Running head: PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
Pain Management in the Surgical/Trauma Patient
Antoinette McNeil, BSN, RN, CCRN
Washington Adventist University
Analysis of Evidence-Based Practice
NURS 535
Chioma Nwachukwu, DNP, RN
October 18, 2012
1
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
2
Pain Management in the Surgical/Trauma Patient
Introduction
There are over 77 million people who suffer from pain. Pain has been defined as whatever the
patient states it is and it occurs whenever the patient states it does (Bernhofer, 2012). Often
time’s pain is what the healthcare worker says it is and it occurs when they say it does. Many
individuals have pain due to surgery or from a trauma that they have sustained. Pain is a nasty
sensory and emotional experience that is associated with actual or potential tissue damage
(Dihle, Bjolseth, & Helseth, 2006). No one can escape the effects of pain.
Pain is always what the patient says it is and not what the healthcare worker says it is for
the client. Patients’ being in pain is unacceptable and hospitals are realizing that their patient
satisfaction scores are being based on how an institution treat or minimizes a patient pain .Too
many patients are left in pain and their pain is not addressed properly. This paper will look at the
inadequacies of pain management and what can be done to improve it
Many healthcare workers underestimate the need to ensure that their patient’s pain is
under control. Patients have the right to have their pain under control. Hospital Consumer
Assessment of Healthcare Providers and Systems Survey (HCAHPS) conducted a survey which
revealed that only 63-74% of hospitalized patients stated that their pain was controlled. With the
knowledge of pain research and treatments for pain management, patients who were hospitalized,
satisfaction regarding pain management has not increased it has remained the same (Bernhofer,
2012). If acute post-operative pain is not managed efficiently for some patients, then their pain
can potentially last for months or even years after the surgery (Reimer-Kent, 2004). One must
remember that the goal of pain management is to control pain and to improve the quality of life
for patients (Vega-Stromberg, Holmes, Gorski, & Johnson, 2002).
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
3
When pain is not managed properly there are complications that can occur. Some of the
complications that can occur when pain is not managed effectively are pneumonia, deep vein
thrombosis (DVT), pulmonary emboli, myocardial infarction, confusion and chronic pain which
can increase morbidity and mortality (Reimer-Kent, 2004). When a patient is in pain they are
less likely to move or cooperate with their care than those who pain is managed or controlled
effectively. Pain affects also ones emotion and responses like anxiety or fear of pain can cause
the perception of pain to be greater than what is actually is (D’Arcy, 2011).
Nursing Theory/Model
When looking at pain management Leininger’s Theory regarding culture, care diversity
and universality (CCDU) is something to look at when addressing pain management. Leininger’s
theory states that care is the essence and focus of nursing, culture care expression may be diverse
among cultures but then they do have commonalities that exist (Sagar, 2012). Nurses must be
knowledgeable regarding the client’s culture and various factors that influence a patient’s need
(Sagar, 2012). Knowing a patient’s culture can help in regard to pain management, there are
some cultures that think it is wrong to take pain medication (Leegaard et al., 2011).
Nurses must also look at their beliefs and or values as it relates to caring for patients who
have unrelieved pain. Many nurses may not believe a patient is in pain, they may be insensitive
to the patient’s sign, they may believe that a patient is not to be totally free of pain, and they may
feel patients are to tolerate some pain (Dihle et al., 2006). Caring is finding out what your patient
needs to be comfortable and help in managing their pain to their comfort.
Impact of the Problem
Uncontrolled pain can lead to an increase risk of post-operative mortality and morbidity
from complications such as pneumonia, deep vein thrombosis (DVT), pulmonary emboli,
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
4
myocardial infarction, confusion and chronic pain (Reimer-Kent, 2004). These complications are
to be taken seriously. When a patient has bilateral or multiple rib fractures, that individual has
the potential to develop pneumonia due to shallow breathing, pulmonary emboli from a DVT and
confusion. When pain is left unmanageable and at least 6 months has passed the pain is classified
then as chronic pain. Chronic pain has been defined at pain that last for 6 months and longer
(Goodman, 2003). When a patient stays on pain medication for several months or more they are
looked as being addicted. When an addicted patient has acute pain, their pain management is
compromised and leads to an unsatisfactory experience managing their pain (McCreaddie et al.,
2010).
