[Hypnoanalgesia, a complementary therapy for painful care procedures]

In the framework of the management of patients receiving hyperbaric oxygen therapy, hypnoanalgesia is a complementary pain management tool, notably during the changing of dressings. Trained in this management of care-related pain, the teams of the hypebaric medicine centre in Lyon share their experience.

Multimodal Pain Management for Enhanced Recovery: Reinforcing the Shift From Traditional Pathways Through Nurse-Led Interventions

Despite recent advances in perioperative patient care, postsurgical pain continues to be undermanaged. There is increasing acceptance of the concept that effective postsurgical pain management is best achieved through combined use of more than one analgesic agent or technique, and overreliance on opioids produces unwanted side effects limiting their utility. Accordingly, a balanced, multimodal approach to pain management within the larger framework of an Enhanced Recovery After Surgery (ERAS) pathway has become standard at many institutions for perioperative care, to control postsurgical pain, reduce opioid-related adverse events, hasten postsurgical recovery, and shorten length of hospital stay. The success of ERAS is dependent on nurses and the multidisciplinary team to execute its standardized processes across the care continuum, including patient education, perioperative care, and postsurgical evaluation. Here, we review current concepts related to multimodal analgesia and ERAS regarding care of adult surgical patients and discuss the perioperative nurse's role within this paradigm.

[Acute analgesia: implementation of a dedicated protocol in an emergency department]

Acute pain relief is an ongoing challenge for both nurses and emergency physicians. Its management remains suboptimal or delayed, despite the existence of valid recommendations. The complexity of the emergency department and the diversity of encountered situations justify a tailored approach, taking into account the patient's clinical characteristics and needs. Such an approach must, under safety conditions assign sufficient autonomy to care providers in order to achieve pain relief. The benefits of an optimal analgesia are numerous. They include a greater patient satisfaction, a reduced length of stay, and a rapid return to mobility. This article highlights the key elements of acute pain management in the emergency department of the Geneva University Hospitals.

Treating acute pain in the hospitalized patient

Many hospitalized patients report moderate-to-severe pain despite the use of epidural or patient-controlled analgesia. This article will explore the use of multimodal options for analgesia in hospitalized patients and focus on a difficult-to-treat acute pain condition, abdominal pain.

[Descriptive study of the postoperative pain assessment and documentation process in a university hospital]

Several studies have shown that patients often receive inadequate treatment of postoperative pain. The aim of the present descriptive study was to examine and analyze various data related to the postoperative pain assessment of 40 patients who underwent elective surgery. Pain journals were to be completed by patients during every waking hour for the first three postoperative days to assess both pain intensity and pain unpleasantness. A post hoc analysis of patient records permitted verification of pain assessment by nurses for each patient. The results showed that not only was postoperative pain rarely assessed using a valid scale, it was also poorly documented. In addition, when nurses assessed and documented postoperative pain using a numerical scale, their results were very different from patients' assessments. For the first postoperative day, the mean (± SD) pain intensity documented by nurses on a 0 to 10 numerical scale was 1.57±0.23, while the mean pain intensity noted by patients using the same scale was 3.82±0.41. Statistical analysis showed that there was no significant correlation between mean pain intensity documented by nurses and the mean pain intensity noted by patients.

Nurses' knowledge and attitudes regarding pain assessment and intervention

Registered nurses were queried about their knowledge and attitudes regarding pain management. Results suggest knowledge of pain management principles and interventions is insufficient.

Managing pain in the older person

The UK population is ageing and a significant proportion of older people experience persistent pain. However, pain assessment in this group can be challenging, particularly when the older person has cognitive or communication impairment. Nurses working in primary and secondary care should take a more proactive role to help overcome patient, professional and institutional barriers to pain assessment and management. This article examines the age-related physiological changes that complicate the prescribing and administering of analgesic drugs in older patients and necessitate careful patient monitoring. It outlines the principles of medication administration for pain management in older people and provides examples of assessment tools that can be used in older patients.

