16.5: Pain Management
By the end of this section, you will be able to:
- Describe pharmacological therapy in pain management
- Identify nonpharmacological therapy in pain management
- Recognize how patient-controlled analgesia (PCA) is used for pain management
Nurses have a responsibility to provide multimodal pain management (ANA Center for Ethics and Human Rights, 2018). Pain management should include different interventions and focus on helping patients improve their quality of life (National Center for Injury Prevention and Control, 2022).
Pain management requires collaboration with the entire interdisciplinary team. Involving specialists such as neurologists, surgeons, and physical therapists can help manage patients’ pain (Dydyk & Grandhe, 2023). Pain can be managed by pharmacological and nonpharmacological therapy. The most effective pain management uses a combination of pharmacological and nonpharmacological interventions.
Pharmacological Therapy
A type of therapy called pharmacological therapy can be very effective in treating pain. Pharmacological therapy is the use of medication to treat a disease, illness, or medical condition. The type of medication depends on the type, duration, and severity of the pain (Ford, 2019). There are three main types of pain medications: opioid analgesics, nonopioid analgesics, and adjuvants. An analgesic is a medication used to relieve pain. When administering pain medications, the nurse must consider the patient’s goals for pain relief and determine if past medications have been effective. The nurse must also consider if the patient is experiencing any side effects that may impact the patient and be aware of contraindications (AHRQ, 2019). Patients should be involved and engaged in their pain management plan. Research has shown improved patient outcomes when patients work together with the healthcare team to manage their pain.
Opioid Analgesics
An opioid analgesic is a powerful prescription medication that helps reduce pain by blocking pain signals. Common opioids include codeine, morphine, fentanyl, oxycodone, and tramadol. Different opioids have different amounts of analgesia, ranging from codeine used to treat mild to moderate pain, up to morphine, used to treat severe pain (Table 16.2). Opioids are commonly administered orally or intravenously, but can also be administered rectally, subcutaneously, intramuscularly, or through the skin.
| Generic Name | Trade Name(s) | Route | Adult Dosages |
|---|---|---|---|
| Codeine with acetaminophen | Tylenol #3 | PO | 30 mg/300 mg |
| Hydrocodone with acetaminophen | Lortab, Norco, Vicodin | PO |
5 mg/300 mg or 325 mg
10 mg/320 mg or 325 mg 5 mg/500 mg |
|
Oxycodone (immediate release and extended release)
or Oxycodone with acetaminophen |
Oxycodone (IR), OxyContin (ER)
Percocet, Roxicet |
PO
PO |
5–10 mg
5 mg/325 mg |
| Fentanyl | Duragesic, Sublimaze | Transdermal IM IV |
12–100 mcg/hr
0.5–1 mcg/kg 0.5–1 mcg/kg |
| Hydromorphone | Dilaudid |
PO
Rectal SubQ, IM, and IV |
4–8 mg
3 mg 1.5 mg (may be increased) |
| Morphine | Duramorph, MS Contin, Oramorph SR, Roxanol | PO and rectal SubQ, IM, and IV |
30 mg (may be increased)
4–10 mg (may be increased) |
Opioids have a high risk of addiction and overdose, so it is important to consider other forms of pain management before prescribing opioids (National Center for Injury Prevention and Control, 2022). The Centers for Disease Control and Prevention (CDC) recommends avoiding opioids for pain management in patients younger than 18 years old and to avoid opioids as first line therapy for chronic pain (Dowell et al., 2022). First line therapy is medical treatment that is recommended as the best option for the initial treatment of a disease or medical condition.
It is important that patients are informed about the side effects and risks of opioids. Side effects of opioids include the following:
- addiction
- confusion
- constipation
- drowsiness
- itching
- nausea and vomiting
- overdose
- physical dependence
- respiratory depression
- tolerance
Constipation, nausea, and vomiting are common side effects of opioids. Opioids slow peristalsis and cause increased reabsorption of fluid into the large intestine, resulting in slow-moving, hard stools. Nurses should educate patients on preventing constipation with a bowel management program including stool softeners, fluids, well-balanced diet, and physical activity (as allowed with pain/postsurgical restrictions) to aid in preventing constipation. Because opioids slow gastrointestinal mobility, nausea and vomiting can also occur when taking opioids. Typically, patients will build enough tolerance against nausea and vomiting after taking opioids for a few days. Respiratory depression is one of the most serious potential side effects of opioids. Nurses must closely monitor patients receiving opioids for respiratory depression and administer naloxone to reverse the opioid effects if needed.
