Pain Management
Deborah L. Gentile
Barbara St. Marie
KEY TERMS
Dermatomes
Epidural
Intraspinal
Intrathecal
Lock-Out Interval
Multimodal Analgesia
Persistent Pain
Range Orders
Titration to Effect
ROLE OF NURSES IN PAIN MANAGEMENT
The prevalence of pain, the disparities in treatment, the increase of vulnerable populations with pain, as well as understanding that when pain is persistent, it becomes a chronic disease, all relate to the importance of prevention or management of pain for individuals and populations. Pain has been deemed a public health challenge (Institute of Medicine, 2011). Nurses across all clinical settings are in a unique position to impact pain management. As a discipline, nurses have a tremendous opportunity to engage in the practice of pain management. The nurse’s role in pain management is broad, and the nursing process—assessment, diagnosis, outcomes identification, planning, implementation, and evaluation—is well suited for this patient population. Furthermore, the capacity of nurses to be an advocate, educator, change agent, and interprofessional collaborator gives nurses a noticeable advantage as they care for the patient in pain.
In addition to the skill sets mentioned above, a number of influencing factors shape the role of the nurse in pain management. Regulatory bodies, standards of care, practice guidelines, and institutional policies and procedures all impact the extent and manner in which nurses provide pain management. The responsibilities of all disciplines involved in
pain management are delineated in The Joint Commission (TJC) standards. TJC standards focus on health care provider orientation, education, patient rights, patient education, and postoperative care and contain wording specific to pain management (TJC, 2012). In recent years, evidence-based recommendations, guidelines, and position statements for pain management have been developed by such groups as the American Society of Anesthesiologists Task Force on Acute Pain Management (Horlocker et al., 2010), the American Society for Pain Management Nursing (ASPMN), and the Institute of Medicine (IOM, 2011). Additionally, the scope and standards of practice for pain management nursing were developed in a joint venture involving ASPMN and the American Nurses Association (ANA) and apply to both the nurse generalist and the nurse specialist in pain management. Institutional policies and procedures guide nurses through definitions, responsibilities, assessment and management expectations, and educational requirements for pain management. Influencing factors change as pain management practice evolves and new knowledge becomes available.
pain management are delineated in The Joint Commission (TJC) standards. TJC standards focus on health care provider orientation, education, patient rights, patient education, and postoperative care and contain wording specific to pain management (TJC, 2012). In recent years, evidence-based recommendations, guidelines, and position statements for pain management have been developed by such groups as the American Society of Anesthesiologists Task Force on Acute Pain Management (Horlocker et al., 2010), the American Society for Pain Management Nursing (ASPMN), and the Institute of Medicine (IOM, 2011). Additionally, the scope and standards of practice for pain management nursing were developed in a joint venture involving ASPMN and the American Nurses Association (ANA) and apply to both the nurse generalist and the nurse specialist in pain management. Institutional policies and procedures guide nurses through definitions, responsibilities, assessment and management expectations, and educational requirements for pain management. Influencing factors change as pain management practice evolves and new knowledge becomes available.
Change Management and Quality Improvement
Even with the many advances in pain management strategies, pharmacology, technology, and techniques, pain continues to be poorly managed. Nurses play a key role in making and maintaining pain management as a strategic priority across all health care venues. The need to improve the quality of patient pain outcomes is imperative for the patient’s overall health. Box 20-1 identifies select physical and physiological harmful effects of unrelieved pain.
EVIDENCE FOR PRACTICEWhat are the effects of unrelieved pain on patient mobility, postsurgical complications, hospital performance, and the cost of care?
