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Course Sample:
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About the Author
Carol Curtiss, RN, MSN
Carol Curtiss, RN, MSN, has been an advanced practice nurse since 1981. She is a nationally and internationally recognized speaker in pain and symptom management, end of life care, oncology care and communication skills. She is a clinical nurse specialist consultant and owner of Curtiss Consulting. Her work spans a variety of clinical settings, including ambulatory care, long term care, home care and hospice settings and she is a national Trainer for the End of Life Nursing Education Collaborative (ELNEC). Ms. Curtiss has presented more than 600 programs in 46 States and 11 countries outside the U.S. She co-authored Cancer Doesn?t Have to Hurt, a book for the public on cancer pain management, as well as more than 35 other professional publications, and served as national president of the Oncology Nursing Society. She received the Oncology Nursing Society Distinguished Service Award in 1999 and the June L. Dahl Pain Management Lectureship: Leadership in Systems Change in 2003 from the American Alliance of Cancer Pain Initiatives. She is an active member of the Oncology Nursing Society, the American Pain Society, the American Society for Pain Management Nursing and Sigma Theta Tau, Delta Mu Chapter.
Ms. Curtiss received her diploma in nursing from Massachusetts General Hospital School of Nursing, Boston, MA; her BS from American International College, Springfield, MA; and her Master of Science in Nursing from Yale University, New Haven, CT.
Introduction
Pain is the most common reason people seek health care in the U.S. (Ashburn & Lipman, 2004). Yet, unrelieved pain is a major public health epidemic. Causes of inadequate pain management have been identified as lack of knowledge by clinicians and the public, lack of priority for pain relief in the health care system, confusion between appropriate use and misuse/abuse of medications, negative misinformation about medications for pain, regulatory concerns, and lack of reimbursement for effective pain management.
Pain assessment and management is a core competency for health professionals and a basic right for all individuals seeking health care. This mandate was strengthened in 1999 when the Joint Commission on Accreditation of Health Care Organizations (JCAHO) implemented new standards to address pain and pain management in all health care settings accredited by JCAHO. Around the same time, the Veterans Health Administration launched a systems-wide effort to improve pain management for their patients. Health care practitioners are mandated to ask all patients about pain routinely, assess patients for pain at first point of contact, plan and implement strategies to reduce pain, and re-assess efficacy at routine scheduled intervals. Results of screening and assessment must be documented in a way that facilitates follow-up.
In acute care settings, pain is often identified as the 5th vital sign. Screening for pain and documentation of pain and pain relief parameters is completed at the same time as other routine vital signs like temperature, pulse and respiratory rate. In 2000, The American Nurses Association (ANA) House of Delegates endorsed the view of pain as the 5th vital sign. Pain is identified as one of several quality improvement indicators for 2003 and beyond by all 50 of State Medicare/Medicaid- mandated Quality Improvement Organizations (QIOs). The Federal Center for Medicare and Medicaid Services (CMS) selected pain as one of its publicly reported outcomes for long term care and home care organizations, with public reporting for acute care settings planned.
Whether mandated or not, effective pain assessment and management are key components of quality health care for all. However, in spite of published standards and guidelines existing for many years, unrelieved pain remains a significant public health problem. Education alone hasn?t changed practice. Sustained improvement in clinical practice requires professional and public education plus an organizational commitment to identify standardized pain assessment and management as a priority and implement policies and procedures to assure consistency, vigilance and competence.
The consequences of poor pain management are numerous:
- Prolonged pain and suffering destroys quality of life.
- Sleep deprivation, anxiety, depression and other significant affects on daily living result from untreated pain
- Pain causes difficulties with overall enjoyment of life, including work and family relationships.
- Pain causes long-term physical and psychological consequences.
- Unrelieved pain in the U.S. costs more than 100 billion dollars annually (Ashburn & Lipman, 2004).
Pain is always subjective. It involves the perception of a sensation as well as a response to the sensation. Pain is always unique to an individual. Self-report, whenever possible, is the "gold standard" for understanding a person?s experience with pain and pain relief. Only the person experiencing pain can know what his or her pain is like. For example, the perception of the individual experiencing postoperative pain may be quite different from the individual experiencing crushing chest pain or from pain caused by cancer. The meaning of pain from childbirth is very different than pain at the end of life.