[Analgesia and sedation in premature newborns]

Analgesics and sedatives are routinely prescribed in intensive care on intubated premature newborns, to ensure their comfort and limit pain. The results of two studies show that there is no significant link between prolonged exposure to these treatments and a more unfavourable long-term neurological outcome.

NICU procedures are getting sweeter: development of a sucrose protocol for neonatal procedural pain

Neonates in the neonatal intensive care nursery experience multiple, painful, tissue-damaging procedures daily. Pain among neonates is often underestimated and untreated, producing untoward consequences. A literature review established strong evidence supporting the use of sucrose as an analgesic for minor procedural pain among neonates. A review of unit practices and nurses' experiential evidence initiated the production of a standardized protocol in our unit at the University of Washington Medical Center NICU in Seattle.Nursing practices surrounding sucrose use differed widely in dose, timing, and patient application. We carefully evaluated evidence documenting the effectiveness as well as the safety of sucrose administration and wrote a protocol and practice standards for our primarily premature patient population. This article describes the development and execution of a standardized, nurse-implemented, sucrose protocol to reduce procedural pain.

[Technical procedures for treating pain]

Nowadays, chronic pain treatment units are comprised by multidisciplinary work teams on which the contribution by each professional involved contributes to the team objective to handle and control pain. Out of all the forms of treatment and action plans developed for patients which deal with all the biological, psychological and social needs related to their experiences with chronic pain, in this article the authors concentrate exclusively on those technological and invasive procedures that are most frequently carried out by medical teams in chronic pain units. In this sense, nurses play an active participatory role in those procedures carried out, mainly in outpatient clinics where a patient is treated as an outpatient and nurses perform clinical services without the need of hospitalization.

Undermedication for pain and precipitation of delirium

INTRODUCTION

Review of the literature revealed an association of pain and delirium in patients with hip fracture. Literature was sparse on pain and delirium in other types of patients.

PURPOSE

The purpose of this study was to determine if there was a difference in the amount of analgesia received by patients in pain who developed delirium compared with those who did not develop delirium.

METHOD

A sample of 43 medical-surgical patients who were hospitalized with pain and who developed delirium was compared with a matched group of 43 medical-surgical patients with pain who did not develop delirium. The percentage of allowed analgesia received by each group was examined.

FINDINGS

The dependent variable of "percentage of allowed analgesia received" was significantly different between the two groups. The mean percentage of analgesia received by those who developed delirium was 26.14% while the mean percentage of analgesia of those who did not develop delirium was 48.21%.

CONCLUSION

The results revealed an association between low dose of analgesia and development of delirium for patients who are in pain. Nurses can increase their focus on adequate pain management for older patients.

The unique contribution of the nursing intervention pain management on length of stay in older patients undergoing hip procedures

The purpose of this study was to examine the unique contribution of the nursing intervention pain management on length of stay (LOS) for 568 older patients hospitalized for hip procedures. Propensity-score-adjusted analysis was used to determine the effect of pain management on LOS. The LOS for hospitalizations that received pain management was 0.78 day longer than that for hospitalizations that did not receive pain management. Other variables that were predictors of LOS included several context-of-care variables (e.g., time spent in the intensive care unit, registered nurse skill mix, etc.), number of medical procedures and unique medications, and several other nursing interventions.

Development, dissemination and implementation of a sedation and analgesic guideline in a pediatric intensive care unit...it takes creativity and collaboration

Sedation and analgesia are administered to critically ill children to provide comfort and pain relief, decrease anxiety and to promote patient safety in relation to life-saving treatments. A comprehensive practice guideline focused on ways to implement evidence-based sedation and analgesia practices was developed, disseminated and implemented by an interprofessional team in the pediatric intensive care unit (PICU) at the Children's Hospital of Eastern Ontario (CHEO) in Ottawa, Canada. The goals of this quality of care initiative were to (1) reduce inconsistent practices, (2) improve patient outcomes related to comfort, and (3) enhance collaboration among health care team members caring for critically ill children. An evidence-based sedation and analgesia management (SAM) guideline for critically ill, intubated and ventilated infants and children was developed over a six-month period by a team composed of PICU physicians, pharmacists and nurses. The quality of patient care initiative focused on consistent use of (a) validated sedation and analgesia assessment tools, (b) a goal-directed approach by identifying daily therapeutic target scores and titrating interventions accordingly, and (c) non-pharmacologic, pharmacologic and adjunctive measures. The authors describe their experience in the development, dissemination and implementation of an interprofessional guideline directed at improving sedation and analgesia and patient safety in the PICU. Tools developed to support the practice change, challenges and lessons learned are shared.

