Pain Management

1. PAIN MANAGEMENT
WITH FOCUS ON PRN
MEDICATION
ADMINISTRATION
Alexa Schroepfer, SCSU Senior Nursing
Student H7000

2. Objectives:
 Nursing staff will understand the importance of
offering PRN pain medications on a consistent
basis as show by evidence based practice
 Nursing staff will be aware of the dynamics of
sedation scoring and nonverbal pain scale to
determine an effective pain medication regime
 Nursing staff will be able to properly document
PRN medication administration and "schedule"
PRN pain medications in Excellian

3. HCAPS/Patient Experience
Results

4. H7000 HCAPS Survey Results
85.00%
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
ANW HCAHPS Pain Management Top Box%
2013-11 2013-12 2014-01 2014-02 2014-03 2014-04 2014-05 2014-06
Staff did everything they could to help with
pain
Pain Management Composite
Pain was well controlled

5. The Evidence
 Clinical Practice Guidelines according to the
American Pain Society

6. Use of Chronic Opioid Therapy in
Chronic Noncancer Pain
 “Pain is defined by the International
Association for the Study of Pain (IASP) as “an
unpleasant sensory and emotional experience
associated with actual or potential tissue
damage or described in terms of damage”
 “Chronic pain is defined by the IASP as “pain
that persists beyond normal tissue healing
time, which is assumed to be three months”

7. Evidence Review
 APS-AAPM Clinical Guidelines for the Use of
Chronic Opioid Therapy in Chronic Noncancer
Pain
 A key recommendation urges clinicians to
continuously assess patients on chronic opioid
therapy by monitoring pain intensity, level of
functioning and adherence to prescribed
treatments.
 Breakthrough Pain: As-needed opioids can be
prescribed based on initial and ongoing analysis
of therapeutic benefit versus risk.

8. National Guideline Clearing
House
 Pain management in older adults. In:
Evidence-based geriatric nursing protocols
for best practice.
 Objective: To provide a standard of practice
protocol for pain management of older adults
such that they will either be pain free or their pain
will be controlled to a level that is acceptable to
the patient and allows the person to maintain the
highest level of functioning possible
 Target Population: Hospitalized older adults

9. Guideline Continued
 Interventions and Practices Considered
 Assessment/Evaluation: Pain assessment at
regular intervals, review of medications, use
standardized measurement tools, assessment of
nonverbal and behavioral signs of pain, pt and
family reports
 Management/Treatment: Individualized approach,
education about analgesic medications and
nonpharmacologic strategies, follow up
assessment-response and documentation

10. Major Recommendations
 Older adults with cognitive impairment
experience pain but are often unable to
verbalize it.
 Pain assessment must be regular, systematic,
and documented in order to accurately
evaluate treatment effectiveness.
 Self-report is the gold standard
for pain assessment.
 Effective pain management requires an
individualized approach.

11. Recommendations Cont.
 Review medications, including current and
previously used prescription drugs, over-the-counter
drugs, and complementary therapies
(including home remedies). Determine
which pain control methods have previously
been effective for the patient.
 Note: Documenting the next available time for
pain medications on the care boards
facilitations effective communication between
the nurse and patient/family.

12. Nursing Care Strategies
 Develop a written pain treatment plan upon
admission to the hospital, or prior to surgery or
treatments. Help the patient to set
realistic pain treatment goals, and document
the goals and plan.
 Educate patients to take medications
for pain on a regular basis and to avoid
allowing pain to escalate.

13. Treatment Guidelines
 Administer pain drugs on a regular basis to
maintain therapeutic levels. Use as needed (PRN)
medications for breakthrough pain.
 Document treatment plan to maintain consistency
across shifts and with other care providers.
 Older adults are at increased risk for adverse drug
reactions due to age- and disease-related
changes in pharmacokinetics and
pharmacodynamics. Monitor medication effects
closely to avoid overmedication or
undermedication and to detect adverse effects.
Assess hepatic and renal functioning.

14. Follow-up Assessment
 Monitor treatment effects within one hour of
administration and at least every 4 hours.
 Evaluate patient for pain relief and side effects
of treatment.
 Document patient's response to treatment
effects.
 Document treatment regimen in patient care
plan to facilitate consistent implementation.

15. Sedation
 “Opioid-induced respiratory depression is a
concerning decrease in the effectiveness of an
individual's ventilatory function after opioid
administration (ASPMN, 2009).”
 “The observation that increased sedation always
precedes respiratory depression indicates that
nurses can play a major role in preventing life-threatening
respiratory depression through
systematic sedation assessments that lead to
appropriate decision making during opioid
administration ”

16. Richmond Agitation and Sedation
Scale

17. Non-verbal Pain Scale

18. Pain Assessment in Nonverbal
Patient
 Establish a procedure for pain assessment
1. Attempt first to elicit a self-report from patient
and explain why self-report cannot be used
2. Identify pathologic conditions or procedures
that may cause pain
3. List patient behaviors that may indicate pain.
Behavioral assessment scales may be used
4. Identify behaviors that caregivers and others
knowledgeable about the patient think may
indicate pain
5. Attempt an analgesic trial

19. Documenting in Excellian
 MAR Sticky Notes

22.  “Scheduling” PRN medications
 Remember to keep diligent about checking last
administration times!
 ONLY “schedule” ahead ONE time.
 This feature should only be used for individual
purposes not for other nursing staff.

26. Closure Statement
 Continuous and thorough pain assessments
can help nurses determine individualized pain
management goals with patients. Proper
documentation and timely administration of
PRN pain medications can help to effectively
control pain.

27. References
 Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C.,
Davies, P., & ... Miaskowski, C. (2009). Clinical guidelines for the
use of chronic opioid therapy in chronic noncancer pain. The
Journal Of Pain, 10(2), 113-130. doi:10.1016/j.jpain.2008.10.008
 Herr, K., Coyne, P., Key, T., Manworren, R., McCaffery, M., Merkel,
S., & ... Wild, L. (2006). Pain assessment in the nonverbal patient:
position statement with clinical practice recommendations. Pain
Management Nursing, 7(2), 44-52.
 Nisbet, A., & Mooney-Cotter, F. (2009). Comparison of selected
sedation scales for reporting opioid-induced sedation assessment.
Pain Management Nursing, 10(3), 154-164.
doi:10.1016/j.pmn.2009.03.001
 U.S. Department of Health & Human Services: Agency for
Healthcare Research and Quality. (2012). Pain management in
older adults. In: Evidence-based geriatric nursing protocols for best
practice. Retrieved from:
http://www.guideline.gov/content.aspx?id=43932&search=prn+pain
+management