As important as pain management is, it is also crucial that healthcare providers are mindful of prescribing opioids to treat pain due to the high risk of addiction and overdose. Addiction is a chronic disease of the brain pursing reward and/or relief by substance use. Patients suffering from addiction have trouble stopping the use of opioids and often struggle with addiction for the rest of their life. Patients can also struggle with tolerance and physical dependence with opioid misuse. Tolerance is when the body builds up resistance to a medication. Physical dependence is when the patient experiences physical symptoms of withdrawal, such as anxiety, diaphoresis, and muscle cramps, when stopping a medication (National Center for Injury Prevention and Control, 2022).
Healthcare providers must be vigilant to avoid addiction and overdose with opioid use especially with the current opioid epidemic in the United States. Opioids can be very effective in pain management when used appropriately, but healthcare providers must monitor for serious side effects (ANA Center for Ethics and Human Rights, 2018).
Disclaimer: Always follow the facility policy for medication administration.
Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
Knowledge: Examine human factors and other basic safety design principles as well as commonly used unsafe practices.
Skill: Demonstrate effective use of strategies to reduce risk of harm to self or others. The nurse will:
- Avoid distractions and disruptions when preparing and administering medications.
- Have a second nurse witness any wasted opioid medication and document the wasted amount.
- Perform hand hygiene before administering medications.
- Perform a comprehensive pain assessment on the patient prior to medication administration.
- Verify the patient’s information prior to medication administration.
- Monitor for adverse effects after medication administration.
- Perform a comprehensive pain assessment after medication administration to assess effectiveness.
Attitude: Value the contributions of standardization and reliability to safety.
Nonopioid Analgesics
Nonopioid analgesics are another effective form of pain management. A nonopioid analgesic is a type of medication that includes nonsteroidal anti-inflammatory drugs (NSAIDs) used for acute and chronic pain relief. Other nonopioid analgesics include acetaminophen, anticonvulsants, lidocaine, tricyclic and tetracyclic antidepressants, and serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants (National Center for Injury Prevention and Control, 2023). Acetaminophen is used to treat mild pain and fever but does not have anti-inflammatory properties. Acetaminophen is often administered orally but can be administered rectally or intravenously. There is a risk of severe liver damage when taking too much acetaminophen or consuming a large amount of alcohol while taking acetaminophen. Nonopioid analgesics have high risks in certain patient populations such as older adults, pregnancy, and patients with liver, cardiovascular, kidney, and gastrointestinal disease (National Center for Injury Prevention and Control, 2023). It is important for nurses to educate these patient populations about the side effects of nonopioid analgesics and the importance of limiting the amount consumed.
NSAIDs provide mild to moderate pain relief while also reducing fever and inflammation by inhibiting the production of prostaglandins. NSAIDs can be used along with opioids for severe pain. Common NSAIDs include ibuprofen, naproxen, ketorolac, and aspirin (Table 16.3). Ibuprofen and naproxen are commonly prescribed NSAIDs and can be taken several times a day. Ketorolac can help treat breakthrough pain and is indicated for short-term management of moderate to severe acute pain . Common side effects of NSAIDs include nausea and vomiting, gastrointestinal bleeding, and kidney failure. There is an increased risk of heart attack, heart failure, and stroke if patients take more NSAIDs than prescribed or longer than directed.
| Drug Name | Administration Considerations | Adverse/Side Effects |
|---|---|---|
| Ibuprofen |
|
|
| Aspirin |
|
|
| Ketorolac |
|
|
| Naproxen |
|
|
Adjuvant Analgesics
An adjuvant analgesic is a type of medication that is not classified as an analgesic but has been found to have an analgesic effect along with opioids (Table 16.4). Adjuvant medications include antidepressants and anticonvulsants such as gabapentin and amitriptyline. Adjuvant analgesics can be very effective for neuropathic pain but may not be as effective for somatic or visceral pain (Jacques, 2022).