BOX 20-1 EXAMPLES OF PHYSICAL AND PHYSIOLOGICAL EFFECTS OF UNRELIEVED PAIN
Cardiovascular Sympathetic nervous system activation: hypercoagulation, increased heart rate, blood pressure, cardiac workload, oxygen demand
Gastrointestinal Stress response causes increase in sympathetic nervous system activity: intestinal secretions, smooth muscle sphincter tone increase, decreased gastric emptying and intestinal motility
Endocrine Excessive hormone release: carbohydrate, protein, and fat catabolism, poor glucose use, decreased insulin, decreased testosterone
Adapted from Wells, N., Pasero, C., & McCaffery, M. (2008). Improving the quality of care through pain assessment and management. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Chapter 17). Rockville, MD: Agency for Healthcare Research and Quality (US). http://www.ncbi.nlm.nih.gov/books/NBK2658/
Furthermore, the quality of pain management impacts the public assessment of health care organizations. To that end, the nurse’s role as a change agent cannot be underestimated. Innovations in pain management have transformed the practice. It is important for nurses to understand basic change management strategies and the use of quality improvement methods in all practice settings.
The Centers for Medicare & Medicaid (CMS) are a driving force for institutions to redesign pain management models of care. In the 1940s, Kurt Lewin developed a model for organizational change that remains relevant and widely used. He described three stages of change: (a) unfreeze, (b) change, and (c) refreeze (Burnes, 2004). If nurses understand and use these stages, they can develop a plan to manage each step of the pain management change process in their respective facilities. The first stage is vital to success in any change effort. It involves generating motivation for the change. It may seem obvious that a problem with effective pain management is the reason enough for change, but there are other factors that influence the stakeholders of any organization struggling with this issue.
The following steps will be valuable to “unfreeze” the way pain management is performed. First, the change should be data driven. The most convincing and least threatening motivator for change to occur in practice is accurate data. Second, align the change with organizational values and strategic goals. And third, identify resistance to change and take time to engage in discussion about fears while recognizing elements of past and current practices that are positive. A comprehensive communication plan about an improvement project or practice change is vital to success.
During Lewin’s second stage, “change,” health care providers begin to embrace the practice change. During this stage, the health care team learns new skills, understands principles around these new skills, and begins to see the positive impact on their patient outcomes and satisfaction. They recognize the personal and organizational benefit of the newly introduced practice. Some of these changes will be time sensitive, but also be aware that each person moves at his or her own pace in adopting practice change.
Lewin’s third stage or “refreezing” reflects adoption of the practice change and its maintenance. The data may begin to improve and provide evidence that supports the change. At this point, it is important that all components of the practice change are carried out in a consistent manner. Consistency will create a sense of stability around the change. A celebration of success is recommended to thank everyone involved in the change for their dedication in improving pain management (Bridges, 2009). Well-planned, clear communication throughout the change process is essential to the success of the change effort.
Quality improvement methods provide an operational model to guide improvement processes. One of the most widely used models is the Plan, Do, Study, Act (PDSA) framework developed by Langley, Nolan, and Nolan (1994). The PDSA cycle mirrors the stages of change described above (Figure 20-1). When the cycle is applied to pain management quality improvement projects, it provides a framework to guide design, measurement, implementation, and improvement of a change process. If the improvement project has multiple phases, a PDSA cycle is used to guide each phase. Batalden and Stoltz (1993) developed a worksheet of useful questions to consider when creating a PDSA cycle (Table 20-1).
Measurement and the need for data are identified in the processes of change and quality improvement. Quality measures or indicators related to pain and its management are a source of improvement opportunities. Pain management and the patient’s perceptions of pain management are some of the categories of quality indicators recommended for organizations to monitor. One quality indicator is a time indicator, such as the “median time to
pain management for long bone fracture” (Agency for Healthcare Research and Quality, 2011). Another example is the time in minutes that it takes from the moment that a patient enters the emergency department until the patient receives an oral or parenteral pain medication. Patient satisfaction with pain management is an example of another outcome quality indicator. Two questions that all acute care patients are asked after discharge are illustrated in Figure 20-2. These originated from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, initiated as a requirement for hospitals receiving Medicare reimbursement. These questions and others are publicly available for use. The results from patient surveys are also available and grouped at the hospital level. Reviewing results for the hospital or unit may provide opportunities for improvement.
