • Obtain the correct medication, noting if patient has any allergies • Instruct the patient and family on rationale for PCA use and identify any side effects • Wash hands and insure patient has an appropriate IV site and orders for maintenance fluids • Connect PCA and tubing 8. Demonstrate proper PCA pump set up and implementation. See manufacturer’s instructions for setting up, loading and programming pump. Follow institutional policies/protocols. 9. State the process for timing and verification of PCA. Two RNs should double check dosage orders and pump settings upon initiation of infusion (as per facility policy). When accepting patients from another unit with medications being infused and when parameter changes including dosages, concentration or rate are made, two RNs should check together these changes (as per facility policy).

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CHAPTER 11 10. List monitoring parameters for a patient receiving PCA. The following should be assessed prior to implementation of PCA and as facility policies and procedures recommend: • Blood pressure • Pulse • Respiration • Pain scale • Sedation scale • Oxygen saturation 11. State parameters for changes in patient status that warrant notification of the physician. Parameters may include the following or as per individual facility policies and procedures: • BP less than or greater than 30% baseline • Respirations less than 8 breaths per minute • Ineffective analgesia • Reduced level of responsiveness 12. State emergency treatment measures if there are severe complications from the administration of the PCA. • Stop pump • Arouse patient and encourage respirations. If respirations are less than 8/min, follow facility policy which includes, but is not limited to, applying oxygen 4-6 L/min by nasal cannula or supporting ventilations with a bag-valve-mask device • Administer naloxone 0.1 – 0.2 mg. IV initially (as per physician orders) • Notify physician • Continue to monitor patient 13. Communicate and document all pertinent information per facility/unit specific policy/protocol.

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CHAPTER 11 A.4 PAIN MANAGEMENT: EPIDURAL ANALGESIA Purpose: One aspect of pain treatment involves the administration of analgesics/local anesthetics via epidural route. The orientee will be able to safely setup and administer these medications. Competency Statement: Provide care for the patient receiving epidural analgesia via continuous infusion. Criteria: 1. State the rationale for epidural opioid administration for pain management. The use of epidural opioids allows for high local concentration of drug at the desired spinal cord receptors with minimal amount of opioid entering the systemic circulation where the opioid can cause undesired side effects. The epidural route allows for selective analgesia depending on the location of the catheter. 2. Identify the location of the epidural space. The epidural space is a potential space that lies between a tough ligament and the dura mater. The epidural space contains a venous network of veins that are large bore and thin walled. The epidural space also contains fat and nerve extensions from the spinal cord. 3. State the mechanism of action for opioids and anesthetics administered into the epidural space. The epidural opioid binds at the opioid receptor site at the substantia gelatinosa in the dorsal horn. There is a vascular uptake of the opioid from the epidural space and the drug diffuses across the dura into the cerebrospinal fluid surrounding the spinal cord. The medication binds with the opiate receptors in the dorsal horn of the spinal cord and modifies the transmission of pain impulses to the brain. Local anesthetic agents block nerve transmission. Unmyelinated nerves and smaller nerves are easier to block, so pain and temperature fibers are usually blocked before motor nerves. Opioids have a synergistic effect with local anesthetics so lowering the drug doses is recommended for both the opioid and the local anesthetic agents. 4. State desired outcomes of epidural analgesia. • Provides intense, prolonged analgesia limiting the total amount of systemic opioids and decreasing the potential for opioid-related side effects • Provides less sedation • Earlier mobilization decreases incidence of DVTs • Patients are able to deep breathe, cough and clear secretions • Decreases in neuroendocrine/metabolic stress responses because regional anesthesia attenuates the cortisol and catecholamine response to surgery (decreases cardiac workload and myocardial oxygen consumption) • Decreases costs secondary to shorter hospital length of stay 5. State contraindications to epidural analgesia. Contraindications to use of epidural opioid analgesia would include: • Patient refusal • Untreated sepsis which could involve the site of injection • Shock • Hypovolemia • Coagulopathies • Skin lesions at the site of injection • History of adverse reactions to opioid medications • Central sleep apnea • Lack of familiarity of technique by patient caretakers 320

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CHAPTER 11 6. List potential complications associated with epidural analgesia. • Total or high spinal blockade • Intravenous injection • Dural puncture resulting in a dural puncture headache • Bleeding resulting in an epidural hematoma • Catheter problems including migration of the epidural catheter, breakage of the catheter and infection 7. State medications used in epidural analgesia. • Fentanyl • Sufentanil • Morphine • Hydromorphone • Ropivacaine • Bupivacaine 8. State characteristics of drugs administered during epidural analgesia. The ability of opioids to diffuse through the dura depends on the medication’s molecular size and lipid solubility. Drugs that are lipid soluble such as Fentanyl are less likely to cause delayed respiratory depression. Drugs that are more water soluble (Morphine) have a greater potential to spread rostrally in the CSF to those brain centers that control respiration and vomiting. 9. List potential adverse effects of medications administered during epidural analgesia. • Respiratory depression – peak time occurs approximately one hour after epidural morphine administration when the blood levels are highest and 6-24 hours after administration when the opioid in the CSF reaches the respiratory centers in the brain • Pruritus • Nausea • Urinary retention • Mild to moderate sedation • Hypotension 10. Describe symptoms of severe complications from epidural analgesia when the epidural is not in the correct location. Intravenous administration of epidural medications will result in: • Dizziness • Tinnitus • Circumoral tingling • Blurred vision • Tremors • Seizures • Cardiovascular collapse Subarachnoid or subdural administration will result in a profound degree of sensory and motor blockade developing within 5-15 minutes of injection. Blockade of the upper cervical segments will result in diaphragmatic paralysis leading to respiratory arrest. Total nerve paralysis occurs if the medication reaches the cranium will result in unconsciousness, apnea, severe hypotension and pupil dilatation. 11. List steps in initiating epidural analgesia. • Gather equipment to include pump and tubing without injection ports • Obtain preservative-free medications

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CHAPTER 11 • • • • • • • • • •

Verify correct patient, note allergies Instruct patient and family on rationale of epidural analgesia use Instruct patient on the use of Patient-controlled epidural analgesia (PCEA) if indicated Instruct patient and family about side effects of procedure and medications Remind patients to report any tingling and/or numbness to fingers or mouth immediately Instruct patient to ask for assistance when getting up for the first time (prevent catheter dislodgment and have help for muscle weakness) Have naloxone readily available at the bedside (or as per hospital policy) The RN may infuse medications only if the catheter has been previously used (as per hospital policy or state nurse practice act) Infuse epidural analgesia as per physician’s orders Two RNs verify correct medication, dose and infusion rate (as per hospital policy)

12. List monitoring parameters after epidural analgesia. Bolusing medication protocols should be according to each facility’s policies and procedures. Monitoring patients with epidural drug administration should include: • Respiratory rate • Sedation scale • Pain scale • Sensory level/motor strength per facility policy • Pulse oximetry may be ordered to verify patient is adequately oxygenating 13. Describe the procedure to assess a patient’s dermatome level. • Dermatome is the segmental distribution of the spinal nerves. Dermatome levels are labeled according to the specific nerve roots exit point on the spinal cord and are sensory levels on the skin • The level of the sympathetic block is higher than the sensory block which is higher than the motor block Nurses test dermatomes to establish the level of block by using sharp, dull, or cold test items to identify the following level in the order of loss of function: • Autonomic or sympathetic functions (vasomotor, bladder control) • Sense of temperature • Pain • Touch • Movement • Proprioception (sense of body location) The last blocked (proprioception) is the first to recover, then movement, touch, pain, temperature and autonomic/sympathetic functions. 14. State parameters for complications that indicate notification of the physician. These parameters are defined by the physician and the facility and may include: • Respiratory rate less than 8 breaths per minute • BP less than or greater than 30% baseline which indicates hypotension or hypertension • Dermatone level above T-4, or unequal block • Leaking epidural catheter site • Sedation scale variance from norm if scales used in facility • Contamination of connector site • Inadequate analgesia

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CHAPTER 11 15. State emergency treatment measures if there are severe complications from the administration of the epidural analgesia. • Stop pump • Initiate emergency measures as per hospital policy • Notify the responsible physician • Arouse patient and encourage respirations • Apply oxygen and support ventilations if needed • Administer rescue medications (as per physician orders) including naloxone, intravenous fluids bolus, and ephedrine/phenylepherine 16. Communicate and document all pertinent information per facility/unit specific policy/protocol.

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CHAPTER 11 Bibliography American Society of PeriAnesthesia Nurses. Resource 7: The Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques (Epidural, Intrathecal, Intrapleural, or Peripheral Nerve Catheters). In: 2008-2010 Standards of Perianesthesia Nurisng Practice. Cherry Hill: NJ; 2008: 76-77. Burden N, Quinn D, O’Brien D, Gregory-Dawes B. Ambulatory Surgical Nursing. 2nd ed. Philadelphia, PA: WB Saunders; 2000. CDC. Many Americans are still living with pain. RN. 2007; Jan 70(1): 14. DeFazio Quinn DM, Schick L. Perianesthesia Nursing Core Curriculum - Preoperative, Phase I and Phase II PACU Nursing. Philadelphia, PA: WB Saunders; 2004. Kastanias P, Snaith KE, Robinson S. Patient-controlled oral analgesia: a low-tech solution in a high-tech world. Pain Management Nursing. Sep 2006; 7(3): 126-32. Loeser JD. Bonica’s Management of Pain. 3rd ed. Philadelphia, PA: Lippincott, Williams, & Wilkins; 2001. Marco CA, Marco AP, Plewa MC, Buderer N, Bowles J, Lee J. The verbal numeric pain scale: effects of patient education on self-reports of pain. Academic Emergency Medicine. Aug 2006; 13(8): 853-9. McCaffery M, Pasero C. Pain Clinical Manual. 2nd ed. St. Louis, MO: Mosby; 1999. Miaskaoski MM. Patient controlled analgesia (PCA). Pain Management Nursing. Dec 2006; 7(4): 134-47. Schoenwald A, Clark CR. Acute pain in surgical patients. Contemporary Nurse. Jul 2006; 22(1): 97-108. Sloman R, Wruble AW, Rosen G, Rom M. Determination of clinically meaningful levels of pain reduction in patients experiencing acute postoperative pain. Pain Management Nursing. Dec 2006; 7(4): 153-8. St. Marie B. American Society of Pain Management Nurses: Core Curriculum for Pain Management Nursing. Philadelphia, PA: WB Saunders; 2002. Sugden A, Cox F. How to assess epidural blockade. Nursing Times. Mar 14-20, 2006; 102(11): 26-7. Weetman C, Allison W. Use of epidural analgesia in post-operative pain management. Nursing Standard. Jul 12-18, 2006; 20(44): 54-64, 66, 68.