| Drug Name | Administration Considerations | Adjuvant Effect | Adverse/Side Effects |
|---|---|---|---|
| Amitriptyline |
|
Decrease feelings of chronic pain |
|
| Gabapentin |
|
Decreased neuropathic pain |
|
| Prednisone |
|
Reduce inflammation |
|
| Baclofen |
|
Relieve muscle spasms and spasticity |
|
| Lidocaine topical |
|
Relieve local pain |
|
Antidepressants can help control how pain signals are delivered to and processed by the brain. Amitriptyline is a tricyclic antidepressant that can help treat neuropathic pain . Amitriptyline can cause sedative effects, so it is usually administered at bedtime. Anticonvulsants can block certain types of pain signals and help decrease neuropathic pain (Jacques, 2022). Gabapentin is an anticonvulsant that can also treat neuropathic pain and restless leg syndrome. Side effects of gabapentin include mental health changes, drowsiness, and weakness.
Other medications such as corticosteroids, muscle relaxants, and topical agents can also help reduce pain. Corticosteroids decrease inflammation and topical agents can be directly applied to the skin to decrease pain (Jacques, 2022). Adjuvant analgesics can help reduce pain in a variety of ways but are not always effective on their own.
Nonpharmacological Therapy
A type of therapy called nonpharmacological therapy can be very effective when used in conjunction with pharmacological therapy. The Joint Commission recommends that healthcare providers use at least one nonpharmacological pain intervention when creating a pain treatment plan (The Joint Commission, 2020). Nonpharmacological therapy is any intervention that helps reduce pain without using medication. Nonpharmacological therapy can include psychological, emotional, and environmental therapies.
Psychological and emotional therapies can be incorporated into the daily lives of patients and can be especially useful in treating chronic pain . Psychological and emotional therapy can include relaxation techniques, music, breathing, art therapy, distraction , meditation, or cognitive behavioral therapy. Changing the environment can also help patients manage their pain. Adjusting lighting, sounds, and temperature to a more relaxing environment has been shown to reduce pain (Ford, 2019). Exercise and physical therapy can also help reduce pain without the side effects of pharmacological therapy. Patients can easily incorporate nonpharmacological therapy such as physical therapy into their daily lives without risks.
Physical Therapy
Many healthcare providers prefer using physical therapy over pharmacological therapy when treating pain (Nall, 2021). Physical therapy involves working with a trained professional to use exercise and movement to improve strength and flexibility. Physical therapy can help chronic conditions such as arthritis, nerve pain, and fibromyalgia (Figure 16.11) (Nall, 2021).
Research shows that physical therapy and exercise improves mobility and overall quality of life (Nall, 2021). Physical therapy and exercise can also lead to weight loss, which can reduce joint and back pain. Exercise can also promote relaxation and stress reduction. Yoga combines movement with breathing and meditation. Yoga can help improve strength, balance, flexibility, and mental health (Nall, 2021).
Physical therapy and exercise do not need to be intense or complicated to be effective. Nurses should educate patients about easy ways to incorporate movement into their daily lives and can help patients find a level of physical therapy that works for them.
Massage
Massages can help relax patients and provide pain relief by loosening tight muscles. A massage is a form of therapeutic touch where a therapist uses touch and pressure to loosen tight muscles and tendons. Touch and pressure block pain signals, which relieves pain and improves the blood flow to tight muscles, which in turn can promote relaxation (Nall, 2021).
Patients should be cautious with massages if they have a skin rash, infection, certain cardiovascular diseases, or are pregnant. Otherwise, there are minimal risks and side effects with massage (Nall, 2021). Sometimes, patients may experience pain during the massage due to the intense pressure of the therapist. Nurses can educate patients to ask their massage therapist to use varying amounts of pressure to provide relaxation and pain relief.
Guided Imagery
A relaxation technique called guided imagery can help ease pain and promote relaxation. It is a technique that uses images or scenes to invoke positive and relaxing feelings. The goal of guided imagery is to stimulate natural relaxation responses to reduce pain, slow breathing, decrease blood pressure and heart rate, and decrease feelings of stress (West, 2022).
Guided imagery can be done with or without direction. Once patients are familiar with guided imagery practice, it is easy to incorporate it into their daily lives. Guided imagery consists of imagining anything the patient deems as relaxing or calming. For example, a patient may imagine being on the beach on a warm, sunny day and listening to the ocean sounds. Another patient may imagine their body fighting off cancer or a chronic illness and being able to function without pain. The image can be whatever the patient chooses, but they should try to engage all their senses during guided imagery (West, 2022). Patients can also use a therapist, an audio recording, or an app to direct them through guided imagery.