pain management for long bone fracture” (Agency for Healthcare Research and Quality, 2011). Another example is the time in minutes that it takes from the moment that a patient enters the emergency department until the patient receives an oral or parenteral pain medication. Patient satisfaction with pain management is an example of another outcome quality indicator. Two questions that all acute care patients are asked after discharge are illustrated in Figure 20-2. These originated from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, initiated as a requirement for hospitals receiving Medicare reimbursement. These questions and others are publicly available for use. The results from patient surveys are also available and grouped at the hospital level. Reviewing results for the hospital or unit may provide opportunities for improvement.
 FIGURE 20-1 Plan, Do, Study, Act Cycle. (Adapted from Langley, G., Nolan, K. M., & Nolan, T. W. (1994). The foundation of improvement. Quality Progress, 27, 81.) |
TABLE 20-1 QUESTIONS TO CONSIDER FOR PLAN-DO-STUDY-ACT (PDSA) OR QUALITY IMPROVEMENT PROCESS | ||||||||||
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Staff Education
Interprofessional staff education encompasses all levels of licensed independent practitioners (LIPs), nursing, advanced practice nurses, and physician’s assistants. Throughout this chapter, we refer to this group of professionals collectively as physician/LIP, emphasizing the key requirements for quality pain management (Box 20-2). The term licensed independent practitioner originated with TJC and is used in standards for privileging and credentialing. According to TJC, an LIP is “any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges.” When standards reference the term “licensed independent practitioner,” this language is not to be construed to limit the authority of a LIP to delegate tasks to other qualified health care personnel (e.g., physician/LIP’s assistants [PAs] and advanced practice registered nurses [APRNs]) to the
extent authorized by the state law or a state’s regulatory mechanism or federal guidelines and organizational policy” (Medscape, 2013).
extent authorized by the state law or a state’s regulatory mechanism or federal guidelines and organizational policy” (Medscape, 2013).
 FIGURE 20-2 Examples of pain management questions to assess patient perceptions of pain management from the HCAHPS survey. (From Centers for Medicare & Medicaid Services. (2013). HCAHPS: Patients’ Perspectives of Care Survey. http://www.hcahpsonline.org/files/HCAHPS%20V8.0%20Appendix%20A%20-%20HCAHPS%20Mail%20Survey%20Materials%20(English)%20March%202013.pdf) |
BOX 20-2 KEY REQUIREMENTS FOR EFFECTIVE PAIN CONTROL
Assessment
Intervention
Reassessment
To educate only nurses leads to frustration due to the inability to initiate change without challenging the health care team responsible for prescribing treatment. Such conflicts can become unpleasant. Education is an expensive process for institutions with limited resources. Developing self-learning packets for the interprofessional team may expedite access to necessary information involved with change. Interdisciplinary health care team education may also be accomplished through lectures, newsletters, or blogs accessed through e-mail.
To move pain management forward as a profession, a collaborative approach is needed. Pre- and postevaluation of the knowledge and attitudes of all disciplines regarding pain should be implemented within a predetermined time frame. Often, the projection of negative attitudes toward people in pain or with coexisting substance use disorder and pain can be changed through mentoring in real time. Patient education should coincide with staff education so that everyone has consistent and clear expectations of the options available.
