PAIN MANAGEMENT

WITH FOCUS ON PRN

MEDICATION

ADMINISTRATION

Alexa Schroepfer, SCSU Senior Nursing Student H7000

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

HCAPS/Patient Experience

Results

H7000 HCAPS Survey Results

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

2013-11 2013-12 2014-01 2014-02 2014-03 2014-04 2014-05 2014-06

ANW HCAHPS Pain Management Top Box%

Staff did everything they could to help withpain

Pain Management Composite

Pain was well controlled

The Evidence

Clinical Practice Guidelines according to the

American Pain Society

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”

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.

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

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

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.

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.

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.

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.

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.

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 ”

Richmond Agitation and Sedation

Scale

Non-verbal Pain Scale

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

Documenting in Excellian

MAR Sticky Notes

“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.

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.

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