All pain management is based on the individual response of the person with pain. Strategies that work for one person may not work at all for another person with similar pain. Algorithms can help with planning by using recommendations from published standards and guidelines, but individual response is unpredictable and will vary significantly from person to person. Although many medications and other interventions are available for pain relief, there is no one medication or modality that provides adequate pain relief for all. The science of pain transmission and pain management are advancing daily so health care providers must remain current about the science and art of pain management and new pain management strategies in order to be able to provide optimal relief for people with pain.
The management of pain is multidisciplinary. Pain itself is multidimensional and requires many disciplines to effectively find relief. A collaborative approach is necessary and should include the person with pain, nurses, physicians, physical therapists, psychological counselors and family members, among others, in order to provide successful pain management. The primary focus of the health care team should be to assist the person with pain to establish goals and to achieve his/her goals regarding pain relief. We must thoroughly assess and reassess the patient to ascertain individual beliefs, goals, values, and practices in order to provide optimal pain management.
Core competencies for health care providers include a basic understanding of the pathophysiology of pain and pain transmission, skills for accurate screening and assessment in both verbal and non-verbal/non-responsive individuals, knowledge of pharmacologic and non-pharmacologic interventions for pain relief, advocacy skills, and the ability to individualize the pain management plan based on each unique set of patient needs.
A Systems Approach to Improving Pain Management
Published standards and guidelines for all types of pain (Appendix A) are remarkably consistent in their recommendations for the assessment and management of pain. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) used the principles in these publications to create pain management standards that require accredited organizations to demonstrate the following (JCAHO, 2003):
- Recognize the right of patients to appropriate assessment and management of pain
- Screen for the presence and assess the nature and intensity of pain in all patients
- Record results of the assessment in a way that facilitates regular reassessment and follow-up
- Determine and ensure staff competency in pain assessment and management in the orientation of all new clinical staff
- Establish policies and procedures that support the appropriate prescribing or ordering of pain medications
- Ensure that pain doesn?t interfere with participation in rehabilitation
- Educate patients and families about the importance e of effective pain management
- Address patient needs for symptom management in the discharge planning process
- Incorporate pain management into quality improvement activities.
In order to improve pain screening, assessment and management for all patients throughout a health care system, organizations must make a systems-wide commitment to pain management. Pain must be viewed as a priority and an important clinical problem by administrators, clinicians, educators, and others. Continuous improvement is key.
Strategies that can help an organization improve the way pain is assessed and managed include the following (Gordon, Dahl & Stevenson, 2000):
- Form an interdisciplinary work group which examines and re-examines pain management issues and practices with the goal of continuous improvement.
- Analyze current practice and look for areas to improve
- Identify achievable goals
- Use regular quality improvement process to evaluate changes
- The work of this group is continuous and on-going in order to identify new opportunities for improvement.
- Create written standards for pain assessment and documentation to assure that pain is recognized, documented, and treated promptly.
- Base standards on published standards and guidelines
- Include minimum required frequencies for screening and assessment of pain in all individuals
- Select a standard published tool for screening and assessment for cognitively intact and cognitively impaired/non-verbal individuals. Select alternative tools for those unable to use the standard tool.
- Document in a way that facilitates reassessment and follow-up.
- Identify steps to resolve issues of unrelieved pain.
- Make information about pharmacologic and non-pharmacologic interventions readily available to clinicians as they plan care.
- In writing, identify clear accountability for pain management.
- Offer ongoing educational opportunities in pain management for staff, patients and families.
- Include information about pain management in orientation of new staff
- Identify pain assessment and management as core competencies for clinical staff during annual performance reviews.
- Create explicit policies and procedures to guide prescribing and the use of specialized techniques for analgesic administration.
- Eliminate unacceptable pain medications from formulary.
- Consider pre-printed orders to standardize pain care.
- Persist, persist, persist -Education alone will not change practice ? systems must be in place to identify pain management as a priority and to assure patients receive attentive pain care.