Interprofessional Pain Management Teams
The multidimensional nature of pain requires an interprofessional approach to pain management. Many acute care facilities have a team of pain experts to consult and provide recommendations for challenging problems with pain. Team members represent a number of disciplines and may include such roles as pain resource nurses, pain clinical nurse specialists, nurse practitioners, physicians/LIPs who are pain specialists, LIPs, pharmacists, pain psychologists, and addiction specialists. Patients with complex pain syndromes that involve pain with underlying pathophysiology comprise a combination of pain caused by tissue damage (nociceptive) and nerve damage (neuropathic) and may require the advanced knowledge and skills in pain management provided by an interprofessional pain team (Portenoy et al., 2006; Webster, 2008). Consultation by a pain team is also appropriate for treatment of refractory pain, comorbidities, high risk for complications, substance use disorder, or concurrent mental health conditions such as untreated depression or anxiety that pose barriers to effective pain management. There is consensus among pain management professionals that pain and mental health disorders cannot be treated as separate entities (ASPMN, 2012). The integration of a variety of pain management options requires the involvement of the interprofessional health care team (Box 20-3).
DEFINITIONS OF PAIN
The classic definition of pain that nurses have embraced for years is, “Pain is whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1968, p. 95). This definition captures the subjectivity of the pain experience and reminds health
care providers of the importance of listening to our patients and partnering as we design a pain management plan. The definition of pain from the International Association for the Study of Pain (IASP) recognizes the sensory and emotional components of pain as well as the fact that pain may exist without evidence of tissue injury. “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (IASP Task Force on Taxonomy, 1994). These definitions lay the groundwork for insight into the phenomenon of pain and may serve to guide our treatments.
care providers of the importance of listening to our patients and partnering as we design a pain management plan. The definition of pain from the International Association for the Study of Pain (IASP) recognizes the sensory and emotional components of pain as well as the fact that pain may exist without evidence of tissue injury. “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (IASP Task Force on Taxonomy, 1994). These definitions lay the groundwork for insight into the phenomenon of pain and may serve to guide our treatments.
BOX 20-3 OPTIONS FOR PAIN CONTROL
Systemic analgesics and adjuvant medications (administered orally, rectally, transdermally, intramuscularly, IV, subcutaneously, by continuous infusion, or by patient-controlled analgesia [PCA])
Intraspinal opioids, including epidural and intrathecal
Regional analgesia using local anesthetic agents
Topical anesthetic agents
Nonsteroidal anti-inflammatory drugs
Electrical analgesia through transcutaneous electrical stimulation or electroacupuncture
Psychological analgesia in the form of hypnosis, relaxation techniques
Types of Pain
Historically, we classify pain according to location, intensity, duration, or underlying mechanism (Arnstein, 2010). The location of the pain may help the clinician determine the etiology of pain and if there is a fixable solution, for example, a fracture or infection. Pain intensity ratings are widely used in practice and allow the patient to rank pain on a numeric rating scale ranging from 0 to 10, with 10 representing the most intense pain. When using the numeric rating scale, 0 to 3 corresponds to mild pain, 4 to 6 corresponds to moderate pain, and 7 to 10 corresponds with severe pain. Helping patients maintain lower pain intensity scores is always considered successful treatment. Duration and underlying mechanism are closely aligned because the duration of pain may change the underlying mechanism. This is the case with acute pain and chronic/persistent pain.
ACUTE PAIN
Acute pain, such as that caused by surgery, childbirth, and trauma, adds to the overall health care burden. The IASP designated October 2010 through October 2011 as the Global Year against Acute Pain. An estimated 100 million surgeries take place annually with 80% of surgical patients reporting postoperative pain (IASP, 2012).
Nociceptors are sensory receptors that respond to a potentially damaging noxious stimulus and can be thermal, chemical, electrical, or mechanical in nature (Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011). The duration of acute pain can last seconds to days.
The autonomic nervous system responds to acute pain by increasing the sympathetic drive. When the sympathetic drive is increased, there is an increase in heart rate, respiratory rate, blood pressure, but there is also vasoconstriction, and a decrease in peristaltic action. This response is a protective mechanism that serves to create a flight-or-fight response. The cause of acute pain is usually known and persists until the underlying cause is resolved. Factors that influence postoperative pain may be found in Box 20-4.