Chronic pain is debilitating and it affects more that one’s health, it also affects one’s
employment. The cost of unmanageable pain is astounding. The estimated cost for lost workdays
exceeds $100 billion yearly (Woodward, 2005). Medicare cost as it relates to pain treatment and
disability cost as it relates to chronic pain cost $124 million or more yearly (Goodman, 2003).
Pain is costly and is not cheap. When patients are hospitalized due to chronic pain and then they
have surgical intervention for their pain, unmanageable pain can lead to prolong hospitalization.
In fact when a patient is a trauma or surgical patient and they have complications due to
ineffective pain management that also leads to prolong hospitalization.
Patients have had their pain mismanaged for years that the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) is holding healthcare institutions
accountable for patient’s pain. JCAHO has pain standards that states patient’s have the right to
appropriate assessment and management of their pain (Vega-Stromberg et al., 2002). JCAHO
has four main components of care which are the following: assessing the patients need; planning
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
5
care, treatment and services; providing care, treatment and services; and finally coordinating care
treatment and services (D’Arcy, 2011).
The American Pain Society (APS) in 1995 stated that the first step in improving the
treatment of pain is assessing and recording the patient’s report of pain (Mularski et al., 2006).
Both the APS and JCAHO refer to patient satisfaction as a standard patient outcome and point of
evaluation (Vega-Stromberg et al., 2002). Since 2001 JACHO has held acute care hospitals
accountable for the assessment, documentation, and management of patient’s pain (Dusek,
Finch, Plotnikoff, & Knutson, 2010).Congress created the Decade of Pain from 2000 to 2010
which focuses on how to improve pain management in patients (D’Arcy, 2011).
Multidisciplinary Approach
Pain management is not a one discipline approach to patient satisfaction regarding pain
management and quality practice. The development of ongoing resources and having support is
essential to maintain quality practice (Vega-Stromberg et al., 2002). Having buy-in by physicians
to ensure that patients pain is manage appropriately is a must, because they can assist in
improving practices (Vega-Stromberg et al., 2002). It has been suggested that the
Anesthesiologist should be responsible for pain management for the first 24 hours postoperatively, prescribing all analgesics including analgesic for break-through pain (Megens, Van
Der Werff, & Knape, 2008).
Nursing has a role in assessing pain in the patient and administrating the treatment that is
prescribed for the patient and assess its effectiveness. Nurses must administer the patient’s pain
medication around the clock after surgery and if non-opioids are ordered then it is to be given
around the clock also even if the patient denies having pain (Reimer-Kent, 2004). Nurses must
evaluate and re-evaluate the patient for pain and the effectiveness of the pain medication.
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
6
For a pain management plan to work leadership and administration are responsible to
provide administrative and financial support for pain management plan. Having institutional
support and accountability is the answer for success (Vega-Stromberg et al., 2002). If
administration does not stand behind the changes to ensure that patient safety as it relates to pain
management progress then it will fail. Also patient satisfaction scores are tied into the
management of pain for the patient.
Evidence-Based Practice for Pain Relief
A study revealed that patients receiving an intrathecal injection before a total knee
arthroplasty has better immediate postoperative pain management than those receiving general
anesthesia (Napier & Bass, 2007). Studies have shown that the use of nonsteroidal antiinflammatory drugs (NSAIDs) and COX-2 inhibitors are useful analgesic adjuncts that can
improve pain relief while reducing the need for opioids postoperatively, these medications have a
combination of analgesic, anti-inflammatory and anti-pyretic effects (Layzell, 2008).