Pathophysiology and Classifications of Pain
Pain affects every body system, including immune response. Persistent pain can permanently damage or "re-wire" the nervous system, causing a permanent hypersensitivity response to pain in the future. Pain destroys quality of life, increases fatigue, can cause sleep deprivation, poor concentration, depression, increased suffering, poor appetite and a host of other complications. Whenever possible, prevent pain and treat it aggressively.
Pain is both a sensory and emotional experience. Let?s review the sensory portion of pain. The process of normal pain transmission is called nociception and involves an extraordinarily complex process that we are learning more about daily.
The process begins with transduction which occurs in the periphery. When a noxious stimulus causes tissue damage, the damaged cells release sensitizing substances that activate or sensitize nociceptors (nerve endings that are preferential to noxious stimuli and begin the process to relay the stimuli along the nervous system). Sensitizing agents released by damaged cells include: prostaglandins, bradykinin, serotonin, Substance P, histamine and others. These substances cause an ion change along the neuronal membrane creating energy called an action potential. The action potential continues delivering the message from the site of damage to the spinal cord, the brain stem and thalamus for processing. This series of steps is called transmission. Perception, or the conscious experience of pain, occurs in the cortex of the brain. Modulation is the final process when neurons originating in the brain stem descend to the spinal cord and release substances such as endogenous opioids, serotonin and norepinephrine that attempt to inhibit the transmission of nociceptive impulses back to the periphery.
Pain is classified as nociceptive, neuropathic, and mixed nociceptive and neuropathic pain. Pain resulting from the normal processing of stimuli described above is called nociceptive pain. Nociceptive pain is further subdivided into visceral and somatic pain. Somatic pain arises from bone, joint, muscle, skin, or connective tissue injury, is usually well localized, and is often described with words like aching or throbbing. Visceral pain arises from obstruction to or pressure on visceral organs such as the gastrointestinal tract, liver capsule, pancreas and other hollow organs. Pain from obstruction often presents as poorly localized, while pain from distention of organ capsules is sometimes more easily localized. Visceral pain may also radiate to other parts of the body.
Neuropathic pain results from an abnormal processing of sensory input by either the peripheral or central nervous system. Pain may be present as a result of injury or as a result of abnormal processing in the nervous system, without evidence of injury. People with neuropathic pain describe it with words like, burning, stabbing, shooting, electric-shock-like, numbness and tingling and other similar responses.
Centrally generated pain caused by injury to or irritation of either the peripheral or central nervous system is called deafferentation pain. Examples are phantom limb pain and burning pain occurring below the level of a spinal cord injury. Dysregulation of the autonomic nervous system, a malfunction causing autonomic abnormalities, is called sympathetically maintained pain. An example is chronic regional pain syndrome (CRPS), formally called Reflex Sympathetic Dystrophy (RSD) (McCaffery & Pasero, 1999).
Peripherally generated neuropathic pain is caused by abnormal processing or damage to peripheral nerves. Examples are trigeminal neuralgia, nerve entrapment, post-herpetic neuralgia and diabetic neuropathy.
Understanding the type of pain helps providers select appropriate interventions to treat pain. Most nociceptive pain will respond to the use of nonopioids and opioids titrated to effect, along with non-drug interventions. Approximately 30% of neuropathic pain will respond to the same interventions as nociceptive pain. The remaining percentage of neuropathic pain often requires the use of co-analgesics (sometimes called adjuvant medications) like tricyclic antidepressants, anticonvulsants and others. Listening for cues from the patient?s self report, along with a thorough history and physical examination, helps identify whether pain is nociceptive or neuropathic.
Pain is also classified as acute, or chronic (sometimes called persistent pain). Pain may be constant, intermittent, intermittent with acute flares or a combination.
Acute pain is self limiting, usually of fairly short duration and improves as healing occurs. Changes in vital signs and diaphoresis caused by the sympathetic nervous system?s "fight or flight" response often accompany acute pain. Examples of acute pain are acute fractures, pain from acute trauma, stress headache, and surgical wounds.