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CHAPTER 11

QUESTIONS: PAIN MANAGEMENT COMPETENCY 1. Potential adverse effects of administration of intravenous opioids include all of the following except: a. respiratory depression / apnea b. hypertension c. loss of consciousness d. loss of protective reflexes 2. The perianesthesia nurse should discontinue the use of intravenous opioids when there is / are: a. respiratory rate of 10 breaths per minute b. drowsiness c. B/P 90/56 d. signs of allergic reaction to the drug 3. All of the following are part of emergency treatment for the patient receiving PCA analgesia except: a. continue pump until a complete physical assessment can be made b. arouse patient / encourage respirations c. administer oxygen or support ventilation d. titrate naloxone IV until desired effects are achieved 4. When caring for a patient who has just had a lumbar epidural catheter placed, all of the following are true except: a. the patient may experience pruritus due to the opioid b. cold temperature fibers are blocked first and an initial sensory blockage assessment can be made using an alcohol wipe c. continuous administration of the medication is appropriate with a dermatome level of T3 d. a pain scale should be used to assess patient response to medication 5. A potential complication associated with epidural catheter usage in the perianesthesia patient includes which of the following? a. sudden onset of distal extremity weakness b. loss of bladder and bowel control c. segmental block d. spinal headache e. all of the above 6. All of the following are considered support measures for treatment during an epidural emergency except: a. assessment of level of sympathetic blockade b. administration of intravenous fluid bolus c. administration of drugs such as naloxone or ephedrine d. supporting ventilations with a bag-valve-mask

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CHAPTER 11

KEY: PAIN MANAGEMENT COMPETENCY QUESTIONS 1. Potential adverse effects of administration of intravenous opioids include all of the following except: a. respiratory depression / apnea b. hypertension c. loss of consciousness d. loss of protective reflexes 2. The perianesthesia nurse should discontinue the use of intravenous opioids when there is / are: a. respiratory rate of 10 breaths per minute b. drowsiness c. B/P 90/56 d. signs of allergic reaction to the drug 3. All of the following are part of emergency treatment for the patient receiving PCA analgesia except: a. continue pump until a complete physical assessment can be made b. arouse patient / encourage respirations c. administer oxygen or support ventilation d. titrate naloxone IV until desired effects are achieved 4. When caring for a patient who has just had a lumbar epidural catheter placed, all of the following are true except: a. the patient may experience pruritus due to the opioid b. cold temperature fibers are blocked first and an initial sensory blockage assessment can be made using an alcohol wipe c. continuous administration of the medication is appropriate with a dermatome level of T3 d. a pain scale should be used to assess patient response to medication 5. A potential complication associated with epidural catheter usage in the perianesthesia patient includes which of the following? a. sudden onset of distal extremity weakness b. loss of bladder and bowel control c. segmental block d. spinal headache e. all of the above 6. All of the following are considered support measures for treatment during an epidural emergency except: a. assessment of level of sympathetic blockade b. administration of intravenous fluid bolus c. administration of drugs such as naloxone or ephedrine d. supporting ventilations with a bag-valve-mask

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CHAPTER 11 A. 5 PAIN MANAGEMENT: COMPLEX REGIONAL PAIN SYNDROME Purpose: The orientee will be able to discuss key aspects of chronic regional pain syndrome. Competency Statement: Discuss key aspects of Complex Regional Pain Syndrome. Criteria: 1. Define Complex Regional Pain Syndrome. Complex Regional Pain Syndrome (CRPS) is described as either Type I: Reflex Sympathetic Dystrophy or Type II: Causalgia. It is also regarded as being a form of neuropathic pain. 2. Discuss the causes/risk factors of Complex Regional Pain Syndrome. Officially no definitive risk factors have been identified that predispose individuals to developing CRPS. Possible causes of CRPS include tissue damage caused by surgery or trauma. Additionally other conditions associated with acute pain can initiate a CRPS Type I. Patients who have suffered a nerve injury in an acute pain setting should be assessed for CRPS Type II development. With surgery and trauma, CRPS Type II may develop quite soon after damage to the nervous system. Possible risk factors for the development of CRPS include extensive immobilization, disuse, cigarette smoking, genetic predisposition and psychological factors. 3. Review the pathophysiology of Complex Regional Pain Syndrome. The definitive pathophysiology of CRPS is not known. Aberrant healing response, exaggerated inflammatory response, protective disuse, dysfunctional sympathetic nervous systems, myofascial dysfunction and central nervous system abnormalities are suspect. These postulations are based on animal research, clinical experience, and speculation. After tissue injury, the body responds to prevent complications and promote healing. However, abnormal healing responses, including exaggerated and persistent guarding and inflammation, can lead to CRPS. Following an injury, the body naturally guards and protects the injured body part to prevent re-injury and optimize healing. During normal healing, the body gradually increases the use of the injured area, which then leads to full recovery. In the CRPS patient, the body continues to guard and protect the injured painful limb either directly because of specific medical treatment or because of the patient’s disuse for fear of pain or because of neurologic neglect-like syndrome. Classic teaching included that CRPS was caused by hyperactivity of the sympathetic nervous system. A new hypothesis is that after a limb is injured, endogenous opioid modulation normally increases in regional sympathetic ganglia to prevent excessive autonomic activity in the limb. It is now believed that in patients with CRPS, this modulation does not occur resulting in autonomic features of opioid withdrawal in the affected limb perpetuating the disuse of the limb. Studies have reported myofascial dysfunction in CRPS patients which can be primary or secondary. If present, patient improvement of pain and symptoms occurs when myofascial trigger points resolve. 4. Describe the symptoms of Complex Regional Pain Syndrome (CRPS). The main symptom of complex regional pain syndrome is intense pain, often described as “burning.” Additional signs and symptoms include: • Skin sensitivity • Changes in skin temperature, color and texture. At times skin may be sweaty; at other times it may be cold • Skin color can range from white and mottled to red or blue. Skin may become tender, thin or shiny in ASPAN 2009 Edition

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• • • • • • • • • • •

the affected area Changes in hair and nail growth Joint stiffness, swelling and damage Muscle spasms, weakness and loss (atrophy) Motor dysfunction, including decreased ability to move the affected part Spreading and recurrent pain Pain triggers Edema Guarding and neglect Myofascial pain Trophic changes Psychological factors

The location of symptoms varies, and patients with chronic regional pain syndrome do not all present with the same symptoms or suffer to the same degree from each symptom. 5. Discuss the treatment of Complex Regional Pain Syndrome. There have been many treatments/plans of care for CRPS patients described in the literature, although the reality is that no cure exists. Some of the documented treatments for CRPS include the following: multidisciplinary treatment, validation of symptoms, education, setting treatment goals, and physiotherapy. Psychological and medical therapies are also part of the treatment plan. Psychological therapies can include group therapy, cognitive behavioral psychotherapy, and group psychotherapy. Other symptom-specific psychological therapies include biofeedback and hypnosis. Medical therapies for CRPS patients can include intravenous sympathetic regional blocks, sympathetic blockades, selective sympathetic ganglion nerve blocks, intravenous Phentolamine infusions, epidural clonidine, and placebo blocks. Literature also recommends a variety of medications used to treat CRPS patients including opiates, antidepressants, corticosteroids, beta blockers, gabapentin, oral sympatholytic agents, clonidine, calcitonin, calcium channel blockers, and local anesthetics. There is also documentation of the use of implantable devices for treatment of CRPS patients including spinal cord stimulators and intrathecal opioid therapy. 6. Discuss the prognosis of Complex Regional Pain Syndrome. The prognosis for a patient with CRPS varies with each individual. Some patients can have remission of the symptoms and others can suffer debilitating pain. Research on CRPS is still needed and is ongoing.

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CHAPTER 11 References Loeser JD, Butler SH, Chapman CR, Turk DC. Bonica’s Management of Pain. Philadelphia, PA: Lippincott, Williams and Wilkins; 2001. NIH. Chronic Regional Pain Syndrome Fact Sheet. Bethesda, MD: NIH; 2003. www.mayoclinic.com/health/complex-regional-pain-syndrome/DS00265; accessed February 19, 2009.

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CHAPTER 11 A.6 PAIN MANAGEMENT: EQUIANALGESIC DOSING Purpose: The orientee will be able to discuss key points related to equianalgesic dosing. Competency Statement: Discuss key points related to equianalgesic dosing. Criteria: Review and discuss the following equianalgesic dosing charts. Equianalgesic Doses of Opioid Analgesics Parenteral Dose (mg) equivalent to 10 mg IV Morphine

DRUG

Oral Dose equivalent to 30 mg Oral Morphine

Morphine

10

30

Fentanyl

0.1

NA

Hydromorphone (Dilaudid)

1.5

7.5

Meperidine (Demerol) (not recommended)

75-100

300

Methadone

20

10

Oxycodone (Percocet, Oxycontin)

NA

30

Sustained Release Morphine (MS Contin)

NA

60

“Morphine Equivalents” is a term that is easier to understand when totaling a patient’s total narcotic usage. To calculate “Morphine Equivalents,” the following chart can be helpful: Morphine Equivalent Chart DRUG

Multiplier

Number of Morphine Equivalents

Morphine

Number of mg x 1

= total

Dilaudid

Number of mg x 6

= total

Fentanyl

Number of mcg x 0.1

= total

Meperidine

Number of mg x 0.1

= total

Total Morphine Equivalents

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CHAPTER 11 B. ADVANCED COMFORT MANAGEMENT INTRODUCTION TO COMFORT THEORY Purpose: The orientee will understand and apply the basic principles of Comfort Theory. Competency Statement: Discuss and apply the basic principles of Comfort Theory to perianesthesia nursing. Criteria: 1. Describe the unique properties of a holistic theory. • Comfort Theory is holistic. The term holistic is an adjective that describes whole or integrated systems rather than their separate parts. Therefore, a holistic theory reflects the principle that persons perceive the complexities of their environment through their senses. This happens simultaneously and their responses are instantaneous, and either inward or outward or both • Persons respond as a whole to physical, psychological, spiritual, social, cultural, and environmental stimuli. Whole persons are set within complex systems, such as social and environmental systems, which provide their context for living and experiencing. Whole persons develop knowledge about the world to form a self-concept and an understanding of their place in the scheme of things. They have memories, personalities, ethics, and feelings and bring these variables to bear on their perceptions of reality • A holistic perspective implies that at least some interventions are multifaceted and are targeted to achieve desired holistic responses. Examples of holistic interventions are hand or back massage, guided imagery, music or art therapy, etc. They are delivered with the intention to comfort and in a caring manner • A holistic perspective implies that at least some desired outcomes of nursing care are positive and reflect an integrated system of whole-person responses. An example of a holistic outcome is enhanced patient comfort, compared to a previous baseline 2. Define basic comfort terms (underlined) and list basic principles of Comfort Theory. • Holistic comfort needs arise simultaneously from four contexts of human experience: physical, psychospiritual, sociocultural, and environmental. Definitions are in the glossary. Examples of each are: o Physical: pain, homeostatic mechanisms (fluid-electrolyte balance, immune function, blood chemistries, metabolic indicators, body weight, etc.), nausea and/or vomiting, elimination, ventilation, circulation, nutrition, and any physical problem related to medical diagnoses o Psychospiritual: anxiety, panic, hopelessness, fear, feelings of being punished, doom, pessimism, loss of meaning for one’s life o Sociocultural: “no one understands me,” traditions not being followed, superstitions, unable to make decisions, no desire for autonomy, unable to understand or sign informed consent, loneliness, and language barriers o Environmental: cold, high technology, low levels of nurse staffing, hectic, confusing, noisy, bright, tension, lack of privacy, institutional barriers to family visits • Nurses assess patients’ holistic comfort needs on an individual basis. There are three types of comfort needs: Relief, Ease, and Transcendence. Nurses attend to these three types of comfort needs simultaneously and as needed. If relief from a specific comfort need cannot be achieved, nurses can intervene to help patients work through their unmet needs or overcome them. When patients are predisposed to certain discomforts, such as loneliness or constipation, nurses intervene to keep the patient at ease by addressing known risk factors. Therefore, nurses persist in addressing the holistic comfort needs of their patients. The three types of comfort are defined as: o Relief: the need to have a specific discomfort relieved o Ease: the need to remain in a state of contentment or well-being o Transcendence: the need to be strengthened, motivated, or invigorated

