10.4 Applying the Nursing Process to Pain Management

Now that we have reviewed basic concepts related to pain and several disorders requiring analgesic or musculoskeletal medication, let’s consider the nursing process and how it applies to administering these medications.

Assessment

Asking a patient to rate the severity of their pain on a scale from 0 to 10, with “0” being no pain and “10” being the worst pain imaginable is a common question used to screen patients for pain. However, according to The Joint Commission requirements, this question can be used to initially screen a patient for pain, but a comprehensive pain assessment is required for adequate pain management.

Nurses perform comprehensive pain assessments before and after administering analgesics. Many mnemonics are used to guide comprehensive pain assessment. See Figure 10.4^[1] for common nursing mnemonics for comprehensive pain assessment.

To adequately manage a client’s pain, it is important to also assess potential barriers that may contribute to inaccurate reports of the severity pain by individuals. Optimal pain management can be achieved by gathering subjective and objective data to accurately measure the severity of an individual’s pain. A person’s health can be negatively impacted if they under-rate or over-rate their pain level. Under-rated severe pain can interfere with an individual’s ability to complete activities of daily life and can contribute to anorexia, insomnia, and feelings of depression and anxiety. Additionally, some clients are not able to adequately communicate their pain. For example, for older adults with cognitive impairment, caregivers play an important role in documenting and communicating pain assessments to nurses and health care providers to ensure adequate treatment of pain.^[2],[3]

Visual Pain Rating Scales

Visual pain scales are commonly used as tools for assessing pain, especially with children and adults who have difficulty using the numerical pain rating scale. See Figure 10.5^[4] for the FACES Pain Rating Scale. To apply this scale, use the following evidence-based instructions. Explain to the client that each face represents a person who has no pain (hurt), some, or a lot of pain. “Face 0 doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.” Ask the person to choose the face that best represents the pain they are feeling.

Implementation

As with all medications, nurses check the rights of medication administration and consider the best route of administration for this client at this particular time. For example, if the client is nauseated and vomiting, then an oral route may not be effective.

When administering opioids, the nurse considers if the prescribed medication is appropriate for the client’s current level of pain. If there are concerns about appropriateness of the medication based on the client’s current status, the prescribing provider should be notified. See Table 10.4 for a list of common opioid medications used to treat moderate to severe pain.^[5] Notice that many opioids are combined with acetaminophen, so the maximum daily dosage of acetaminophen must be monitored.

Table 10.4 Common Opioid Analgesics Used to Treat Mild to Severe Pain

WHO Ladder

A general rule of thumb when administering analgesics is pain control should be based on the pain level reported by the client and the least invasive medication with the least side effects should be used to treat that level of pain. The WHO ladder was originally developed for selection of analgesics for clients with cancer. It illustrates the concept that pain control should be based on the level indicated by the client. See Figure 10.6^[6] for an image of the original WHO ladder.

The original WHO ladder consisted of three steps^[7]:

• First Step – Mild pain: Non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen are administered with or without adjuvants
• Second Step – Moderate pain: Weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid analgesics are administered with or without adjuvants
• Third Step – Severe and/or persistent pain: Potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, hydromorphone, oxymorphone) are administered with or without non-opioid analgesics, and with or without adjuvants

Adjuvant refers to medications typically used for indications other than pain but can be help in various painful conditions. Adjuvants include antidepressants (including tricyclic antidepressants [TCAs]), serotonin-norepinephrine reuptake inhibitors (SNRIs), anticonvulsants such as gabapentin and pregabalin, topical anesthetics such as a lidocaine patch), topical therapies such as capsaicin, corticosteroids, bisphosphonates, and cannabinoids.^[8]

The fundamental concept of the WHO ladder is that it is essential to thoroughly assess pain in each individual and then manage that pain by using appropriate medications. For clients receiving opioids, the optimum dosage for pain relief must be balanced with the side effects of the drug. Additionally, clients should receive health teaching about the uses and side effects of pain medications to avoid misuse without compromising their benefits.^[9]

The WHO ladder has undergone several modifications over the years and is currently used to manage other types of acute and chronic pain. A limitation of the original scale was the absence of nonpharmacological treatments in the pain management path. Consequently, a fourth step was added to the ladder. This fourth step includes numerous nonpharmacological procedures used for treating persistent pain, such as epidural analgesia, intrathecal administration of analgesic and local anesthetic drugs, neurosurgical procedures, and nerve blocks.^[10]

The updated WHO analgesic ladder focuses on the quality of life and extends the strategy to treat pain. For acute pain, the strongest analgesic (indicated for the reported severity of pain) is the initial therapy and later toned down, whereas, for chronic pain, a stepwise approach from bottom to top may be employed.^[11]

For example, if a client reports acute pain rated as “2,” then it is appropriate to start at the lowest rung of the ladder and administer a prescribed NSAID. However, it may be clinically indicated to start at “Level 3” on the WHO ladder for clients who present with severe, acute pain and administer a potent opioid like morphine.

Managing Side Effects

In addition to administering analgesics, nurses anticipate side effects/adverse effects and plan appropriate monitoring, as well as administering additional medication if needed. For example, an adverse effect of opioid analgesics is respiratory depression. After administering an opioid medication, the nurse plans to monitor the client’s respiratory rate and pulse oximetry level. Other common side effects of opioids include constipation or nausea, so the nurse anticipates administering medications such as stool softeners or antiemetics.

Health Teaching and Health Promotion

Nurses teach clients, their family members, and caregivers about appropriate pain management, pain medications, and symptoms to report that may indicate side effects/adverse effects. In addition to medication teaching, nurses also provide information about nonpharmacological therapy, including physical treatments (e.g., heat or cold therapy, exercise therapy, weight loss) and cognitive-behavioral treatments (e.g., distraction/diversion and cognitive behavioral therapy).

Controlled substances like opioids also have special regulations regarding storage, auditing counts, and disposal or wasting of medication. See more information about controlled substances in the “Legal/Ethical” chapter. If a nurse has a concern that a client or one of their family members is misusing controlled substances, the provider should be notified. Misuse refers to using illegal drugs and/or prescription drugs in a manner other than directed by the provider, such as using in greater amounts, more often, or longer than prescribed, or using someone else’s prescription.

Evaluation

Nurses evaluate and document the client’s response to the administered analgesics based on the medication’s onset and peak. With analgesic medications, the nurse typically evaluates the client for a decreased level of pain 30 minutes after IV administration and 60 minutes after oral medication. If the client’s pain level is not acceptable at that time, the nurse investigates alternate pharmacological and nonpharmacological treatments, such as aromatherapy, repositioning, hot or cold treatments, and listening to music.

Because the nurse is the client’s advocate, the health care provider should be notified if the client’s pain is not being adequately managed by the prescribed analgesics.