The use of acetaminophen and/or NSAIDs before surgery was given to achieve minimal
pain perception (Megens et al., 2008). The World Health Organization (WHO) developed an
analgesic ladder to guide providers in prescribing choice of pain medication (D’Arcy, 2011).
Looking at Level 1 where the patient is having mild to moderate pain use NSAIDs. Looking at
Level 2 where the patient is having moderate to severe pain use a combination of opioid and
acetaminophen. Looking at Level 3 where the patient is having severe pain a strong opioid
should be used (D’Arcy, 2011).
There are other therapies that are used also for pain management. Patient-controlled
analgesia (PCAs) would be successful if the patient was reasonably comfortable when it is
begun; therefore pre-loading with opioids is a must (Layzell, 2008). Epidural analgesia is one of
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
7
the most effective methods available for the management of pain the surgical patient with sever
acute pain (Layzell, 2008). There are bupivacaine collagen sponges where the sponge is placed
directly over the surgical site. The medication is released were it is needed and the sponges
biodegrades over a few days (Layzell, 2008).
Elastomeric pumps are disposable infusion pumps which have medication placed in its
reservoir. The pressure generated by the filled reservoir and the flow restrictor set a fixed flow
rate to dispense the medication. A catheter is placed near a nerve or in the wound incision at the
end of the operation, which is connected to the pump that has the medication which is an
anesthetic. The medication usually flows for at least 48 hour period. With this pump is allows the
patient to mobilize early which leads to an early discharge from the hospital (Layzell, 2008).
There also is the transdermal iontophoresis which is a process that allows a delivery of
charged molecule across intact skin using a very small electrical current. Fentanyl has an
iontophoretic transdermal system (IONSYS), which is totally patient controlled. A patch is
placed on the skin the chest or the upper arm, which holds 80 doses of Fentanyl. The medication
last either for 24 hours or until the 80 doses is gone. The patient can activate the delivery system
and there is a 10min lock-out time. The dose that is delivered is only 40 mcg of Fentanyl. This is
only for short term use and is not a system to be used for all patients (Layzell, 2008).
Methods to Improve Pain Management
Patient education regarding pain management is vital especially before the surgical
intervention, but this is not feasible when the patient is a fresh trauma. If the trauma patient is
coherent and understands all that is being said then patient teaching regarding pain management
is to be done. The patient is to be included in their care which includes pain management. Many
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
8
times a patient knows what pain medication works best for their pain thus healthcare providers
should listen and not ignore the patient.
Physicians need more education regarding pain management. The physicians have a
committee that looks at educational topics and they should have topics that relate to pain
management. Pharmacist education looks at the advantages and disadvantages of opioids that are
used. Physical and Occupational therapy looks at education on the impact of pain on goals and
develop strategies on improving pain management (Vega-Stromberg et al., 2002).
Nurses first of all need to recognize their need to for information to better care for their
patients of different ages and cultures and understand better about pain management (Leegaard et
al., 2011). The acute care settings need to have in-services regarding pain management that will
educate nurses on pain and how to better care for their patient in pain. Nurses must recognize
that they are the first line of intervention for the patient, thus by assessing and reassign the
patient for pain is paramount. Nurses need to attend conferences regarding pain management.
Evaluation
To determine if changes the institution made regarding to pain management is working,
they can do a survey before the patient leaves the hospital or when the patient has gone home.
The survey that most hospitals participate in is the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS). One of the questions that are asked is pain control. All
institutions want their patient satisfaction scores to be higher that what it is now. Patient scores
hospitals low when their pain has not been managed well. Look at a patient’s length of stay for
certain surgical diagnosis. Evaluating pain for a certain surgical diagnosis and the pain is
managed properly there should be a drop in patient’s length of stay. By early teaching regarding
pain management, promoting using the incentive spirometer, coughing and deep breathing and
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
9
allowing the use of sequential compression devices for DVT prophylaxis will lead to a decrease
of the complications that can occur from unmanaged pain.