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• •

• •

o The technical definition of comfort is: the satisfaction of the basic human needs for relief, ease or transcendence in four contexts of experience, arising from healthcare situations that are stressful o When the four contexts of comfort are juxtaposed with the three types of comfort, a 3 X 4 celled “comfort grid” (also called taxonomic structure) is created that is useful for research1 Nurses design comfort interventions to meet holistic needs Nurses account for intervening variables when considering their plan of care and effectiveness of interventions o Intervening variables are defined as factors over which nurses or agencies have little control, but which affect the direction and success of Comfort Care plans or comfort studies o Examples of intervening variables are types or extent of social support, financial well-being, education, prognosis, addictions, personality traits, physical fitness, religiosity, etc. Nurses assess comfort level after interventions are implemented, compared to a previous baseline Enhanced comfort has a positive relationship to Health Seeking Behaviors, which can be internal, external, or a peaceful death2 o Health Seeking Behaviors (HSBs) are defined as behaviors in which patients engage consciously or subconsciously that move them toward well-being; HSBs can be internal, external, or a peaceful death2 o Examples of HSBs are: • Internal: healing, improved immune function, etc. • External: improved functional status, mobility, strength, appetite, etc. • Peaceful death: a death in which conflicts are resolved, symptoms are well-managed, advance directives are honored, and acceptance by the patient and family members allows for the patient to “let go” quietly3 • When patients are strengthened to engage in HSBs, they experience a feedback look whereby comfort is enhanced further3

• When patients engage in HSBs, Institutional Outcomes are also improved o Institutional Outcomes are defined as indicators that healthcare organizations being complete, whole, sound, upright, professional, and ethical providers of healthcare3 o Examples of Institutional Outcomes (IO) are increased patient satisfaction, shorter length of stay, fewer hospital readmissions, lower cost, more occupied beds, better “report card,” etc.3 3. Describe the relationship between comfort and pain. • The comfort grid is useful for describing the relationship between comfort and pain. Pain is located in the cell physical-relief and, when not relieved, can be a major detractor from holistic comfort. (Remember that there can be other discomforts in this cell such as nausea, vomiting, constipation, hunger for food or air, thirst, electrolyte imbalance, and other physiological problems of which the patient may or may not be aware.) Picturing this arrangement between pain and comfort, it is clear that comfort is an umbrella term under which effective pain management is a significant part. Pain management isn’t the only aspect of comfort because there are 11 other cells as well as other possible candidates for physical-relief

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CHAPTER 11 ASSESSMENT SKILLS FOR COMFORT MANAGEMENT Purpose: The orientee will complete a comfort assessment using interviewing techniques and physical assessment skills to elicit comfort history, symptomatology, previous comfort interventions and response. In order to assess deficits in holistic comfort, comfort needs (discomforts) such as feeling anxious, cold, tense or stiff from faulty positioning, etc. are considered. Competency Statement: Perform a basic comfort assessment. Criteria: 1. Assess location of discomforts (including anxiety and cold) and extent of total comfort. • The presence of discomforts will be assessed on the initial history taking interview and at regular intervals; assessment will at least include: the intensity of discomfort(s), quality of the discomforts (location, description, duration, frequency, possible causes, and characteristics); and response following previous comfort interventions including effectiveness and any adverse side effects Subjective data of who, what, where, why and when provides the first clues in discomfort(s) assessment. Objective data include observation of facial grimace, frowning, teeth clenching, crying, moaning, restlessness, agitation, fidgety movements, rubbing an area, guarding, muscle or facial tension, etc. Physiologic changes such as vital signs, support patients pain/discomfort response. Discomfort behaviors are highly individual and the absence of any specific behavior does not mean the absence of discomfort(s). 2. Note extent of comfort, or discomfort(s), using comfort scale. • Numerous reliable and valid age-appropriate, condition-appropriate and language-appropriate comfort scales are available for use. The tools must be easy to use, allow for fast assessment, allow for easy documentation and be multicultural and multilingual. Some of these assessment tools include: o Comfort Line (visual analog scale) for Total Comfort3 o Simple verbal descriptive scale of discomfort(s) or comfort o Comfort Behaviors Checklist4 o Numeric Rating Scale for pain or comfort o Behavioral rating scale o Body Diagram for discomfort(s) o Daily Diary for discomfort(s) or comfort o Thermal Comfort Scale (in review) o State Anxiety Scale5 o Perianesthesia Comfort Questionnaire6 • These scales evaluate the patient’s comfort and/or discomfort(s) with established criteria; eliminate bias and standardize care. Using them to guide practice will increase patient comfort and satisfaction and help to develop and implement a dependable comfort program. Comfort scales that are age and cognitively appropriate should be used to identify discomfort intensity and effectiveness of comfort interventions • Measurement and evaluation of comfort and discomfort varies depending on the scale utilized and the interpretation of scale criteria by the patient 3. Obtain description of quality of discomfort(s) (including anxiety, cold, etc.). • Quality of discomforts can be described according to the character, frequency and duration with which the patient is experiencing the discomforts. The nurse should ask the patient or parent of the pediatric patients to describe, in their own words, what the discomfort(s) feels like. The patient may describe pain or discomforts as aches, pulls, throbs, burns, sharp, cramps, boo-boos, owies, hurts, ASPAN 2009 Edition

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CHAPTER 11 dull, prickling, cold, scared, alone, hot, etc. Discomfort(s) can include somatic, visceral and neuropathic distress • Ask: when did the discomfort(s) start? Do they vary according to the time of day or activity? Are there any patterns? How long do they last? These questions will assist the healthcare provider in assessing the quality of the patient’s discomforts 4. Seek description of onset and duration of discomfort (including anxiety, cold, etc.). • The individual’s self report is the most reliable indicator of the existence and intensity of discomfort(s). The nurse should examine the site of the discomforts and assess physical findings • Ask: How much discomfort does the patient have in an average day? What time of the day is the discomfort the worst? What gets the discomfort started? Does the discomfort stay or come and go? What have you tried to make the discomfort better? How upsetting is the discomfort? What do you think causes the discomfort? Does discomfort cause problems with your activities of daily living? 5. Obtain information on aggravating and alleviating factors. • By asking the questions of which pharmacological and non-pharmacological methods help with specific discomfort(s), one can assess any aggravating and alleviating factors. Identify contributing factors to discomfort(s), e.g., anxiety, fear, family problems, etc. It is critical to explore common barriers to reporting discomfort and using analgesia or other comfort interventions. Identify how the patient expresses their discomfort 6. Seek information on effects of discomfort(s) (including anxiety, cold, etc.). • The impact of specific discomforts on daily function, sleep, appetite, emotion, concentration and other factors should be assessed. Assessing their effects may indicate that the discomfort(s) creates fear, suffering, and hopelessness. Patients should have established an individual comfort goal and expectations should be established in terms of achieving the comfort goal 7. Define behavior indicators for discomforts and comfort. • Behavioral indicators for discomfort (including anxiety, cold, etc.) may include crying, moaning, groaning, screaming, sweating, whimpering, facial expressions, reluctance to move or be moved, being quiet and withdrawn, anxious, restless, desperate, highly motivated to get help, frequent use of PCA, frequent request for pain med or other comfort interventions. Or the patient may exhibit few or no behavioral signs of pain. A disadvantage of using the behavior demonstrated may result in the observer dismissing the patient’s self-report of discomfort • Behavioral indicators of comfort may include motor signs that appear peaceful, calm or relaxed; vocalizations that sound content; ability to accept kindness, assistance, touch; ability to eat or drink fluids; smiling; even and slow breathing, ability to rest or sleep 8. Assess causes for discomfort (including anxiety, cold, etc.) other than the actual surgical site. • Patients may have pre-existing conditions which affect their comfort levels such as back/neck pain. Bladder distention can be extremely uncomfortable. Postoperative complications such as myocardial or pulmonary ischemia, hemorrhage, or rupture of viscous may cause pain. The nausea and vomiting cycle is also affected by discomforts and anxiety • Anxiety is a pain intensifier.7 Anxiety, fear, anger, guilt, loneliness, and helplessness adds to the overall experience of discomfort(s). To fulfill the dual mission of effective pain management and enhancement of comfort, nurses must determine what stimuli caused or might cause these individualistic negative responses that make pain worse, and then intervene appropriately • Cold is a pain intensifier, because it causes the body to tense and/or shiver. Feelings of cold can be from a cold environment, from vasodilating medications or anesthesia, and/or anxiety6

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CHAPTER 11 9. Perform assessment to verify response to comfort interventions. • Asking the following questions allows the healthcare provider to assess the patient’s response to medications or other comfort interventions. What analgesia has the patient received? What other interventions were tried? How effective were these interventions in relieving their discomforts, including anxiety or cold? Are the medications or other interventions affecting their vital signs? How much activity can the patient engage in prior to experiencing pain or discomforts? Were there any changes in the dosage of medications for anxiety or other discomforts? Was any additional medication or comfort intervention needed for breakthrough pain? Document the level of comfort using the scale that the patient identified as acceptable 10. Complete the comfort assessment by asking about patient’s comfort in all four contexts in which comfort occurs: (physical, sociocultural, psycho spiritual and environmental). 11. Reassess for residual discomforts not alleviated by pain medication or comfort interventions, such as partial anxiety, stressful environment, panic, muscle tension, nausea, restlessness, vertigo, need for information, need for reassurance or hope, need to talk, etc. 12. Assess need for transcendence, the type of comfort that enables patients to work through or rise above their anxiety, pain, or other discomforts that cannot be relieved. 13. Communicate and document all pertinent information per facility/unit specific policy/protocol. Document patient preferences for comfort interventions, and any negative responses to medications or comfort interventions.