Persistent (chronic) pain does not go away on its own, may last longer than the injury or may occur without evidence of injury. With persistent pain, the sympathetic nervous system adapts and vital signs rarely change, even if pain is excruciating. In fact, the person may not "look" in pain at all, but may have a blunted, flat, "mask-like" expression on his/her face. Because people with persistent pain rarely look in pain and vital signs can not be used to evaluate the presence of pain, self-report is the most reliable indicator of pain and pain relief. Examples of persistent pain are arthritis pain, pain from diagnoses like cancer, AIDs, multiple sclerosis, chronic regional pain syndrome (CRPS) or fibromyalgia.
Most health care professionals are taught to look for moaning, groaning, grimacing, muscle guarding, diaphoresis and vital signs changes to evaluate pain. This data is accurate ONLY for acute pain! Individuals with persistent pain rarely demonstrate these changes and exhibit much more subtle signs of pain ? lack of sleep, poor appetite, irritability, and other less obvious signs and symptoms.
Differences in Individual Responses to Pain
Pain is a unique experience for each individual, even when the source of the pain is the same. Some of the reasons for these differences are physiologic responses, psychosocial views and experiences, and cultural and religious values and beliefs. A brief explanation follows:
Physiologic differences
Each person has her/his own "built-in" pain relieving mechanisms. We all manufacture endogenous opioids called endorphins and enkephalins. These substances are released as an internal protection when an individual is in pain, laughs, exercises or is under stress. Endogenous opioids and opioid analgesics we administer for pain actually attach to the same opioid receptors and work to relieve pain. The amount of endogenous opioids is genetically mediated and differs markedly from person to person. Those with a great ability to produce endogenous opioids have a strong internal mechanism to relieve pain not enjoyed by those who manufacture lower amounts of the substances. Pain response is physiologically individual.
How an individual responds to pain medications is wide, variable, and unpredictable. Even with similar pain, individual responses to medications, even within the same family of medication, may be very different from person to person. For example, ask your family or friends what medication each prefers for mild pain. Some will say acetaminophen; others will insist that aspirin, ibuprofen, ketoprofen, naproxyn sodium, or others will work best for them. They?ve tried alternatives and know the medication that works best. Perhaps you also have a "favorite" medication for mild pain. Physiologically, we all respond differently to medications and there is no way to predict the response. When one medication in a class is ineffective, another in the same class may help. This applies to medications in all classes, including nonopioids, opioids and co-analgesics.
The amount of medication required to relieve pain varies widely and unpredictably in each person. There may be a 6-10 fold difference or more (clinically, sometimes 100 fold difference) in the amount of medication needed to relieve similar pain in two different people (McCaffery & Pasero, 1999). Once again, response is variable and unpredictable. Therefore, titration to individual response and assessment are imperative.
Psychological differences
The meaning of pain often affects an individual?s response to pain. For example, a woman struggling with infertility quickly forgets the pain of her childbirth experience. Compare this with the meaning of pain and response to pain in a 37 year old woman suffering from severe rheumatoid arthritis whose pain causes an inability to concentrate on her work or to move about freely. The meaning attributed to pain will influence responses to pain.
Past experiences with pain and pain relief also affect the way a person responds to pain. Fear, anxiety and depression increase pain perception. Previous successful pain management experiences may give a person more confidence that pain can be relieved. Past experiences with unrelieved pain may increase anxiety in anticipation of a similar experience.
Cultural values and beliefs
An individual?s values and beliefs will influence the way a person responds to pain, pain relief, and acceptance or rejection of interventions to treat pain. Each of us is taught or experiences a set of learned behaviors, including how to respond to pain. Some are taught to be stoic, others to be verbal, and others to respond in ways that may be different from our own. We tend to be more comfortable and confident with our own ways of interpreting and responding to pain, and to undervalue responses of others that may be different from ours. Remember, there is no "correct" way to respond to pain ? only "different" ways. The challenge is to suspend judgment when an individual responds differently from us and to accept a person?s response to pain as unique, individual and correct for that person!
