Optimizing perioperative pain management

AORN Journal,  Nov, 2002  by Paul Arnstein

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Relief of pain and alleviation of suffering are among the responsibilities of all nurses, regardless of population served, specialty, or practice setting. Given that 23 million surgical procedures are performed per year and pain is estimated to be undertreated in half of all cases, improving perioperative pain management is a worthy endeavor. (1) A decade ago, research-based clinical practice guidelines were issued by the US Department of Health and Human Services urging health care professionals to implement simple and effective strategies to improve the way pain is managed for patients with surgical, traumatic, or other acutely painful conditions. (2) Since then, accreditation organizations and case law have upheld patients' right to pain control and the duty of nurses to assess and relieve pain. Recent studies, however, suggest that the majority of hospitalized patients have untreated or undertreated pain. (3)

Pain accompanies or follows virtually every surgical procedure; therefore, perioperative nurses are challenged to prevent pain when possible, assess for pain, implement safe and effective interventions to relieve pain as soon as it is detected, and provide vigilant follow-up to maintain satisfactory comfort levels. Part of this challenge involves changing the organizational culture that allows uncontrolled pain to persist. This culture may be based on the outdated notion that experiencing pain is harmless, perhaps even an opportunity to strengthen one's character. Also outdated is the belief that pain medication, even when properly used, is more dangerous than unrelieved pain.

THE PROBLEM WITH UNCONTROLLED PAIN

Perioperatively, uncontrolled pain may harm patients by impairing cardiac (eg, increasing heart rate, coronary vascular resistance, myocardial oxygen consumption), pulmonary (eg, hypoventilation, atelectasis, hypoxemia), and endocrine (eg, impaired metabolism, hormonal imbalances) functioning. (4) A growing body of research supports the link between serious postoperative complications (eg, deep vein thrombosis, postoperative infections, sepsis, paralytic ileus, acute renal failure) and uncontrolled pain. (5) Additionally, pain interferes with sleep, impairs immune functioning, and lowers the quality of life for patients and their significant others. (6)

Uncontrolled postoperative pain can affect a person's life long alter the surgical incision is healed. Unrelieved severe pain produces physical and chemical neuroplastic changes in the spine and brain in such a way that prolongs and intensifies the pain experience. (7) Evidence shows that if severe pain is allowed to persist for more than 24 hours, neuroplastic processes change the structure and function of the nervous system, increasing the intensity, duration, and distribution of pain while contributing to the development of incurable chronic pain. (8)

Supporting the need to prevent pain when possible, several studies have shown that the use of preincisional local anesthetics dramatically reduces postoperative pain for days and months after surgery, up to one year. (9) When pain persists for more than one year, the majority of patients become disabled, depressed, and contemplate suicide. (10) Uncontrolled postoperative pain has been shown to hasten tumor metastasis and death in animals. (11) Thus the quality, and perhaps the quantity, of life depends on the effective control of perioperative pain.

WHAT PERIOPERATIVE NURSES CAN DO

Beyond advocating for the routine use of preemptive analgesia, perioperative nurses must assess for the presence and intensity of pain. According to new Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Centers for Medicare and Medicaid Services standards, pain must be assessed in all patients initially and at regular intervals. Pain reassessment must occur at transition points of care (eg, transfers to and from the OR, transfers to and from the postanesthesia care unit [PACU]). Also, the assessment and measurement of pain intensity must be recorded in a manner that facilitates regular implementation, evaluation, and reassessment of pain relieving interventions. (12)

Pain assessment. The patient's verbal report of pain is considered the most accurate measurement available. Accreditation standards for the initial assessment of patients with pain state that a measure of pain intensity and quality (eg, pain character, frequency, location, duration) is appropriate. Assessment of the intensity of, quality of, and responses to treatments are required after any procedure (eg, line insertion, surgery). Nurses can use the acronym COLDERR when taking a patient's history to remember the components of pain. The acronym stands for

* character--sensation (eg, sharp, aching, burning);

* onset--when pain started, how it has changed;

* location--where it hurts (ie, all locations);

* duration--whether pain is constant versus intermittent in nature;

* exacerbation--factors that make pain worse;

* relief--factors that make pain better (eg, medications); and