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CHAPTER 11 OVERVIEW FOR COMFORT MANAGEMENT Purpose: The perianesthesia nurse needs a body of knowledge to establish a foundation from which the comfort experience can be managed. Comfort management involves applying nursing comfort interventions to target comfort needs in four contexts. The orientee will be able to apply comfort interventions, determine if they have been successful, and continue to apply or adapt those interventions as needed. Competency Statement: Provide comfort interventions for the patient experiencing discomfort in any context. Criteria: 1. Describe the design of comfort interventions. • Comfort interventions are those nursing actions that are targeted to patients’ holistic comfort needs, using the taxonomic structure as a guide. Comfort interventions can be holistic where one intervention targets several components of comfort. Examples of holistic comfort interventions are: hand or back massage, guided imagery, music or art therapy, etc. They are delivered with the intention of addressing many cells in the taxonomic structure (TS). The purpose of comfort interventions is to enhance holistic comfort in a caring manner. Teaching patients relaxation techniques including deep breathing, progressive muscle relaxation, imagery, distraction and massage are nursing measures that do not require a physician’s order for the nurse to implement • Several non-holistic comfort interventions can be applied during one nurse-patient encounter to enhance holistic comfort, using the TS as a guide. Examples of this strategy are positioning/repositioning, elevation, applying ice as ordered, splinting the incision with a pillow and holding during coughing, use of pacifiers or bottles containing glucose water, being held in a rocker, applying warm blankets, burping patients, providing music therapy, providing a quiet environment, providing a non-stimulating environment, hair, mouth, and oral care, and encouraging visitation of friends, family and significant others 2. Describe patient responses (adverse or positive) to comfort interventions that were administered. • Improvement in vital signs: BP, pulse, respirations in normal range or lower indicates relaxed state • Resting state induced: patient appears relaxed, may have eyes closed • Muscular relaxation: facial muscles relaxed, body tension eased 3. Communicate and document all pertinent information regarding pain and comfort per facility/unit specific policy/protocol.

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CHAPTER 11 Glossary Comfort: the satisfaction of the basic human needs for relief, ease or transcendence arising from healthcare situations that are stressful.1 Comfort Care: when Comfort Theory is applied to actual patient care, it is called Comfort Care. Comfort interventions: interventions that are intentionally targeted to all contexts of patient comfort and seek to elicit a holistic and positive effect.2 Contexts of Comfort: the four contexts in which comforting occur (physical, social, psycho spiritual and environmental).2 Discomfort: the condition of being uncomfortable in body or mind; mild distress. Ease: a type of comfort defined as a state of contentment.2 Environmental comfort: the external background of human experience (temperature, light, sound, odor, color, furniture, landscape, etc.)2 Intervening Variables: factors over which nurses or agencies have little control, but which affect the direction and success of Comfort Care plans or comfort studies. Pain intensifiers: negative thoughts and feelings that heighten the perception of pain within the conscious mind.8 Physical comfort: includes bodily sensations, homeostatic mechanisms, immune function, etc.2 Psycho spiritual comfort: the internal awareness of self, including esteem, identity, sexuality, meaning in one’s life, and one’s understood relationship to a higher order or being.2 Relief: a type of comfort defined as a state of having a specific discomfort relieved.2 Sociocultural comfort: interpersonal, family, and societal relationships (finances, teaching, healthcare personnel, etc.) Also family traditions, rituals, and religious practices.2 Suffer: to feel pain or distress; to sustain harm, injury pain or death; to tolerate or endure pain, evil, injury or death; on a continuum, suffering is the opposite of total comfort. Taxonomic structure: a 12-cell grid that depicts the content domain of comfort. The 12 cells result when the types of comfort [Relief, Ease, and Transcendence (across the top)] are juxtaposed with contexts of comfort [Physical, Psychospiritual, Sociocultural, and Environmental]. The TS is used to identify comfort needs of a given population of patients, design interventions to meet those needs, and design Comfort Questionnaires [congruent with the intervention(s)] to measure change in comfort over time. Transcendence: a state of having been strengthened or invigorated.2

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CHAPTER 11 References 1. Kolcaba KY. A taxonomic structure for the concept of comfort. Image. 1991; 23: 237-240. 2. Schlotfeldt R. The need for a conceptual framework. In: Verhonic P, ed. Nursing Research. Boston, MA: Little & Brown; 1975: 3-25. 3. Kolcaba KY. Comfort Theory and Practice: A Vision for Holistic Health Care. Springer; 2003. 4. Kolcaba K. The Comfort Behaviors Checklist. (in review). 5. Spielberger C. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, Inc; 1983. 6. Kolcaba K, Wilson L. Comfort Care: A framework for perianesthesia nursing. Journal of PeriAnesthesia Nursing. 2002; 17(2): 102-114. 7. Yancey P, Brand P. The gift of pain. (previously titled The Gift Nobody Wants). Grand Rapids, MI: Zondervan Publishing House; 1997.

Bibliography Burden N, Quinn D, O’Brien D, Gregory-Dawes B. Ambulatory Surgical Nursing. 2nd ed. Philadelphia, PA: WB Saunders; 2000. DeFazio Quinn DM, Schick L, eds. PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St. Louis, MO: Saunders; 2004. DeFazio-Quinn D, ed. Ambulatory Surgical Nursing Core Curriculum. Philadelphia, PA: WB Saunders; 1999. Kolcaba K. Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook. 2001; 49(2): 86-92. Kolcaba KY. “The Comfort Line Website” http://www.uakron.edu/comfort . Litwack K, ed. Core Curriculum For Perianesthesia Nursing Practice. 4th ed. Philadelphia, PA: WB Saunders; 1999.

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CHAPTER 11

QUESTIONS: ADVANCE COMFORT MANAGEMENT COMPETENCY 1. The four contexts in which comfort is experienced are: a. physiological, cognitive, cultural, environmental b. spiritual, physiological, cognitive, environmental c. physiological, psychospiritual, sociocultural, environmental d. sociocultural, cognitive, physiological, environmental 2. Pain management is the same as comfort management. a. true b. false 3. According to Kolcaba, comfort is defined as the immediate state of being strengthened through having met human needs for _______, ______, and ____________ . a. pain, support and empathy b. ease, relief and transcendence c. social support, relief and ease d. transcendence, empathy and social support 4. Comfort measures for patients in perianesthesia care include: a. assisting with guided imagery b. providing a soothing environment c. giving emotional support d. all of the above 5. It is important to measure, informally or formally, your patient’s comfort before and after a comfort intervention because: a. you want to prove to the patient that your intervention worked b. you want to document the effectiveness of your intervention c. you need the information to ask for a raise d. it is not important to measure your patient’s comfort at all 6. An example of an informal measurement of comfort is: a. asking your patient about his or her comfort b. asking the patient to complete a comfort questionnaire c. asking the patient to put a dot on a 10 centimeter line with 10 being the highest possible comfort d. asking the patient to define holistic comfort 7. The feelings of being anxious or cold are called: a. infantile feelings b. inexperienced c. pain intensifiers d. unnecessary 8. An example of visible comfort behaviors are: a. sweating b. muscular tension c. being quiet and withdrawn d. relaxed demeanor ASPAN 2009 Edition

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KEY: ADVANCE COMFORT MANAGEMENT COMPETENCY QUESTIONS 1. The four contexts in which comfort is experienced are: a. physiological, cognitive, cultural, environmental b. spiritual, physiological, cognitive, environmental c. physiological, psychospiritual, sociocultural, environmental d. sociocultural, cognitive, physiological, environmental 2. Pain management is the same as comfort management. a. true b. false 3. According to Kolcaba, comfort is defined as the immediate state of being strengthened through having met human needs for _______, ______, and ____________ . a. pain, support and empathy b. ease, relief and transcendence c. social support, relief and ease d. transcendence, empathy and social support 4. Comfort measures for patients in perianesthesia care include: a. assisting with guided imagery b. providing a soothing environment c. giving emotional support d. all of the above 5. It is important to measure, informally or formally, your patient’s comfort before and after a comfort intervention because: a. you want to prove to the patient that your intervention worked b. you want to document the effectiveness of your intervention c. you need the information to ask for a raise d. it is not important to measure your patient’s comfort at all 6. An example of an informal measurement of comfort is: a. asking your patient about his or her comfort b. asking the patient to complete a comfort questionnaire c. asking the patient to put a dot on a 10 centimeter line with 10 being the highest possible comfort d. asking the patient to define holistic comfort 7. The feelings of being anxious or cold are called: a. infantile feelings b. inexperienced c. pain intensifiers d. unnecessary 8. An example of visible comfort behaviors are: a. sweating b. muscular tension c. being quiet and withdrawn d. relaxed demeanor 340

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CHAPTER 11 C. PEDIATRIC PAIN MANAGEMENT PAIN MANAGEMENT FOR INFANT, CHILD, AND ADOLESCENT OVERVIEW The pediatric population, infant, child, and adolescent are a population historically undertreated for pain. In addition, this population is at risk for the consequences of over pain management. Purpose: To demonstrate an understanding of the special needs of the pediatric patient regarding pain assessment and measurement, the implementation and evaluation of responses to medications, as well as alternative interventions to traditional pain management. Competency Statement: Demonstrate the ability to perform a thorough pain assessment, and to measure, plan, implement, and evaluate appropriate pain management in the infant, child, and adolescent.

Criteria: 1. Describe the differences between assessment and measurement. • Assessment and measurement are different processes in the management and evaluation of pain. Measurement is quantifiable and gives answers on quantity, extent, and the degree of pain. Assessment is a broader concept, including measurement but involving clinical judgment based on observations A. Acute and Chronic Differences: Acute pain has had measures developed for assessment because the focus of pain assessment has been on procedural and postoperative pain interventions. Chronic pain, either long-term repeated pain or the stress from repeated traumatic procedures, is not as well understood and has not had as many measures built for assessment. Characteristics seen with chronic type pain: • Inertia • Diminished alertness • Withdrawal • Hostility • Indifference • Visual aversion or “frozen” watchfulness B. Unidimensional and Multidimensional Approaches: Unidimensional approach measures one indicator (e.g., heart rate), one type of indicator (e.g., facial expression), and takes only one approach to the measurement (e.g., behavioral). Physiologic indicators: • Increased heart rate • Respiratory rate • Blood pressure • Palmar sweating • Intracranial pressure • Decreases in transcutaneous oxygen saturation levels, transcutaneous carbon dioxide levels or vagal tone • Autonomic changes such as skin color, nausea, vomiting, gagging, hiccoughing, diaphoresis, and dilated pupils