Conclusion
Pain management is vital for patient comfort and safety. There is much to be learned
regarding how to best treat post-surgical or pain due to physical trauma. Healthcare providers
must be proactive in attending in-services or conferences regarding pain management. With
changes with CMS as it relates to payment to healthcare facilities pain management will be a
factor on how well a patient’s pain was managed. JACHO has standards regarding pain
management thus acute care institutions must be in compliance. Having the Anesthesiologist
involved in pain management is beneficial for the patient. All disciplines must work together for
the betterment of the patient.
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
10
References
Bernhofer, E. (2012, January). Ethics: Ethics and Pain Management in Hospitalized Patients. The
Online Journal of Issues in Nursing, 17.
http://dx.doi.org/10.3912/OJIN.Vol17No01EthCol01
Dihle, A., Bjolseth, G., & Helseth, S. (2006). The gap between saying and doing in postoperative
pain management. Journal of Clinical Nursing, 15(), 469-479.
Dusek, J. A., Finch, M., Plotnikoff, G., & Knutson, L. (2010, March). The Impact of Integrative
Medicine on Pain Management in a Tertiary Care Hospital. Journal of Patient Safety,
6(1), 48-51.
D’Arcy, Y. (2011). Compact Clinical Guide to Acute Pain Management An Evidence-Based
Approach for Nurses. New York, NY: Springer.
Goodman, G. R. (2003, April-June). Outcomes Measurement in Pain Management Issues of
Disease Complexity and Uncertain Outcomes. Journal of Nursing Care Quality, 18(2),
105-111.
Layzell, M. (2008, April 10). Current interventions and approaches to postoperative pain
management. British Journal of Nursing, 17(7), 414-419.
Leegaard, M., Watt-Watson, J., McGillion, M., Costello, J., Elgie-Watson, J., & Partridge, K.
(2011, July/August). Nurses’ Educational Needs for Pain Management of Post-Cardiac
Surgery Patients A Qualitative Study. Journal of Cardiovascular Nursing, 26(4), 312320.
McCreaddie, M., Lyons, I., Watt, D., Ewing, E., Croft, J., Smith, M., & Tocher, J. (2010).
Routines and rituals: a grounded theory of the pain management of drug users in acute
care settings. Journal of Clinical Nursing, 19(), 2730-2740.
PAIN MANAGEMENT IN THE SURGICAL/TRAUMA PATIENT
11
Megens, J. H., Van Der Werff, D. B., & Knape, J. T. (2008, July). Quality improvement:
implementation of a pain management policy in a university pediatric hospital. Pediatric
Anesthesia, 18(7), 620-627.
Mularski, R. A., White-Chu, F., Overbay, D., Miller, L., Asch, S. M., & Ganzini, L. (2006,
June). Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain
Management. Journal of General and Internal Medicine, 21(6), 607-612.
Napier, D. E., & Bass, S. S. (2007, November/December). Postoperative Benefits of Intrathecal
Injection for Patients Undergoing Total Knee Arthroplasty. Orthopaedic Nursing, 26(6),
374-378.
Reimer-Kent, J. (2004, October). Improving Post-oprative Pain Management by Focusing on
Prevention. Nursing BC, 20-24.
Sagar, P. L. (2012). Transcultural Nursing Theory and Models. New York, NY: Springer .
Vega-Stromberg, T., Holmes, S. B., Gorski, L. A., & Johnson, B. P. (2002, October). Road to
Excellence in Pain Management: Research, Outcomes and Direction (ROAD). Journal of
Nursing Care Quality, 17(1), 15-26.
Woodward, D. (2005, July-September). Developing a Pain Management Program Through
Continuous Improvement Strategies. Journal of Nursing Care Quality, 20(3), 261-267.