The autonomic nervous system responds to acute pain by increasing the sympathetic drive. When the sympathetic drive is increased, there is an increase in heart rate, respiratory rate, blood pressure, but there is also vasoconstriction, and a decrease in peristaltic action. This response is a protective mechanism that serves to create a flight-or-fight response. The cause of acute pain is usually known and persists until the underlying cause is resolved. Factors that influence postoperative pain may be found in Box 20-4.
Postoperative pain varies with the individual, and the nurse should remain cognizant of variables associated with pain. A relatively minor surgery with little trauma may create high pain intensity scores for an individual. A complex surgical procedure may create minimal to moderate pain intensity for an individual. We cannot assume that we are able to anticipate the level of pain following surgery. Universally, nurses must advocate for the patient by ensuring that their pain rating is valued and everything is being done to manage their pain well.
Practice guidelines for acute pain management in the perioperative setting have been developed for the interprofessional community of providers who deliver care under the supervision of anesthesiologists by the American Society of Anesthesiologists Task Force on Acute Pain Management. A number of position statements addressing acute pain management have been developed by ASPMN. Two examples are “Pain Management in Patients with Substance Abuse Disorders” (Oliver et al., 2012) and “Pain Assessment in the Patient Unable to Self-Report” (Herr, Coyne, McCaffery, Manworren, & Merkel, 2011). It is expected that all nurses manage their patients’ pain well. Patients benefit when nurses study for and take the Pain Management Nursing examination through the American Nurses Credentialing Center. A Core Curriculum for Pain Management Nursing (St. Marie, 2010) exists to advance nurses’ knowledge in pain management.
CHRONIC (PERSISTENT) PAIN
In the United States, it has been estimated that 100 to 130 million people suffer from chronic pain (Fishbain, Johnson, Webster, Greene, & Faysal, 2010; IOM, 2011). This rate is higher than that of diabetes (American Diabetes Association, 2011), heart disease (Roger et al., 2011),
and cancer (American Cancer Society, 2012) combined. In recent years, there has been a shift from the term “chronic” pain to “persistent” pain, to relieve patients of the stigmatization associated with chronic pain. Persistent pain may or may not have a known nociceptive input and has no autonomic response (Litwack, 2009; Rosner, 1996). Injury or disease may cause persistent pain, but it is perpetuated by factors that are seemingly unrelated or remote from the original cause (Turk & Okifuji, 2010). Persistent pain has been described using chronological markers of 3 to 6 months duration or it’s described as pain that extends beyond the expected period of healing. Recent conceptualizations of persistent pain characterize it as extending for a long period of time and/or represent low levels of underlying pathology that does not explain the presence or extent of the pain (Turk & Okifuji, 2010). Persistent pain is now thought of as a chronic disease and can be a result of central sensitization (Sluka, O’Donnell, Danielson, & Rasmussen, 2012).
and cancer (American Cancer Society, 2012) combined. In recent years, there has been a shift from the term “chronic” pain to “persistent” pain, to relieve patients of the stigmatization associated with chronic pain. Persistent pain may or may not have a known nociceptive input and has no autonomic response (Litwack, 2009; Rosner, 1996). Injury or disease may cause persistent pain, but it is perpetuated by factors that are seemingly unrelated or remote from the original cause (Turk & Okifuji, 2010). Persistent pain has been described using chronological markers of 3 to 6 months duration or it’s described as pain that extends beyond the expected period of healing. Recent conceptualizations of persistent pain characterize it as extending for a long period of time and/or represent low levels of underlying pathology that does not explain the presence or extent of the pain (Turk & Okifuji, 2010). Persistent pain is now thought of as a chronic disease and can be a result of central sensitization (Sluka, O’Donnell, Danielson, & Rasmussen, 2012).