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CHAPTER 11 Approaches: Most common approach is behavioral and most common indicator is facial expression; most common facial actions associated with pain: • Bulging brow • Eyes squeezed tightly shut • Nasolabial furrow • Open lips • Vertical mouth stretch • Horizontal mouth stretch • Lips pursed • Taut tongue • Tongue protrusion Multidimensional approach combines a variety of subjective and objective assessments or a composite measurement. A composite pain measurement is made up of a variety of dimensions and factors within one instrument: • Physiological • Behavioral • Sensory • Affective C. CRIES, PIPP, NIPS, FLACC • Many of the measures used in unidimensional pain measurement require trained persons to identify the numerous features and facial actions and are better suited to research than clinical evaluation. Studies have also found that no single indicator will provide reliability or validity when trying to identify pain • Pain is multidimensional and it is better to assess it by more than one indicator or by multiple dimensions. This will give as much information as possible. There are several that have been tested more thoroughly for reliability and validity than others The CRIES scale is a neonatal pain measure that consists of five physiologic and behavioral indicators. Each indicator is rated on a 3-point scale (0, 1, 2) that results in a total score ranging from 0 to 10. The title CRIES is an acronym of the indicators: • Crying • Requires O2 for saturation >95 • Increased V/S (HR and BP) • Expression • Sleepless The PIPP (Premature Infant Pain Profile) was developed to assess acute pain in pre-term and term neonates. It is a 7-indicator pain measure that includes behavioral, physiologic, and contextual indicators: • Gestational age • Behavioral state • Heart rate • Oxygen saturation • Brow bulge • Eye squeeze • Nasolabial furrow

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CHAPTER 11 Several different situations and gestational age groups were tested and in all situations and age groups, the PIPP score accurately reflected differences in pain and non-pain situations. Each indicator is evaluated on a 4-point scale (0, 1, 2, 3) for a possible score of 21 for infants of lesser gestational age and a total of 18 for infants of greater gestational age at birth. A total score of 6 or less generally indicates minimal or no pain, and scores of 12 or higher indicate moderate to severe pain. The NIPS (Neonatal Infant Pain Scale) is another tool used to assess pain in neonates. NIPS assess facial expression, cry, breathing patterns, extremities, and state of arousal. Each category receives a score of 0-1, except cry which is 0-2, resulting in a possible score of 0-7. • Facial Activity: Furrowed brow, bulging, creasing, eyes tightly closed • Breathing Patterns: Rapid, slow, shallow, deep • Posture: Limb withdrawal, thrashing, rigidity, flaccidity, fist clenching • Vocalizations: Crying, whimpering, and groaning • Arousal: Changes in sleep/wake cycles, feeding behavior, activity level, fussiness, irritability, and listlessness The FLACC scale is a behavior assessment scale used to assess pain in children who do not have sufficient cognitive and communicative ability to use the face or numeric scales developed for toddlers and school-age children. Each behavior is rated 0-2 with a total score of 0-10 for the following behaviors: • Face • Legs • Activity • Cry • ability to Console Pain, by whichever method chosen, should be assessed at regular intervals: admission, every two to four hours for the first 24 hours, then every four hours, after analgesic administration when pain is suspected, or the infant/child’s condition is expected to be associated with pain. 2. Discuss assumptions and beliefs regarding neonates and infants. Many decisions concerning pain, intervention, and outcomes are made based on assumptions and beliefs. Fallacy: Neonates and infants are incapable of feeling pain. Fact: All infants, including neonates and pre-term infants, have the ability to feel pain. Fallacy: Fact:

Infants are not as sensitive to pain. Anything that causes pain in adults also causes pain in infants. Some things that do not cause pain in adults may cause pain in infants.

Fallacy: Fact:

Neonates and infants cannot express pain. Infants respond to pain with a variety of physiologic and behavioral indicators. Lack of response does not mean lack of pain.

Fallacy:

Assessment of pain is inaccurate and unreliable with neonates and infants and questionable in the non-verbal toddler. Pain must be assessed by use of multiple indicators, with special attention when indicators change. Ongoing open communication must take place between staff and parents about infant’s pain so that accurate assessments and insights will occur.

Fact:

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Neonates and infants are incapable of remembering pain. Neonates and infants experiencing long-term pain, repeated pain, and/or stress of traumatic repeated procedures show an increase in depression, insomnia, change in feeding patterns, and impaired coping responses.

Fallacy:

Opioid analgesics and anesthetics cannot be safely given to neonates and infants because of their immature capacity to metabolize and eliminate drugs and their sensitivity to opioid-induced respiratory depression. The appropriate opioid dose is the amount of opioid that controls pain with the fewest side effects. By 3 to 6 months of age healthy infants can metabolize opioids similarly to other children.

Fact:

Fallacy: Fact:

Fear of addiction. Narcotics are no more dangerous for children than they are for adults. Addiction to opioids used to treat pain is extremely rare in children.

3. Discuss the pharmacokinetics of medications in the pediatric patient. • Caregivers must have an understanding of Pharmacokinetics, which is the movement of drugs in the body over a certain period of time, and Pharmacodynamics, which is the dose-response relationship. Both of these factors provide the basis for safe and effective pain management in anesthesia, analgesia, or both Pharmacokinetics: are affected by the quality of absorption, distribution, and elimination of medications by the infant. Absorption is determined by gastric acidity and gastric emptying. The neonate’s blood is more neutral or alkaline, an environment that affects drugs that are acid labile, causing them to reach higher levels of concentration than in children and adults. The distribution of medications is determined by protein binding ability and compartmentalization of body water. The newborn has lower protein binding than older children and adults and this results in a higher proportion of medication left free to penetrate tissues, which causes a higher distribution volume. Elimination depends on hepatic and renal metabolism. Neonates and pre-term neonates have delayed maturation of enzyme systems, which results in slower hepatic metabolism, causing a slower drug clearance rate. This causes toxic levels of opioids, acetaminophen, NSAIDs, and local amide anesthetics to be reached with lower unit doses or longer dose intervals. Renal function reaches adult values by approximately 6-12 months. Pharmacodynamics: of acetaminophen, salicylates, and NSAIDs does not have significant difference once the infant is older than 1 month of age. Drug choices depend on the purpose, the cost, the duration needed, and the available route of administration. Neonates who have continual severe pain may require larger doses of opioids to receive adequate pain management because they develop opioid tolerance very rapidly. 4. Describe pharmacologic / non-pharmacologic (Behavioral) and Adjuvant Therapies. There are several principles of good pain management, which must be kept in mind when choosing specific therapies: • “Infants, children, and adolescents can and do experience pain, and the lack of adequate pain management has significant adverse consequences” (AHCPR, 1992) • Establish a relationship of trust with the parent/child, accepting and believing the child’s selfreport of pain • Provide preventative pain management when possible, use pain relief measure before the pain

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CHAPTER 11 occurs or increases. When pain medication is administered “around the clock” for continuous pain, less total drug is usually required • Patient-controlled analgesia (PCA), by intravenous, subcutaneous, and epidural routes can be safely and effectively self-administered by children six to eight years of age and older who are able to comprehend the PCA instruction. Exceptions for children under this age can be made by the attending physician • Use a variety of interventions/strategies for pain relief • The assessment and treatment of pain in infants, children, and adolescents is essential and failure to provide appropriate and adequate pain control is substandard practice Pharmacologic: Oral medications are effective for controlling pain and if the infant/child is tolerating oral intake, may be more convenient and less expensive than parenteral therapy. Intravenous is the preferred parenteral route. Non-opioid drugs have a ceiling effect on analgesia whereas opioids do not have a ceiling effect and increased doses will provide increased pain relief. Non-Opioids: • Acetaminophen (Tylenol) – Most commonly used non-opioid analgesic. Has little anti-inflammatory effect • NSAIDs (non-steroidal anti-inflammatory drugs) • Aspirin – Possible role in Reye’s Syndrome. Platelet aggregation effect is not reversible, used in juvenile rheumatic arthritis and Kawasaki’s Disease • Ibuprofen (Motrin) – Superior anti-inflammatory effects • Ketorolac (Toradol) – Potent analgesic, only parenterally administered NSAID, approved for short term use only (maximum five day) NSAIDs are contraindicated in patients with coagulopathy, patients at risk for stress ulcers, GI hemorrhage, and allergies to aspirin. Use with caution in patients with renal dysfunction or asthma. Opioids: • Codeine – most commonly administered in the oral form, usually with acetaminophen. Pediatric pain specialists do not recommend IV administration because of serious side effects including apnea and severe hypertension. Nausea and vomiting are side effects. Fewer N/V problems associated with Oxycodone, some pediatric pain specialists are prescribing this as the preferred oral opioid • Morphine – is the most common drug used to treat pain. Morphine induces a histamine release, so it should be used with caution in children with asthma and in children who are hypovolemic. It is poorly absorbed from the GI tract, if administered by mouth (po) or by rectum (pr), give 3-5 times the IV dose. Hydromorphone (Dilaudid) may produce less sedation and nausea than Morphine so it is often used in place of Morphine for PCA use because of these side effects. It is however, 5-7 times more potent than Morphine, so the dosage must be adjusted • Fentanyl (Sublimaze) – has few cardiovascular effects other than bradycardia, so it is ideal for use in children with congenital heart disease or neurosurgical patients. Fentanyl can cause chest wall rigidity when administered rapidly. It has a short duration of action (less than minutes) so it is ideal for short painful procedures. Fentanyl can be given by transmucosal (candy), transdermal (patch), epidural, and intravenous routes The appropriate opioid dose is the amount of opioid that controls pain with the fewest side effects. The American Pain Society recommends that opioid analgesics be given an adequate trial by close titration before changing to a different medication. The effects – including adverse effects – of any opioid may be potentiated when given in combination with sedatives. Opioids should be given with greater caution to children with asthma, chronic lung disease, obesity, hepatic or renal impairment, and debilitated children. ASPAN 2009 Edition

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CHAPTER 11 Respiratory depression occurs infrequently following analgesic administration. It usually occurs after a single narcotic dose when the drug peaks. Children less than 6 months of age and with a history of opioid sensitivity are at greater risk for respiratory depression. Monitoring of sedation levels is an important way to prevent respiratory depression. Sedation will precede the opioid induced depression so if the child’s sedation level increases the opioid should be discontinued until the sedation level decreases and the respiratory rate is within normal limits for the child’s age. If respiratory depression occurs the infusion should be stopped immediately, call for help, assess for breathing, open the airway, administer the appropriate resuscitation measures and consider the administration of Narcan (Naloxone Hydrochloride). • Naloxone hydrochloride (Narcan) – is an opioid antagonist. It reverses respiratory depression, analgesia, and sedation produced by opioids. It can be used if the child is apneic or has inadequate respiratory effort. Narcan should be titrated to reversal of adverse effects. Rapid reversal of profound analgesia may have severe clinical effects including hypertension and, in rare cases, pulmonary edema Non-Pharmacologic: Despite increasing awareness of pediatric pain, children continue to suffer pain and anxiety during medical care. The combined use of non-pharmacologic techniques with pharmacologic methods can reduce or prevent pain and anxiety associated with most medical procedures. This integration of techniques can maximize the advantages while minimizing the disadvantages of either approach employed alone. Infants: Positioning – proper positioning can affect many physiologic and neurobehavioral parameters in the infant. Several positions have been evaluated and reported to increase oxygenation and tidal volume. Some reports state that “facilitated tucking” (holding the infant’s extremities flexed and contained close to the trunk) lowered the heart rate and resulted in less crying. Containment – Swaddling and bundling decreases stress and allows a feeling of “nesting”. It increases the feelings of security and self-control and babies tend to be calmer and gain weight more rapidly. Nonnutritive Sucking – Nonnutritive sucking has been associated with increases in oxygenation, respiratory and gastrointestinal function. Nonnutritive sucking has also been used as a pain management technique. Sucrose – The administration of sucrose alone and in combination with nonnutritive sucking (pacifiers) has been the most frequently studied nonpharmacologic intervention for relief of procedural pain in neonates. Several systematic reviews and meta-analysis studies have been done showing the pain-relieving effects of sucrose. The studies provide support for ongoing research for the safety and efficacy of sucrose. Children and Adolescents: Play – Play provides an opportunity for children to express fear and pain. Use dolls and/or action figures and medical play objects to allow children to safely act out their fears. This can make procedures less threatening. These familiar objects from home can also provide comfort during a procedure. Therapeutic Touch – All children need to be touched, stroked, and held. Parents instinctively provide therapeutic touch to their children by rubbing their child’s head, stroking their back or extremities while comforting them. Music and Distraction – Distraction is a powerful method of pain relief that children can use by