The meaning of pain, how one expresses pain, and acceptable treatments for pain may also be culturally influenced. For example, in some religions and some cultures, "voluntary pain" (enduring pain for a "greater good") is believed to result in benefits for the individual. In some cultures, expressing pain is seen as a sign of weakness. In other cultures, pain is not talked about at all because of concern that voicing pain may bring additional pain to family members. For other cultures, the expectation is that pain will be openly expressed and loudly voiced so that family members may comfort the individual and reduce the pain. Health care providers must include cultural assessment as part of the assessment process and understand an individual?s values and beliefs as we design plans for pain relief with the patient and family.
Some questions to elicit beliefs about pain are (Lasch, 2000):
- What do you call pain? What words do you use?
- Why do you think you have this pain?
- What does this pain mean to your body?
- Do you have concerns or fears about your pain?
- What are the chief problems this pain causes for you?
- What kind of treatment do you think will work?
- What remedies have you already tried?
- Have you seen a traditional healer? Do you want to?
- Who in your family, if anyone, do you talk to about your pain? May I discuss your pain with this person?
Assessment of Pain
Screening for pain
Screening for pain simply means using a screening tool to ask all patients/residents/clients whether or not pain is present and, if present, whether or not pain has changed since the last screening. Screening identifies pain and must trigger an assessment in those who report pain. Screening should be done, as indicated in written policy, at predetermined intervals ? for example, every shift or, in ambulatory or home care settings, every visit. Pain is often treated as a vital sign in acute care settings and evaluated, at minimum, each time vital signs are taken and more often if pain is unrelieved. In home care and long term care, screening for pain should occur along with other important clinical concerns. For example, in long term care, vital signs are not taken daily or even weekly unless there is a problem, but bowel screening occurs at least daily and sometimes more often. Screen for pain when screening for bowel function in long term care. Include a question about pain or comfort levels in routine questioning at each home care visit.
If policies exist indicating which standard tool to use, and the policy identifies a level of discomfort or pain that must be reported to licensed staff for further assessment, anyone can screen for pain. An example of such a policy is, "On a scale of 0-10, any report of pain at level 3 or above OR any level identified as unacceptable to the person with pain must be reported to the nurse (or other specific licensed provider) who will complete an assessment". With this policy in place, a certified/licensed nursing assistant, physical therapy assistant, family member or other individual can ask about pain as long as they are instructed to report pain levels to a designated person who can complete an assessment and plan strategies for relief. The ability to recognize and report pain is a basic competency for any individual in health care who interacts with patients/clients/residents.
Record screening results, along with other important clinical information, in the medical record in a way that is easy to track and which facilitates re-assessment and follow-up.
When a person reports pain, assessment must be completed to find more information about the problem, and to design a plan to intervene in the pain. Screening and documentation are not enough. The goal is to identify and do something to reduce pain. Screening and assessment without intervening to reduce pain is considered poor care.
Steps for Screening
- Develop and implement a written policy that identifies a minimum required frequency for screening (e.g.: every shift or every visit) for ALL patients/residents/clients, and identifies a level on the scale that requires further assessment and intervention.
- Select a standard tool appropriate for the individual patient/client/resident (see selected screening tools below).
- Teach the person how to use the tool and the purpose of screening for pain.
- Use the same tool for the person every time. Reinforce teaching.
- Record ratings in the medical record in a way that can be easily tracked and followed over time.
- When a person reports pain, complete a pain assessment to find more information about the pain and plan interventions to manage the pain.
- Continue to screen to evaluate the effectiveness of plan
A variety of reliable and valid screening tools are published. One commonly used scale is the 0-10 numeric scale. Pain is rated from 0 (indicating "no pain") to 10, (indicating the "worse possible pain") ( see Figure 1). For most people, pain reported at 1-4 is considered mild, 5-6 is moderate and 7-10 is severe (Cleeland, et. al., 1994). There are different variations of numeric scales that include a visual analog scale (VAS) or different ranges of numbers (e.g.: 1-5). The Wong-Baker Faces Scale (with numerical aspect) is appropriate for some children, some mentally challenged adults, and some patients with mild cases of dementia (Wong & Baker, 1988). An important point is to select one scale that is appropriate for the developmental level and abilities of the individual and use that scale each time screening and assessment are done.
Figure 1. SELECTED PAIN RATING SCALES
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