Casting: complications and after care

This article continues a short series of articles on how to apply casts. It examines some of the complications experienced by patients and discusses how emergency nurses can improve after-care services.

Exploring pain management in older people with hip fracture

Pain following a fractured neck of femur can be severe; in addition patients often have underlying medical problems. This article examines the problems associated with good pain control for older patients following fractured neck of femur. It introduces a Changing Practice article, due to be published in next week's issue, which outlines the development of a nurse-led service to provide preoperative femoral nerve blocks.

A cancer pain primer

Opportunities exist for improving cancer pain management. Medical-surgical nurses must partner with patients and families to achieve optimal pain management. They must use valid tools to assess patients and be knowledgeable about pharmacologic and nonpharmacologic measures to manage pain.

Chronic pain: clinical features, assessment and treatment

A significant number of people in the UK experience chronic pain, resulting in high levels of suffering and reduced quality of life. Management of chronic pain is complex, time consuming and not always successful. Good communication between patients and healthcare professionals is essential to ensure realistic treatment plans and outcomes can be negotiated. Accurate assessment is also key, and nurses play a fundamental role in ensuring patients with chronic pain receive the most appropriate care.

Spinal opioids in postoperative pain relief. 2: Adverse effects

This is a two-part unit on using spinal opioids to manage postoperative pain. Part 1 outlined the pharmacology of spinal opioids. Part 2 discusses the selection of patients and their nursing care. It also focuses on the incidence of and response to adverse effects. For further information on contraindications, nursing care and patients' clinical requirements, see Portfolio Pages on nursingtimes.net.

Spinal opioids in postoperative pain relief 1: pharmacology

This is a two-part unit on using spinal opioids to manage postoperative pain. Part 1 outlines the pharmacology and adverse effects. For details on spinal anatomy and dose levels, plus a table that outlines the differences between spinal anaesthesia and analgesia, and epidural analgesia, see Portfolio Pages at nursingtimes.net.

Nursing2008 Pain management survey report

How sharp are you about pain management? See how your responses to this survey compare with those of nursing colleagues across the country and beyond.

Translation research in long-term care: improving pain management in nursing homes

BACKGROUND

Pain prevalence in nursing homes remains high, with multiple resident, staff, and physician barriers presenting serious challenges to its improvement.

AIMS

The study aims were to (1) develop and test a multifaceted, culturally competent intervention to improve nursing home pain practices; (2) improve staff, resident, and physician knowledge and attitudes about pain and its management; (3) improve actual pain practices in nursing homes; and (4) improve nursing home policies and procedures related to pain.

METHODS

A multifaceted, culturally competent intervention was developed and tested in six Colorado nursing homes, with another six nursing homes serving as control sites. Both educational and behavioral change strategies were employed.

FINDINGS

The intervention was successful in improving the percentage of residents reporting constant pain in the treatment homes. Contextual factors (implementation of Medicare's Nursing Home Compare report card) appeared to exert a positive influence on pain documentation. There was no reduction in the percentage of residents reporting pain or reporting moderate/severe pain.

DISCUSSION

Multiple challenges to quality improvement exist in nursing homes. Turnover of nursing staff reduced actual exposure to the intervention, and turnover of directors of nursing influenced constancy of message and overall facility stability. Residents often failed to report their pain, and physicians were reluctant to alter their prescribing practices.

IMPLICATIONS

Any intervention to improve pain management in nursing homes must target explicitly the residents, nursing home staff, and primary care physicians. Implementation strategies need to accommodate the high turnover rates among staff, as well as the changes among the nursing home leadership.