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CHAPTER 11 watching television or listening to music. These can temporarily divert attention away from the pain. Children can be distracted by singing along with the music, counting, and tapping to the beat of a favorite song. They can be distracted by a familiar voice reading a favorite story. Other forms of distraction are having the child deep breathe, blow bubbles, make pinwheels spin, use party blowers, and looking through the changing shapes of a kaleidoscope. Relaxation and Guided Imagery – Cuddles, blankets, favorite toys, and pacifiers are all techniques of relaxation. Depending on the child’s age help them to assume comfortable positions. Ask the child to take a deep breath and “go limp as a rag doll” while exhaling slowly, then ask the child to yawn. Starting with the toes, systematically instruct the child to let each body part “go limp” and “feel heavy”. Children have very active imaginations. During painful procedures, encourage the child to: (1) concentrate on a favorite vacation or party; or (2) spray the pain away with a can of shrinking solution; or (3) turn the “pain” switch to the off position. Hypnosis – Hypnosis can be easily learned by children. It has been shown to be very effective in reducing pain and discomfort and diminishing anxiety. Heat and Cold – Heat promotes vasodilation and increases the blood supply to the area. Cold slows the ability of the pain fiber to transmit the pain impulse. Whenever heat and cold are utilized care must be taken to prevent thermal injuries. TENS – Transcutaneous electrical nerve stimulator delivers small amounts of electrical energy to the skin via electrodes. It is thought that TENS works either through modulation of painful input into the spinal cord or through endorphin release. Adjuvant Analgesics in Children – A number of conditions, which occur in adults, are treated with adjuvant analgesics. These same conditions can occur in children and may be responsive to the same adjuvant analgesic treatment. Examples are chronic regional pain syndrome (reflex sympathetic dystrophy), phantom pain, neuropathic pain resulting from chemotherapy, and neuropathy associated with HIV. These may be responsive to the same adjuvant analgesic treatment. The same guidelines are used for both children and adults, except for dosing. Dosing is based on recommendations given when the drugs are used for their original indications; dosing for anticonvulsants are essentially the same whether they are used for seizure disorder or for pain relief.

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CHAPTER 11 Bibliography Acute Pain Management Guidelines Panel. Acute Pain Management in Infants, Children and Adolescents: Operative and Medical Procedures – Quick Reference Guide for Clinicians. AHCPR pub. No 91-0592. Rockville, MD. Agency for Health Care Policy and Research. U.S. Dept. of Health and Human Services, March 1994. Burden N, Quinn D, O’Brien D, Gregory-Dawes B. Ambulatory Surgical Nursing. 2nd ed. Philadelphia, PA: WB Saunders; 2000. DeFazio Quinn DM, Schick L, eds. PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St. Louis, MO: Saunders; 2004. McCaffery M, Pasero C. Pain Clinical Manual. 2nd ed. St. Louis, MO: Mosby; 1999. Yaster, et al. Pediatric Pain Management and Sedation Handbook. St. Louis, MO: Mosby; 1997.

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CHAPTER 11

QUESTIONS: PEDIATRIC PAIN MANAGEMENT COMPETENCY 1. The most reliable measure of pain in the newborn is: a. continued crying without comfort b. trained assessment of physiological/behavioral responses c. parent(s) assessment of newborn responses d. numerical pain scale 2. The behavioral activity offering the most specificity as an indicator of pain is: a. sleep/wake cycles b. vocalizations c. facial activity d. limb withdrawal 3. The Neonatal Infant Pain Scale (NIPS) is a pain assessment tool used for assessing pain in neonates. The NIPS scale assesses: a. cry, breathing patterns, and extremity movement b. facial expression and psychological responses c. vocalizations, state of arousal, and movement d. facial expression, cry, breathing patterns, extremities, and state of arousal 4. The FLACC behavior assessment scale is used to assess pain in children who: a. have attention deficit disorder b. have insufficient cognitive skills/communication c. have minimal pain intensity d. have long-term or repeated procedure pain 5. Assessment of pain is inaccurate and unreliable with neonates and infants and questionable in the non-verbal toddler. a. True b. False 6. At 3-6 months of age healthy infants can metabolize opioids similarly to other children. a. True b. False 7. It is safe and effective to use IV PCA administration in children older than 8 years of age provided they: a. understand the relationship between pain and pushing the PCA button b. have a parent(s) who are going to be with them in the room at all times c. can manipulate the PCA button and understand how to push it correctly d. have a designated primary pain manager who will control the PCA button

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CHAPTER 11

KEY: PEDIATRIC PAIN MANAGEMENT COMPETENCY 1. The most reliable measure of pain in the newborn is: a. continued crying without comfort b. trained assessment of physiological/behavioral responses c. parent(s) assessment of newborn responses d. numerical pain scale 2. The behavioral activity offering the most specificity as an indicator of pain is: a. sleep/wake cycles b. vocalizations c. facial activity d. limb withdrawal 3. The Neonatal Infant Pain Scale (NIPS) is a pain assessment tool used for assessing pain in neonates. The NIPS scale assesses: a. cry, breathing patterns, and extremity movement b. facial expression and psychological responses c. vocalizations, state of arousal, and movement d. facial expression, cry, breathing patterns, extremities, and state of arousal 4. The FLACC behavior assessment scale is used to assess pain in children who: a. have attention deficit disorder b. have insufficient cognitive skills/communication c. have minimal pain intensity d. have long-term or repeated procedure pain 5. Assessment of pain is inaccurate and unreliable with neonates and infants and questionable in the non-verbal toddler. a. True b. False 6. At 3-6 months of age healthy infants can metabolize opioids similarly to other children. a. True b. False 7. It is safe and effective to use IV PCA administration in children older than 8 years of age provided they: a. understand the relationship between pain and pushing the PCA button b. have a parent(s) who are going to be with them in the room at all times c. can manipulate the PCA button and understand how to push it correctly d. have a designated primary pain manager who will control the PCA button

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CHAPTER 11 D. GERIATRIC PAIN MANAGEMENT A. Purpose: The elderly are a population at risk for both over and under management of pain. The learner will demonstrate awareness of the special needs of the geriatric population regarding assessment and treatment of pain, as well as the evaluation of responses to medications and other interventions. Competency Statement: Provide effective assessment of pain for the geriatric patient. Criteria: 1. Use appropriate pain scale or scales. The geriatric patient may have visual, auditory or cognitive deficits. The use of a combination of pain scales outlined in the overview may provide a more credible assessment in determining pain levels. In addition, the nurse may need to rely on nonverbal or behavioral changes such as grimacing, guarding, restlessness, agitation and combativeness to assist with pain assessment. Geriatric patients should have eyeglasses and hearing aids in place during assessments to maximize understanding. 2. Consider level of cognition when assessing the elderly. Elderly patients may be temporarily disoriented related to an unfamiliar environment. Anesthetics and narcotics can lead to sedation, blurred vision and confusion, impeding understanding and assessment. Instructions may need to be given several times. Responses by cognitively impaired patients to questions regarding pain are more likely to mirror cognitively intact patients’ responses, if they are asked in a simple yes/no format. Cognitively impaired patients may not be able to remember past pain intensity ratings, but may only report present level of discomfort. B. Purpose: There are many incorrect perceptions and myths regarding pain in the elderly. Nurses, patients and families must be educated to dispel inaccuracies in order to effectively manage pain, and provide comfort to the geriatric patient. Competency Statement: Provide perioperative pain management care to the geriatric that is not influenced by myths, perceptions or unfounded beliefs. Criteria: 1. Identify misconceptions regarding pain in the elderly • The elderly experience less pain than younger adults • Pain is a normal part of aging • Pain perception is decreased with age • The elderly cannot tolerate opioids • The use of pain medications leads to addiction • Pain is a punishment and a way of penance Patients are also prone to under report pain because they want to be “good patients” or feel that health professionals will “know” when pain is experienced and will intervene. These myths and misconceptions may cause undue suffering and inadequate management of pain.

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CHAPTER 11 C. Purpose: Certain physiologic and metabolic changes occur through the process of aging. Inadequate pain management stresses many body systems and may produce negative outcomes. The learner should consider the patient’s history and physical findings when managing pain. Competency Statement: Consider patient’s current metabolic and physiologic status when providing pain management. Criteria: 1. Define consequences of inadequate pain relief. • Prolongation of stress response • Delay of wound healing • Immunosupression • Increased oxygen demand • Coagulopathy issues • Decrease in gastric and intestinal motility These and other consequences make the geriatric patient especially vulnerable to added stress on vital organs and systems. In addition, the cycle of pain leads to muscle tension, anxiety and decreased mobility, which may result in DVT, pulmonary embolism, atelectasis and pneumonia. 2. Identify age related changes regarding absorption, distribution, metabolism and excretion/elimination of medications. Factors that slow the rate of drug absorption in the elderly are: • decreased gastric pH • decreased intestinal blood flow • increased gastric emptying time Distribution depends on the ratio of lean body tissue to fatty tissue, and the amount of total body water and plasma proteins available to transport the drug. In the geriatric patient there is: • less lean muscle mass • increased body fat • decreased total body water • increased plasma protein Drugs remain and act in body tissues for a longer period of time in the elderly. Likewise, lipid soluble medications are likely to deposit and accumulate in subcutaneous fat. Protein binding capacity of medications is greatly influenced by nutritional status of the elderly. Metabolism is influenced by hepatic blood flow and other functions of the liver. In the elderly there is: • decreased liver mass • decreased microtonal enzyme activity • decreased hepatic blood flow • decreased elimination or clearance of medications • increased elimination half life of medications