The process of guided imagery includes the following steps:
- Choose a quiet place without distractions.
- Get in a comfortable position and close your eyes.
- Focus on whatever image you choose and engage all your senses.
- Continue to add more details to the scene and visualize the scene for as long as is needed.
- Gradually open your eyes and reengage with the present environment (West, 2022).
Guided imagery can be especially helpful in patients with chronic pain . Patients who suffer from pain on a daily basis often seek alternative therapies to help manage their pain. Guided imagery can be an easy method for patients to incorporate into their daily lives and on the go.
Guided imagery scripts can be used to help promote relaxation and reduce pain. Guided imagery scripts can be tailored toward specific scenarios, such as sleep promotion, pain reduction, or reducing panic attacks.
Distraction
Another important tool for nurses to use in pain management is distraction . Distraction is a method that moves patients’ attention away from pain (Ibitoye et al., 2019). Distraction moves patients’ attention away from pain by modifying the nociceptive responses to decrease pain. Methods of distraction include music, videos, conversation, games, interactive toys, and controlled breathing. Music specifically can help reduce pain and relax patients. Music is often used as a pain reduction tool before, during, and after surgery. Research has found that listening to music when having surgical procedures can help reduce anxiety and pain (Nall, 2021).
Distraction can especially help reduce pain in pediatric patients. Blowing bubbles, playing games, and watching videos can help reduce anxiety and pain in children. Younger children are more easily distracted, and more invasive interventions can often be avoided if distraction is used effectively in pain management (Trottier et al., 2019).
Biofeedback
Biofeedback is a technique that uses visual or auditory feedback to control bodily functions such as heart rate and breathing patterns. During biofeedback therapy, sensors are used to measure bodily functions and show changes with different adjustment methods. When the body is in pain, physical factors such as heart rate, respiratory rate, and muscle contraction can change. Biofeedback helps a patient recognize these changes and make a conscious effort to relax. Decreasing heart rate and respiratory rate, as well as relaxing muscles, can help stimulate pain reduction in patients. Patients who suffer from chronic pain are ideal candidates for biofeedback therapy, as patients typically need multiple sessions to see results. Biofeedback is a popular nonpharmacological pain intervention due to its minimal risk and side effects (Mayo Clinic staff, 2023).
Biofeedback machines are available in physical therapy clinics, hospitals, and outpatient clinics. Some biofeedback machines are now available for home use. During biofeedback therapy, electrical sensors will monitor brain waves, body temperature, muscle contraction, heart rate, and respiratory rate. A healthcare provider will monitor these sensors and make suggestions to the patient to try to alter these bodily functions. Over time, the patient can learn to make these alternations without monitoring (Mayo Clinic, 2023).
Patient-Controlled Analgesia
Hospitalized patients with severe pain may receive patient-controlled analgesia (PCA) , which allows the patients to safely self-administer opioid medications using a programmed pump. PCA is used to treat acute, chronic, labor, and postoperative pain. A computerized pump contains a syringe of opioid analgesics and is connected directly to a patient’s intravenous (IV) line. Doses of medication can be self-administered as needed by the patient by pressing a button. However, the pump is programmed to only allow administration of medication every set number of minutes with a maximum dose of medication every hour. These pump settings, and the design of the system requiring the patient to be alert enough to press the button, are safety measures to prevent overmedication that can cause sedation and respiratory depression. For this reason, no one but the patient should press the button for administration of medication (not even the nurse). In other cases, the PCA pump delivers a small, continuous flow of pain medication intravenously with the option of the patient self-delivering additional medication as needed, according to the limits set on the pump. PCA is useful for patients who have acute pain due to conditions such as trauma, burns, or pancreatitis (Pastino & Lakra, 2023). Patients with mild chronic pain may be good candidates for PCA.
Nurse:
David, BSN
Clinical setting:
Medical ICU
Years in practice:
1
Facility location:
Hospital in a small town in Nevada
I had just started working in the medical ICU at my hospital as a new graduate nurse. Our orientation was about ten weeks, and I was almost to the end of my orientation. I was working with my preceptor but was pretty much doing everything on my own at that point.