BOX 20-4 FACTORS THAT INFLUENCE POSTOPERATIVE PAIN
Site, nature, and duration of the surgical procedure
Type of incision location
Degree of intraoperative trauma
Physiologic and psychological features characteristic of the patient
Preoperative education preparation
Amount of preoperative pain or past pain experiences
Presence of complications
Intraoperative management of pain
Anesthetic management before, during, and after surgery
Quality of postoperative care
INPATIENT
When patients on chronic opioid therapy for treatment of their persistent pain are admitted to the hospital for acute treatment that requires further pain management, they may find opioids used for the acute pain is not as effective with usual expected dosing. They may require two to three times the opioid dose of someone who does not have opioid tolerance.
PATIENT SAFETYThe side effect of respiratory depression can remain problematic even in those with opioid tolerance, and safety parameters for closer monitoring need to be implemented.
Multimodal analgesia is a rational approach for managing pain through various pathways and techniques. Preoperative plan for postoperative analgesia would include regional analgesia techniques and opioid and nonopioid analgesics. Knowledge of the amount of opioids used by the patient is gleaned through two methods, medication reconciliation and reviewing the state prescription drug monitoring program. When interviewing the patient, determine the dose and frequency of opioids as accurately as possible (do not accept a vague answer to amount of opioids, this information needs to be accurate) and document the findings in the medical record. A health care provider with a Drug Enforcement Agency (DEA) number and access to this data bank can access records indicating the Scheduled II opioids and benzodiazepines prescribed to the patient within a requested time frame. These databases are updated routinely through community and hospital pharmacies. If the patient is receiving opioids or benzodiazepines from a Veterans Administration Hospital (VAH), or VA-affiliated nursing facilities including assisted living facilities, or methadone clinics, the opioids may or may not be included in this database, depending on the state. This information can be shared with the patient during the medication reconciliation interview to collaboratively determine how much opioid the patient actually consumes. The goal is to accurately understand the baseline use of opioids to estimate the patient’s tolerance and probable range of postoperative opioids and nonopioid analgesics. Opioid-tolerant patients continue to require close monitoring on a monitored or unmonitored nursing unit during the early postoperative period (Swenson, Davis, & Johnson, 2005).
OUTPATIENT
There are clinical guidelines for opioid use in chronic noncancer pain that support safe and effective chronic opioid therapy (Chou et al., 2009). One of the most important recommendations addresses patient selection and risk stratification for opioid therapy. Risk stratification can help the prescriber determine the risk involved with prescribing opioid therapy and the monitoring strategies needed for this. In the outpatient setting, there are other strategies used to manage persistent pain problems. These strategies involve various nerve blocks, trigger point injections, implantable spinal cord stimulators, and implantable intraspinal infusion pumps. Patients who may benefit from pain control technology experience pain from spinal cord injuries or have pain that is refractory to conventional methods of pain control.
MECHANISMS OF PAIN
Classifying pain according to its underlying mechanism provides the interprofessional team a means to determine how the pain is transmitted and how to intervene. There are peripheral and central mechanisms of pain that transmit nociceptive and neuropathic pain signals. Nociceptive pain occurs when a normally functioning nervous system is alerted to tissue damage. Nociceptive pain serves as an alarm system to tell us that something is wrong and requires attention. Somatic pain is a type of nociceptive pain that originates in the skin, muscles, bone, or soft tissue. The character, intensity, and location of this type of pain are closely aligned with the type and extent of the injury (Arnstein, 2010). Another type of nociceptive pain is visceral pain. Visceral pain involves hollow and solid organs. It is more diffuse than somatosensory pain and can be referred to distant locations making it difficult for patients to clearly describe the exact pain location.
Neuropathic pain is related to damaged or malfunctioning nerves caused by disease, injury, or unknown reasons (Arnstein, 2010). Neuropathic pain may occur in the peripheral or central nervous systems. Peripheral neuropathy may be experienced by many people with diabetes. Someone with a spinal cord injury may experience central neuropathic pain. Not all patients who suffer nerve damage experience neuropathic pain. The mechanisms involved in this type of pain are very complex, and it is a difficult type of pain to manage.