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CHAPTER 11 Most medications are excreted or eliminated through the kidneys. In the elderly there is: • decreased glomerulofiltration rate • decreased creatinine clearance • decreased renal blood flow and function These factors lead to longer half life elimination and increased apparent volume of distribution. D. Purpose: Routes of administration and incremental dosing should be considered when caring for the geriatric patient. Certain medications may have more side effects and be a less preferred option in treating the elderly. The learner should identify preferred routes, dosing guidelines, and risks and benefits of various categories of drugs. Competency Statement: Identify the most effective dosing schedules and routes of administration. Criteria: 1. Use appropriate dosing schedules. It is wise to start with low doses and proceed slowly. Adjust time intervals to relieve pain without cumulative build up. Titrate to effect, using drugs with shorter half lives and fewer side effects. Avoid intramuscular injections because of pain, potential tissue and nerve damage and slow absorption. This is particularly true in the postoperative area, where there may be decreased blood flow, hypothermia, and decreased muscle activity, delaying drug absorption and requiring additional dosing. These additional doses may “flood” the bloodstream as circulation improves, leading to adverse reactions. The risk of respiratory depression is five times higher with IM route than with IV. PCA may not be the best option for elderly or confused patients. A small continuous basal dose may be effective in maintaining comfort. Following the immediate post op period, around the clock dosing with additional rescue doses for break through pain may provide the most consistent level of comfort. 2. Consider adverse effects of medications. NSAIDS are 4 times more likely to cause GI bleeding in the elderly. Reflux and dyspepsia are also common side effects. Renal failure, lower extremity edema and increased bleeding time are also risks to the elderly. Sedation, confusion, headache depression and psychosis are also untoward reactions. Acetaminophen has significant hepatic effects. Limit amount to 3000 to 4000 mg per day. May mask signs of infection and tends to elevate INR. Meperidine (Demerol) should be avoided in the elderly. A toxic metabolite, normeperidine, is a CNS stimulant and causes irritability, tremors, muscle twitching, agitation and seizures. Propoxyphene (Darvon) Metabolism produces a toxic metabolite, norpropoxyphene, which has a half life of 30-36 hours. There is a high potential for accumulation leading to CNS depression, pulmonary edema and cardiotoxicity. This is a poor choice of drug for any patient with renal insufficiency.

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CHAPTER 11 Bibliography St. Marie B. Core Curriculum for Pain Management Nursing. Philadephia, PA: WB Saunders; 2002. Ham R, et al. Primary Care Geriatrics. 4th ed. St. Louis, MO: Mosby; 2002. US Department of Health and Human Services. Acute Pain Management in Adults: Operative Procedures. February 1992. American Pain Society. Principles of analgesis: Use in the treatment of Acute Pain and Cancer Pain. 4th ed. 1999.

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CHAPTER 11

QUESTIONS: PAIN MANAGEMENT IN THE GERIATRIC PATIENT COMPETENCY 1. When assessing pain in the geriatric patient, the nurse may need to use a combination of pain assessment tools. a. True b. False 2. Misconceptions regarding pain in the elderly include all except: a. pain is a normal part of aging b. pain perception is decreased in the elderly c. elderly patients can tolerate pain better than the young d. elderly patients may under report pain because they want to be a good patient 3. Consequences of inadequate pain management include: a. increased oxygen demand b. delayed wound healing c. prolongation of the stress response d. all of the above 4. Metabolic issues to consider in the geriatric patient include: a. decreased hepatic blood flow b. decreased renal blood flow c. decreased muscle mass d. increased plasma proteins e. all of the above

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CHAPTER 11

KEY: PAIN MANAGEMENT IN THE GERIATRIC PATIENT COMPETENCY 1. When assessing pain in the geriatric patient, the nurse may need to use a combination of pain assessment tools. a. True b. False 2. Misconceptions regarding pain in the elderly include all except: a. pain is a normal part of aging b. pain perception is decreased in the elderly c. elderly patients can tolerate pain better than the young d. elderly patients may under report pain because they want to be a good patient 3. Consequences of inadequate pain management include: a. increased oxygen demand b. delayed wound healing c. prolongation of the stress response d. all of the above 4. Metabolic issues to consider in the geriatric patient include: a. decreased hepatic blood flow b. decreased renal blood flow c. decreased muscle mass d. increased plasma proteins e. all of the above

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CHAPTER 11 E. PAIN MANAGEMENT: INTERVENTIONAL PAIN THERAPIES Please note: It is recommended that completion of basic pain and comfort competencies are prerequisites for this section. These competencies include the following: • Perform a basic pain/comfort assessment • Provide care for the patient experiencing pain/discomfort • Provide care for the patient using patient controlled analgesia (PCA) • Provide care for the patient receiving epidural analgesia or patient controlled epidural analgesia (PCEA) • Understand and apply the basic principles of Comfort Theory to perianesthesia nursing • Perform a basic comfort assessment • Provide comfort interventions for the patient experiencing discomfort in any context • Demonstrate the ability to perform a thorough pain assessment, and to measure, to plan, to implement, and to evaluate appropriate pain management in the infant, child, and adolescent • Provide effective assessment of pain for the geriatric patient • Provide perioperative pain management care to the geriatric patient that is not influenced by myths, perceptions or unfounded beliefs • Consider patient’s current metabolic and physiologic status when providing pain management • Identify the most effective dosing schedules and routes of administration when providing pain management to the geriatric patient The selected procedures described are not an all inclusive listing. OVERVIEW OF INTERVENTIONAL PAIN THERAPIES Purpose: The perianesthesia nurse needs a body of knowledge to adequately care for patients receiving interventional pain therapies. The perianesthesia nurse will be able to describe interventional pain therapies including the definition, rationale/goal, and complications/patient considerations. Competency Statement: Describe interventional pain therapies used in the perianesthesia setting. Criteria: 1. Describe interventional pain therapies including definition, rationale/goal, and complications/patient considerations. I.

Trigger Point Injections Definition • Local anesthetic with or without steroid injected into a trigger point (a palpable firm tense muscle band) Rationale/Goal • Trigger point injections can be helpful if an isolated painful point in the muscle with radiation of the pain (a trigger point) can be identified by palpation. Injection into and needling of the trigger point spread out the offending muscle fibers and can provide long term pain relief

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CHAPTER 11 Complications/Patient Considerations • Standard post procedure care II.

Intercostal Blocks Definition • Local anesthetic or steroid injected into the intercostal space (thorax) Rationale/Goal • Very effective method to relieve pain from median sternotomy or fractured sternum • Useful in controlling postoperative pain of the chest or abdomen • For chronic pain cases when combined with celiac plexus blockade, can be used for diagnosis of abdominal wall pain vs visceral pain • Used for diagnostic & therapeutic benefit in acute and chronic pain from herpes zoster • Produces effective analgesia with little central respiratory depression and minimal interference with pulmonary function Complications/Patient Considerations • Pneumothorax is one of the most serious complication (needle punctures the parietal pleura and the visceral pleura to allow air to leak from the lung into the pleural cavity) • Vessel puncture of the intercostal artery and vein can lead to hematoma or rapid uptake of the local anesthetic drug • Flank hematoma can be quite significant in an anticoagulated patient, therefore appropriate candidate selection is a serious consideration • Systemic toxicity from the local anesthetic agent used • Blood levels of anesthetic drugs are higher after multiple intercostal nerve blocks than the other commonly used regional anesthetic procedures

III. Epidural Steroid Injection (Regional techniques are discussed in the Pain and Comfort Management Competency). Definition • Steroid with or without local anesthetic injected into the epidural space Rationale/Goal • Injection of steroids can decrease neurogenic inflammation and produce membrane stabilization that results in pain relief Complications/Patient Considerations • These injections are indicated primarily for the treatment of radicular extremity pain that has not responded to more conservative treatments • Epidural steroid injections are not indicated for the treatment of mechanical or muscular axial back pain IV.

Facet Blocks Definition • Steroid with or without local anesthetic injected into the facet joints • Can be in the lumbar, thoracic or cervical area • Can be used for therapeutic and diagnostic interventions

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CHAPTER 11 Rationale/Goal • Intraarticular steroid injection produces significant pain relief that outlasts the action of a local anesthetic Complications/Patient Considerations • Needle placement during the procedure and the local anesthetic delivery can result in exacerbation of pain V.

Intravenous Regional Block (Bier Block) Definition • Injection of a local anesthetic into an exsanguinated (through the use of timed tourniquet) extremity Rationale/Goal • Commonly used for surgical procedures on an extremity • Used for procedures lasting 1 hour or less Complications/Patient Considerations • Premature deflation of the tourniquet

VI.

Gasserian Ganglion Block Definition • Injection of a destructive liquid such as ethyl alcohol into the vicinity of the external opening of the foramen ovale , the foramen rotundum, or the infraorbital foramen to destroy a peripheral division of branch of the trigeminal nerve Rationale/Goal • The destruction of the peripheral division of a branch of the trigeminal nerve provides pain relief for patients with trigeminal neuralgia Complications/Patient Considerations • The injection of the ethyl alcohol is painful but usually transient and well tolerated • The peripheral alcohol injections cause temporary sensory loss or paresthesia

VII.

Sympathetic Block Definition • Injection of a local anesthetic into a sympathetic ganglion • Can be done in the sphenopalatine ganglion, stellate ganglion • Can be thoracic sympathetic block or lumbar sympathetic block Rationale/Goal • The simultaneous blockade of the C-fibers is intended to provide pain relief and not cause somatic numbness or motor blockade • The efficacy of multiple sympathetic blocks may be evaluated for the possible intention of performing a sympathectomy Complications/Patient Considerations • For years sympathetic blocks were performed to diagnose complex regional pain syndrome (CRPS) type 1 but is no longer considered a powerful diagnostic tool

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CHAPTER 11 VIII. Neurolytic Block Definition • Injection of a nerve-destroying substance (Ethyl Alcohol, Phenol) into a specific area Rationale/Goal • The toxic insult leads to an increase in endoneurial fluid pressure which increases the permeability of the blood-nerve barrier and leads to accumulation of fluid in the endoneurial space. Elevated endoneurial fluid pressure causes stretching of the perineurium and compression of the perineurial vessels and in turn produces ischemia of the nerve fiber Complications/Patient Considerations • Painful on injection so consider injection of local anesthetic first • Development of neuralgias post procedure IX.

Hypophysectomy Definition • Surgical excision of the hypophysis cerebri for patients with intractable cancer pain Rationale/Goal • Original researchers thought by removing the hormonal stimulation, tumors would decrease in size and therefore would result in pain relief • Current studies demonstrate pain relief even without clinical improvement of the tumor Complications/Patient Considerations • Pain relief effective in about 70% of the patients • The clinical benefit of this procedure became outweighed by the risks as medical management of chronic pain progressed such that the operation is chiefly of historical interest at present

X.

Commissural Myelotomy Definition • Commissural myelotomy disrupts pain-conducting fibers as well as a polysynaptic pain pathway that runs through the center of the spinal cord. Indications for myelotomy are bilateral and midline pelvic or perineal pain. The procedure may produce sphincter or motor dysfunction. Open myelotomy involves a multilevel laminectomy and exposure of the appropriate lumbar or sacral segments of the spinal cord. By use of an operating microscope, a midline incision is made and the spinal cord is divided vertically. A cervicomedullary junction (extralemniscal) myelotomy that is performed stereotactically with CT guidance, local anesthesia, and intraoperative physiologic assessment can achieve pain relief over wide areas of the body including midline structures. Potential complications include temporary dysesthesia and limb apraxia. Although the purpose of the operation is to produce a cuirass of loss of pain sensibility by dividing the spinothalamic and spinoreticulothalamic fibres as they decussate in the anterior commissure of the cord, this result is not always obtained Rationale/Goal • To produce bilaterally symmetrical analgesia at the level of the myelotomy. Based on the concept that fibers carrying nociceptive information cross at the anterior commisine of the spinal cord Complications/Patient Considerations • Risk of the intradural surgery itself

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CHAPTER 11 • • • • XI.