We would occasionally get postsurgical patients, and that day I was assigned my first postsurgical patient. I was told this patient had undergone surgery to repair a femur fracture and would be in traction and have a PCA. The patient was coming to the ICU from the operating room (OR) in the next thirty minutes. I was very nervous, but my preceptor reassured me that I could handle this patient assignment.
When the patient arrived, they were screaming in pain and had wires and lines everywhere from the OR. Together with my preceptor and charge nurse, we quickly got the patient into the room and connected to the monitors. We surveyed the lines and verified the medications that were currently running. The OR nurse and anesthesia gave a quick report as they “had to get moving on the next case.” I was surprised that I did not get a chance to ask any questions. My preceptor said that often happens with postsurgical patients and we can always call the OR if we have questions later.
I then went to look at my patient’s PCA pump. I was nervous because I had never seen a PCA pump and was not sure what it was. I remember hearing about them in nursing school but had no clue what I was supposed to do with it. My preceptor helped me look up the medication dose and rate in the MAR and showed me how to verify that the pump was set to the correct dose. She showed me how to document the dual nurse sign-off and the volume remaining in the pump. She then told me it was important to ensure the patient knew how to use the pump. The patient was fully awake from anesthesia and was able to answer our questions appropriately. My preceptor told me that you cannot let a confused or sedated patient use a PCA pump because they cannot always understand how it works. The patient verbalized our teaching and answered our pain assessment questions.
Throughout the rest of my shift, I frequently checked the PCA and the patient’s pain levels. The patient expressed minimal pain throughout my shift and used the PCA periodically. I was shocked that the PCA managed to control the patient’s pain so well right after surgery. My preceptor explained that PCA was a common form of pain management after surgery because it works so well. Even though setting up and managing the PCA was scary, I am glad I had the experience and the support of my preceptor to learn a new skill.
Benefits of PCA
The ability of the patient to self-administer pain medication has been shown to increase patient satisfaction and deliver timely pain interventions (Pastino & Lakra, 2023). It also reduces the stress of the nurse and patient of having to adhere to a dosing schedule of PRN analgesics that may not be adequate to treat the patient’s pain. PCA may be a good option for patients who are unable to tolerate oral pain medications or for patients who have breakthrough pain and need frequent dosing. The patient can time their own medication according to the pain severity for better pain reduction and control.
Nursing Considerations for PCA
PCA pumps must have certain orders relating to the bolus dose , basal rate , and lockout time . The bolus dose is the dose that the patient receives each time they press the button on the PCA pump and is used for breakthrough pain. The basal rate is the continuous rate of the medication that maintains effective pain management. The lockout time is the amount of time after a bolus dose that the pump will not administer medication to the patient, even if they press the button, to prevent overdose. The PCA doses may be dependent on the type of medication, IV site, patient’s weight, current research, and facility guidelines (Pastino & Lakra, 2023). It is important to review your facility’s guidelines when programming PCA dosing.
There are contraindications for PCA. If the patient cannot understand how the PCA works and follow directions, they would not be good candidates for PCA. Allergies, infection, increased intracranial pressure, chronic kidney failure, and bleeding disorders are also contraindications for PCA (Pastino & Lakra, 2023).
Side effects of PCA use are the same as opioids and include constipation, nausea and vomiting, urinary retention, and pruritus (itching). The most serious potential adverse effect of opioids is respiratory depression. Respiratory depression is usually preceded by sedation. The nurse must carefully monitor patients receiving opioids for oversedation, which results in decreased respiratory rate. Patients at greatest risk are those who have never received an opioid and are receiving their first dose, those receiving an increased dose of opioids, or those taking benzodiazepines or other sedatives concurrently with opioids. If a patient develops opioid-induced respiratory depression, the opioid is reversed with naloxone (Narcan) that immediately reverses all analgesic effect.
Nurses must follow facility guidelines when administering PCA and ensure that the pump is set up correctly. Many facilities have safeguards in place such as a dual nurse sign-off, scanning medications into the electronic medication administration record (eMAR) , and guardrails on the pumps to prevent medication errors. To document the amount and frequency of pain medication the patient is receiving, as well as to prevent drug diversion, the settings on the pump are checked at the end of every shift by the nurse as part of the bedside report. The incoming and outgoing nurses double-check and document the pump settings, the amount of medication administered during the previous shift, and the amount of medication left in the syringe.