Improving Post-operative Pain Management by Focusing on Prevention

Nursing BC, Oct 2004 by Reimer-Kent, Jocelyn

I work on a busy surgical floor. Recently, we seem to be short of patient controlled analgesic (PCA) pumps. When this happens, post-operative ward patients on PCA pumps are taken off earlier than usual to make the equipment available for patients coming out of the operating room. Once the PCA pump is removed, analgesics ordered to treat pain are meperidine intramuscularly (IM) PRN or acetaminophen with codeine orally (PO) PRN. Neither of these seems to provide effective pain relief. How can I ensure better pain control for my post-operative patients?

Several factors in your current pain management plan contribute to your dilemma, including

* using opioids as the primary analgesic to treat post-operative pain;

* switching abruptly from administering analgesics continuously via PCA pump to PRN;

* having poor PRN analgesics (meperidine and codeine) to choose from;

* administering analgesics by IM injection; and

* approaching post-operative pain in a reactive manner.

Improving post-operative pain management lies in focusing on prevention. A preventive approach should be a multi-modal approach whereby the dominant non-opioid is supported, as appropriate, by an opioid. The benefit of this approach is that non-opioids have an opioid-sparing effect. Therefore, the time that a client has to be on a PCA pump can be shortened or the need for a PCA pump can be eliminated. By understanding the importance of prevention, you will be able to ensure better pain control for your post-operative patients.

The Pain Experience and the Importance of Prevention

Pain is a condition for which treatment is based on applying objectivity to a subjective experience. The patient's experience of pain may be subjective, but the potential adverse effects to the patient's bio-psychosocial-spiritual well-being (if post-operative pain is prolonged and unrelieved) clearly are not.

We often think in terms of the adverse effects of analgesic/opioid overdose that can cause problems such as respiratory depression, but what about the preventable adverse effects of analgesic underdose that cause needless pain and suffering? Unrelieved pain can increase the risk of post-operative mortality and morbidity from illnesses such as pneumonia, deep vein thrombosis, pulmonary emboli, myocardial infarction, delirium and chronic pain. Unrelieved pain may also help to explain why a patient may have a more labile emotional status after surgery as well as why a patient may be unable to maintain healthy functioning within a family unit and/or social system during recovery.

Following surgery, individual patients receive care from several registered nurses prior to discharge. Consequently, pain management is often fragmented. For example, the operating room nurse transfers the patient to the recovery room nurse who, within a few hours, transfers care of the patient to the ward nurse. While in the ward, the patient's care is transferred among registered nurses as they leave and come on shift. Finally, the care is transferred to the patient and/or family at discharge. In this type of system, effective pain management for the individual patient may be inconsistent, depending on what each registered nurse and/or patient believes and does about ensuring that pain is effectively managed. When post-operative pain is managed in a PRN or reactive manner, the problem may be exacerbated.

Pain experienced in the moment may be related, in part, to the manner in which pain has been treated in the past. Yet, rarely do registered nurses in acute care have an opportunity to evaluate more than the immediate outcome of their pain management interventions. Within the process described in the previous paragraph, registered nurses will know little, if anything, about the patient's future pain. If acute post-operative pain is not managed effectively, it may, for some patients, persist for months and even years after surgery. Macrae (2001) writes about the "neglected topic" of chronic post-surgical pain and draws attention to research that links chronic pain with poor post-operative pain management.

Because we know surgical trauma is the root cause of acute post-operative pain and that unrelieved pain contributes to post-operative morbidity and mortality, jeopardizes patient safety, prolongs hospital stay and increases overall cost of care, then why do we not take a preventive approach to post-operative pain? Unfortunately, despite evidence that reactive pain management is ineffective and does not help to prevent pain, this method is still used in most surgical centres. Opioids administered as needed tend to be the primary analgesic with this approach. However, non-opioids administered around-the-clock tend to be the primary analgesic with a preventive approach. A preventive approach involves administering the right medication (with minimal adverse effects), in the right dose, at the right time, by the right route and for the right duration. Patients also need frequent assessments to detect breakthrough pain, which in turn needs to be promptly treated. By making pain the fifth vital sign, registered nurses can systematically evaluate the effectiveness of the pain management plan (Katz, 2002; Registered Nurses Association of Ontario, 2002; Reimer-Kent, 2003; Wild, 2001).