Dysesthesias Motor weakness Gate ataxia Bladder dysfunction

Percutaneous Chordotomy Definition • The destruction of spinal cord fibers for the relief of unilateral pain caused by malignant disease • The injection of local anesthetic is used to insert a chordotomy needle into the patient's spine. CT (computerized tomography) imaging is used to determine the correct placement of the needle tip

A radiofrequency (RF) high temperature generator is used and the surgeon performs electro-stimulation creating a destructive thermal lesion Rationale/Goal • A non-pharmacological approach for management of intractable cancer pain • The procedure is a palliative one, not a cure for the primary disease, i.e. cancer Complications/Patient Considerations • Procedure used when systemic pharmacological therapies have not provided adequate pain relief or the patient experiences intolerable side effects with pharmacological regimens tried to relieve the patient's pain • Candidates for percutaneous radiofrequency cordotomy meet individual pain center criteria but generally would: • Have unilateral, somatic, and cancer related pain • A life expectancy of, or require pain relief, for no fewer than 18 months • Achieve inadequate pain relief by the conventional pharmacological regimens (e.g, narcotics with or without non-steroidals and anti-inflammatory medications) • Patients are observed for approximately 48 hours after the procedure • Patients may experience interference with thermal and touching sensations in the affected region • All patients experience numbness over the affected body site • The pre-procedure use of anticoagulants is not a contraindication (eligibility may be still acceptable for platelet counts > 80,000 per mL and prothrombin time less than 18 seconds) for the RF chordotomy procedure, but these patients must be closely monitored y during the first postoperative day

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CHAPTER 11 Bibliography Criscuolo C. Interventional Approaches to the Management of Myofascial Pain Syndrome. Current Pain and Headache Reports. 2001; 5(5): 407-411. Hahn M, McQuillan P, Sheplock G. Regional Anesthesia: An Atlas of Anatomy and Techniques. Philadelphia, PA: Mosby; 1996. Kapural L, Mekhail N. Anesthetic Techniques in Pain Management. Current Pain and Headache Reports. 2001; 5(6): 515-524. Tollison C, Satterwaite J, Tollison J. Practical Pain Management. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002. Tuna O. Percutaneous Chordotomy for Managing Cancer Pain. AORN Journal. 2001; 74(3): 361, 364, 366-369, 371-378. Waldman S. Interventional Pain Management. 2nd ed. Philadelphia, PA: WB Saunders; 2001.

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Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Preceptor Signature____________________________________________________

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Perform a pain assessment. CRITERIA: 1. Assess location of pain. 2. Assess pain intensity using a pain scale. 3. Obtain a description of the quality of pain. 4. Seek a description of onset and duration of pain. 5. Obtain information of the pain aggravating and alleviating factors. 6. Seek information on the impact of pain on activities of daily living. 7. Describe pain behavior indicators. 8. Assess causes for multiple causes of pain. 9. Perform re-assessment to examine the response to medication intervention for pain. 10. Communicate and document all pertinent information per facility/unit specific policy/protocol.

PAIN MANAGEMENT: ASSESSMENT Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Performs with Assistance

Independent

Date__________________________

Date__________________________

Observed

Retake & Date

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

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364

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Provide care for the patient experiencing pain. CRITERIA: 1. Define pain-related terms. 2. Describe nonpharmacologic interventions for pain. 3. Describe the rationale for administration of pharmacologic agents for pain. 4. List potential side effects of pharmacologic interventions for pain management. 5. List precautions and monitoring required during pharmacologic interventions for pain management. 6. State the rationale for discontinuing pharmacologic interventions for pain management. 7. Communicate and document all pertinent information per facility/unit specific policy/protocol.

PAIN MANANGEMENT: INTERVENTIONS Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting

ASPAN 2009 Edition

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Discusses with Preceptor

Pass & Date (90%)

Provide care for the patient using patient controlled analgesia (PCA). CRITERIA: 1. State the rationale for patient administration of PCA. 2. State desired outcomes of PCA therapy. 3. Identify who can order the administration of PCA. 4. List three (3) opioids that can be administered using a PCA. 5. List five (5) potential adverse effects of PCA administration. 6. State common examples for drug concentration, incremental, and basal ranges, and lockout intervals for opioids used during PCA administration. 7. List steps in initiating PCA administration. 8. Demonstrate proper PCA pump setup and implementation. 9. State the process for timing and verification of PCA. 10. List monitoring parameters for a patient receiving PCA. 11. State parameters for changes in patient status that warrant notification of the physician. 12. State emergency treatment measures if there are severe complications from the administration of the PCA. 13. Communicate and document all pertinent information per facility/unit specific policy/protocol. Meets Criteria Does Not Meet Criteria Re-Validate – Meets Criteria Employee Signature____________________________________________________

PAIN MANAGEMENT: PATIENT CONTROLLED ANALGESIA (PCA) Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

365

366

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

CRITERIA: 1. State the rationale for epidural opioid administration for pain management. 2. Identify the location of the epidural space. 3. State mechanism of action for opioids administered into epidural space. 4. State desired outcomes of epidural analgesia. 5. State contraindications to epidural analgesia. 6. List potential complications associated with epidural analgesia. 7. State medications used in epidural analgesia. 8. State characteristics of drugs administered during epidural analgesia. 9. List potential adverse effects of meds administered for epidural analgesia. 10. Describe symptoms of severe complications from epidural analgesia when the epidural is not in the correct location. 11. List steps in initiating epidural analgesia. 12. List monitoring parameters after epidural analgesia. 13. Describe the procedure to assess a patient’s dermatome level. 14. State parameters for complications requiring notification of the MD. 15. State emergency treatment measures if there are severe complications from the administration of the epidural analgesia. 16. Communicate and document all pertinent information per facility/unit specific policy/protocol.

Provide care for the patient receiving epidural analgesia via continuous infusion.

PAIN MANAGEMENT: EPIDURAL ANALGESIA Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting

ASPAN 2009 Edition

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Discuss key aspects of Chronic Regional Pain Syndrome. CRITERIA: 1. Define Chronic Regional Pain Syndrome. 2. Discuss the causes/risk factors of Chronic Regional Pain Syndrome. 3. Review the pathophysiology of Chronic Regional Pain Syndrome. 4. Describe the symptoms of Chronic Regional Pain Syndrome. 5. Discuss the treatment of Chronic Regional Pain Syndrome. 6. Discuss the prognosis of Chronic Regional Pain Syndrome.

PAIN MANAGEMENT: CHRONIC REGIONAL PAIN SYNDROME Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

367

368

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Discuss key points in equianalgesic dosing. CRITERIA: 1. Review and discuss the equianalgesic dosing charts in the chapter text.

PAIN MANAGEMENT: EQUIANALGESIC DOSING Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting

ASPAN 2009 Edition

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Discuss and apply the basic principles of Comfort Theory to Perianesthesia nursing. CRITERIA: 1. Describe the unique properties of a holistic theory. 2. Define basic comfort terms (underlined terms) and list basic principles of Comfort Theory. 3. Describe the relationship between comfort and pain.

ADVANCED COMFORT: INTRODUCTION Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

369

CHAPTER 11

370

A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting

ASPAN 2009 Edition

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Provide comfort interventions for the patient experiencing discomfort in any context. CRITERIA: 1. Describe the design of comfort interventions. 2. Describe patient responses (adverse or positive) to comfort interventions that were administered. 3. Communicate and document all pertinent information regarding pain and comfort per facility/unit specific policy/protocol.

ADVANCED COMFORT: OVERVIEW Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

371

372

Independent

Date__________________________

Performs with Assistance

Preceptor Signature________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Date____________________

Employee Signature________________________________________________

Meets Criteria Does Not Meet Criteria

Demonstrate the ability to perform a thorough pain assessment, and to measure, plan, implement, and evaluate appropriate pain and comfort management in the infant, child, and adolescent. CRITERIA: 1. Describe the differences between assessment and measurement. 2. Discuss assumptions and beliefs regarding neonates and infants. 3. Discuss the pharmacokinetics of medications in the pediatric patient. 4. Describe pharmacologic / non-pharmacologic (behavioral) and adjuvant therapies.

PAIN AND COMFORT MANAGEMENT: PEDIATRICS Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Name_______________________________________________________

Competency Based Orientation for the Perianesthesia Nurse

CHAPTER 11

A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting

ASPAN 2009 Edition

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Provide effective assessment of pain for the geriatric patient. CRITERIA: 1. Use appropriate pain scale or scales. 2. Consider level of cognition when assessing the elderly.

PAIN AND COMFORT MANAGEMENT: GERIATRICS Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

373

374

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Provide perioperative pain management care to the geriatric patient that is not influenced by myths, perceptions, or unfounded beliefs. CRITERIA: 1. Identify misconceptions regarding pain in the elderly.

PAIN AND COMFORT MANAGEMENT: GERIATRICS Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting

ASPAN 2009 Edition

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Discuss patient’s current metabolic and physiologic status when providing pain management. CRITERIA: 1. Define consequences of inadequate pain relief. 2. Identify age related changes regarding absorption, distribution, metabolism, and excretion/elimination of medications.

PAIN AND COMFORT MANAGEMENT: GERIATRICS Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

375

376

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Identify the most effective dosing schedules and routes of administration. CRITERIA: 1. Use appropriate dosing schedules. 2. Describe adverse effects of medications.

PAIN AND COMFORT MANAGEMENT: GERIATRICS Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting

ASPAN 2009 Edition

Independent

Date__________________________

Performs with Assistance

Preceptor Signature____________________________________________________

Observed

Retake & Date

Date__________________________

Re-Validate – Meets Criteria

Discusses with Preceptor

Pass & Date (90%)

Employee Signature____________________________________________________

Meets Criteria Does Not Meet Criteria

Describe interventional pain therapies used in the perianesthesia setting. CRITERIA: 1. Describe interventional pain therapies including definition, rationale/goal, and complications/patient considerations: • Trigger Point Injections • Intercostal Blocks • Epidural Steroid Injection • Facet Blocks • Intravenous Regional Block (Bier Block) • Gasserian Ganglion Block • Sympathetic Block • Neurolytic Block • Hypophysectomy • Commissural Myelotomy • Percutaneous Chordotomy

PAIN MANAGEMENT: INTERVENTIONAL PAIN THERAPIES Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with “N/A.” Competency Statement

Written Competency Test

Competency Based Orientation for the Perianesthesia Nurse Name_______________________________________________________ Date____________________

CHAPTER 11

377