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Jan.10.2020

Pain Acute (Adult Inpatient)

Clinical Description

  • Care of the hospitalized patient experiencing an unpleasant sensation and emotional experience as a result of potential or actual tissue damage related to an injury or disease process.

Key Information

  • Pain is a symptom, not a diagnosis; it is what the person says it is (subjective, not objective).
  • Lack of physiologic response or absence of pain behavior (e.g., quiet, withdrawn, sleeping) should not be interpreted as absence of pain.
  • If the patient is unable to respond, assume pain is present during painful activity and procedures.
  • Autonomic responses will decrease with duration of pain and are a less reliable indicator over time; always consider the presence and impact of preexisting chronic pain.
  • Adequate pain control can increase functional ability, as well as reduce complications, recovery times and length of stay. Poorly managed or unrelieved acute pain can lead to the presence of chronic (persistent) pain.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Acceptable Pain Control and Functional Ability

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: Self Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • health literacy
    • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Pain Acute

Signs/Symptoms/Presentation

  • body posture tense
  • concentration poor
  • diaphoresis
  • eating pattern change
  • fidgeting
  • flat affect
  • generalized weakness
  • grimacing
  • guarding
  • irritability
  • moaning
  • pacing
  • pleasure or interest in activity decreased
  • reluctance to move
  • reluctance to perform self-care
  • report of pain
  • restlessness
  • rocking
  • rubbing
  • sleep pattern altered
  • splinting
  • undue quietness
  • withdrawn appearance

Vital Signs

  • heart rate increased
  • respiratory rate increased

Problem Intervention

Develop Pain Management Plan

  • Acknowledge patient as the expert in pain self-management.
  • Use a consistent, validated tool for pain assessment; include function and quality of life.
  • Evaluate risk for opioid use.
  • Set pain management goals; determine acceptable level of discomfort to allow for maximal functioning.
  • Determine mutually-agreed-upon pain management plan, including both pharmacologic and nonpharmacologic measures; integrate management of chronic (persistent) pain.
  • Identify and integrate past successful treatment measures, if able.
  • Encourage patient and caregiver involvement in pain assessment, interventions and safety measures.
  • Re-evaluate plan regularly.

Associated Documentation

  • Pain Management Interventions

Problem Intervention

Prevent or Manage Pain

  • Evaluate pain level, effect of treatment and patient response at regular intervals.
  • Minimize painful stimuli; coordinate care and adjust environment (e.g., light, noise, unnecessary movement); promote sleep/rest.
  • Match pharmacologic analgesia to severity and type of pain mechanism (e.g., neuropathic, muscle, inflammatory); consider multimodal approach (e.g., nonopioid, opioid, adjuvant).
  • Provide medication at regular intervals; titrate to patient response; premedicate for painful procedures.
  • Manage breakthrough pain with additional doses; consider rotation or switching medication.
  • Monitor for signs of substance tolerance (increased dose to reach desired effect, decreased effect with same dose).
  • Manage medication-induced effects, such as constipation, nausea, urinary retention, somnolence and dizziness.
  • Provide multimodal interventions, such as as physical activity, therapeutic exercise, yoga, TENS (transcutaneous electrical nerve stimulation) and manual therapy.
  • Train in functional activity modifications, such as body mechanics, posture, ergonomics, energy conservation and activity pacing.
  • Consider addition of complementary or alternative therapy, such as acupuncture, hypnosis or therapeutic touch.

Associated Documentation

  • Bowel Elimination Promotion
  • Complementary Therapy
  • Medication Review/Management
  • Sensory Stimulation Regulation
  • Sleep/Rest Enhancement

Problem Intervention

Optimize Psychosocial Wellbeing

  • Facilitate patient’s self-control over pain by providing pain information and allowing choices in treatment.
  • Consider and address emotional response to pain.
  • Explore and promote use of coping strategies; address barriers to successful coping.
  • Evaluate and assist with psychosocial, cultural and spiritual factors impacting pain.
  • Modify pain perception using techniques, such as distraction, mindfulness, guided imagery, meditation or music.
  • Assess for risk factors for developing chronic pain, such as depression, fear, pain avoidance and pain catastrophizing.
  • Consider referral for ongoing coping support, such as education, relaxation training and role of thoughts.