CONCLUSIONS

Pain is a complex problem in the nursing home setting. Multiple factors must be considered in both the design and implementation of interventions to improve pain practices and reduce pain prevalence in nursing homes.

The use of oral transmucosal fentanyl citrate during high-dose-rate gynecologic brachytherapy

Gynecologic brachytherapy is a form of cancer treatment in which radioactive sources are placed into the pelvic organs via specialized applicators. Traditional low-dose-rate (LDR) brachytherapy has been performed over several days in a hospital setting. Since the 1990s, high-dose-rate (HDR) brachytherapy has been used increasingly because of its decreased treatment time, outpatient administration, and equal or superior efficacy compared with LDR treatment. However, the management of procedural pain in the radiation oncology setting has not been studied extensively. The purpose of this article is to discuss the use of oral transmucosal fentanyl citrate (OTFC) for the management of pain during gynecologic HDR brachytherapy. OTFC provides noninvasive, rapid analgesia with a low incidence of side effects and may be appropriate for other forms of procedure-related cancer pain.

Management of pain in cardiac surgery ICU patients: Have we improved over time?

This study described the pain experience of cardiac surgery ICU patients. After their transfer to the surgical unit, 93 patients were interviewed using a questionnaire about their pain experience while they were in the ICU. Sixty-one patients (65.6%) recalled being ventilated and 72 patients (77.4%) recalled having pain. Turning was the most frequent source of pain experienced by the patients. A large proportion of the patients (47.3%) identified the thorax as the location of their pain. All patients had a sternal incision. Pain was mild for 16 patients, moderate for 21, and severe for 25 of them. While ventilated, head nodding and movements of the upper limbs were the most frequent means of communication used by the patients. Despite advances in pain management, the study's findings are disturbingly similar to those of 17 years ago [Puntillo KA. Pain experiences of intensive care unit patients. Heart Lung 1990;19:526-33]. Evidence from research about clinical guidelines for pain management needs to be applied to the care of cardiac surgery patients in order to reduce patient suffering.

Anaesthesia for day surgery

The Department of Health (DH) proposes that 75% of elective surgery should be performed as a day case procedure (NHS Plan 2000). To achieve this some modification of the traditional selection criteria may be required and careful thought given to the patient pathway, including the anaesthetic technique. Successful anaesthesia for day case surgery requires a balanced anaesthetic technique and multidisciplinary input which commences at booking, runs through preoperative assessment and continues to a nurse-led discharge. Suitable patients need to be selected (Digner 2007), prepared both physically and psychologically, undergo minimally invasive surgery with a suitable anaesthetic technique encompassing good pain relief and the avoidance of postoperative nausea and vomiting (PONV). Pain and PONV are the most common causes for a patient to require unplanned admission (Junger 2001).

Registered nurse management and monitoring of analgesia by catheter techniques: position statement

The American Society for Pain Management Nursing believes that the administration of analgesia and the management of the associated effects are fundamental nursing responsibilities. This position statement will address the registered nurse's responsibilities for the management and monitoring of analgesia by catheter techniques in all patients of all ages and in all care settings. It will provide recommendations for the health care institution, licensed independent practitioner, and registered nurse to ensure the safe and effective implementation of these pain control methods. The position statement reinforces the American Society for Pain Management Nursing's belief that the administration of analgesia by catheter techniques is within the registered nurse scope of practice.

Pain management decision making among long-term care physicians and nurses

The purpose of this study is to explore attitudes and beliefs that affect decisions about prescribing and administering pain medications in older adults who live in long-term care (LTC), with a particular emphasis on those with cognitive impairment. At each of the four participating LTC facilities, data were gathered from three separate groups of health care professionals: physicians, registered nurses, and registered practical nurses. Based on grounded theory, a model was developed that highlighted critical decision points for nurses and physicians regarding pain management. The major themes that emerged from the data concerned pain assessment (lack of recognition of pain, uncertainty about the accuracy of pain assessment and diagnosis) and treatment (reluctance to use opioids, working to individualize pain treatments, issues relating to physician trust of the nurse on prescribing patterns). These findings may facilitate the development of innovative approaches to pain management in LTC settings.