PAIN MANAGEMENT STRATEGIES FOR THE INFUSION NURSE
Opioids
The term opioid analgesics are preferred to other terms such as narcotics or opiates. Opioids are effective when they bind with particular opioid receptors in the body. This section addresses only the mu and kappa receptor agonists. The mu receptor is the most powerful opioid receptor and requires binding with opioids that have an affinity to mu such as morphine sulfate, hydromorphone, and fentanyl citrate. Examples of opioid analgesics with an affinity to the kappa receptor are nalbuphine and buprenorphine HCl (Buprenex®). When a person takes a mu agonist such as morphine and also takes a kappa agonist such as nalbuphine, nalbuphine will compete with morphine so that morphine is no longer able to create analgesia. Furthermore, if the patient is physically dependent on long-term mu agonist opioid therapy, and receives a kappa agonist, he or she may experience physical withdrawal.
Demerol, or meperidine hydrochloride, is an opioid analgesic and has been well documented as problematic by the American Pain Society (2008) and the U.S. Agency for Health
Care Policy and Research Acute Pain Guidelines. When a patient receives meperidine, the body creates a metabolite called normeperidine. As the administration of meperidine continues, the normeperidine accumulates, creating toxicity resulting in seizures (Latta, Ginsberg, & Barkin, 2002).
Care Policy and Research Acute Pain Guidelines. When a patient receives meperidine, the body creates a metabolite called normeperidine. As the administration of meperidine continues, the normeperidine accumulates, creating toxicity resulting in seizures (Latta, Ginsberg, & Barkin, 2002).
The route of administration should reflect careful consideration of optimal and timely response. Intramuscular injections are painful, making it necessary for the patient to endure pain before receiving relief. A common misconception is that opioid dosing by the IV route is equal to the IM route (American Pain Society, 2008).
SIDE EFFECTS
Side effects and complications associated with opioids may be found in Box 20-5. Opioid-induced sedation and respiratory depression are two of the most serious opioid-related adverse events. An expert consensus panel, at ASPMN, reviewed the scientific evidence and developed guidelines. Content of these guidelines includes assessment and monitoring practices for adult hospitalized patients receiving opioid analgesics for pain management. Interventions for patient care, education, and system-level changes should focus on promoting quality care and patient safety (Jarzyna et al., 2011).
Sedation is an expected and common adverse effect when beginning opioid therapy and when doses are increased (Pasero et al., 2011). Sedation precedes respiratory depression. The Pasero Opioid-induced Sedation Scale (POSS) is a valid and reliable instrument used to assess advancing sedation during opioid therapy. The POSS consists of five levels of sedation from sleep to somnolent with minimal or no response to verbal and physical stimulation. Assessment using the POSS is one element of monitoring patient safety during pain management with opioid analgesics. If the electronic medical record does not have POSS available for assessment, then the organization should explore having it added or devise a cue for nurses to document sedation. The assessment is simple, fast, and vital to the safety of the patient receiving opioids.
Unintended opioid-induced advancing sedation can result in respiratory depression. Respiratory depression has been defined as < 8 respirations per minute (Dahan, Aarts, & Smith, 2010). Clinically significant respiratory depression has been described as a decrease in the rate and depth of respirations from the patient’s baseline and not entirely based on
a specific number of respirations per minute (Pasero et al., 2011). Respiratory depression is caused by an accumulation of carbon dioxide in the blood, which communicates with the brain (medulla oblongata) to slow respirations until the carbon dioxide level returns to normal. All opioids can depress brain stem-regulated ventilation, producing a dose-dependent reduction in respiratory rate (Yaney, 1998).
a specific number of respirations per minute (Pasero et al., 2011). Respiratory depression is caused by an accumulation of carbon dioxide in the blood, which communicates with the brain (medulla oblongata) to slow respirations until the carbon dioxide level returns to normal. All opioids can depress brain stem-regulated ventilation, producing a dose-dependent reduction in respiratory rate (Yaney, 1998).
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