Associated Documentation

  • Diversional Activities
  • Spiritual Activities Assistance
  • Supportive Measures

Education

CPG-Specific Education Topics

Overview

  • risk factors

  • signs/symptoms

Self Management

  • activity

  • coping strategies

  • impact on employment

  • medication management

  • nonpharmacologic pain management

  • sleep/rest

When to Seek Medical Attention

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

Population-Specific Considerations

Geriatric

  • Renal and liver function studies, as well as serum protein levels, should be measured, especially in elderly adults, prior to starting certain medications, such as opioid and nonsteroidal anti-inflammatory agents.
  • Elderly adults are more likely to tolerate pain versus report it.
  • Decreased hearing or vision in the elderly adult may limit the use of pain assessment tools that rely on verbal and visual communication for interpretation.
  • In elderly patients with cognitive deficits, ineffective pain management may increase dementia-related behaviors, which may result in decreased pain treatment.

Pregnancy

  • Young women of childbearing age and those who are currently pregnant or lactating should have the specific risks of opioid use reviewed prior to administration.

References

  • Afolalu, E. F.; Ramlee, F.; Tang, N. K. Y. Effects of sleep changes on pain-related health outcomes in the general population: A systematic review of longitudinal studies with exploratory meta-analysis. Sleep Medicine Reviews. 2018;39, 82-97. doi:10.1016/j.smrv.2017.08.001 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • American Association of Critical-Care Nurses. (2013). Practice alert: Assessing pain in the critically ill adult. Aliso Viejo, CA: American Association of Critical-Care Nurses. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Benzon, H. T.; Rathmell, J. P.; Wu, C. L.; Turk, D. C.; Argoff, C. E.; Hurley, R. W. (2014). Practical management of pain. Philadelphia: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
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  • Drew, D. J.; Gordon, D. B.; Morgan, B.; Manworren, R. C. "As-Needed" Range Orders for Opioid Analgesics in the Management of Pain: A consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Management Nursing. 2018;19(3), 207-210. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
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  • IsHak, W. W.; Wen, R. Y.; Naghdechi, L.; Vanle, B.; Dang, J.; Knosp, M.; Dascal, J.; Marcia, L.; Gohar, Y.; Eskander, L.; Hanna, S.; Sadek, A.; Aguilar-Hernandez, L.; Danovitch, I.; Louy, C.; Yadegar, J. Pain and depression: A systematic review. Harvard Review of Psychiatry. 2018;26(6), 352-363. doi:10.1097/HRP.0000000000000198 [Metasynthesis,Meta-analysis,Systematic Review]
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  • Krupić, F.; Čustović, S.; Jašarević, M.; Šadić, S.; Fazlić, M.; Grbic, K.; Samuelsson, K. Ethnic differences in the perception of pain: A systematic review of qualitative and quantitative research. Medicinski Glasnik. 2019;16(1), 108-114. doi:10.17392/966-19 [Metasynthesis,Meta-analysis,Systematic Review]
  • Lee, J. H. The effects of music on pain: A meta-analysis. Journal of Music Therapy. 2016;53(4), 430-477. doi:10.1093/jmt/thw012 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • McClintock, A. S.; McCarrick, S. M.; Garland, E. L.; Zeidan, F.; Zgierska, A. E. Brief mindfulness-based interventions for acute and chronic pain: A systematic review. Journal of Alternative and Complementary Medicine. 2018; doi:10.1089/acm.2018.0351 Source[Metasynthesis,Meta-analysis,Systematic Review]
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  • Tick, H.; Nielsen, A.; Pelletier, K. R.; Bonakdar, R.; Simmons, S.; Glick, R.; Ratner, E.; Lemmon, R. L.; Wayne, P.; Zador, V. Evidence-based nonpharmacologic strategies for comprehensive pain care: The Consortium Pain Task Force white paper. Explore. 2018;14(3), 177-211. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
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Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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