Evidence-Based Practice: Managing Acute Pain

Pain is a complex process that involves an unpleasant sensation that may be caused either by actual or potential tissue damage. Essentially, it is whatever the person who is experiencing it says it is. Pain can be chronic or acute, mild to severe, and of sudden or slow onset. Acute pain is usually experienced for a limited time and confined to one area. In most cases, it is a warning of injury.

Older patients may not communicate clearly about the pain they are experiencing. In fact, rather than report pain, some older patients may simply tolerate it. No evidence exists to suggest that pain intensity actually decreases with age.

The most effective approach to treating acute pain combines medications and nonpharmacologic measures. Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for countering inflammation. Opioid analgesics can be added when nonopioids alone do not relieve pain. Unless contraindicated, nonopioids should be included even when pain is severe enough to require an opioid. The oral route is preferred. Analgesics should be administered on a regular schedule if pain is present most of the day. They can be used on an as-needed basis for breakthrough pain.

ASSESSMENT

  • Assess for pain at least every 4 hours and within one hour after a pain management intervention. Use a validated pain scale and note the pain’s location and intensity. Determine if pain limits activities of daily living or affects sleep and quality of life.
  • For patients who are unable to communicate effectively, check for a history of conditions that cause pain. 
  • In patients with dementia, be alert for behaviors that may indicate pain. 
  • Watch for adverse effects of medications, including signs and symptoms of physical dependence. 
  • Assess for effects of pain on cognition, such as forgetfulness and inattention.

PLANNING AND IMPLEMENTATION

  • Begin medications as soon as possible after pain is detected. 
  • Do not withhold pain medication for acute abdominal pain to facilitate diagnosis. 
  • Administer NSAIDS and aspirin for moderate to severe pain, as prescribed. 
  • Administer oral oxycodone with paracetamol, as prescribed. 
  • Continue nonopioid drugs, as prescribed, even when opioids are given.
  • For acute postoperative pain, administer the following, as ordered:
    • acetaminophen
    • oral dexibuprofen
    • oral diflunisal
    • single-dose oral etodolac
    • single-dose oral flurbiprofen
    • single-dose oral ketoprofen
    • single-dose oral naproxen or naproxen sodium
    • single-dose dipyrone.
  • Administer IV or IM parecoxib, as prescribed. 
  • If pain is constant or present for 72 hours after the injury or surgery, administer round-the-clock pain medications, as prescribed. 
  • Follow patient-controlled analgesia (PCA) protocols for postoperative pain, as prescribed. 
  • Institute nonpharmacologic interventions, such as relaxation techniques, guided imagery, distraction, therapeutic touch, massage therapy, and art or music therapy. 
  • Recognize and treat drug-related side effects.

DISCHARGE PLANNING

Teach the patient and family about:

  • the importance of reporting pain, pain management options, appropriate dosages and administration schedules, and possible adverse effects of treatment. 
  • nonopioid medications, topical local anesthetics, and nonpharmacologic options, including the proper use of heat or cold therapy. 
  • the importance of avoiding over-the-counter (OTC) medications unless approved by the primary care provider. 
  • addiction and dependence, the risks of taking too many prescriptions, and managing constipation.

EVALUATION

Before discharge, the patient should:

  • experience pain relief or a level of pain he or she finds acceptable. 
  • not have significant adverse effects caused by medications. 
  • have developed nonpharmacologic strategies to reduce pain. 
  • be able to return to self-care and normal functioning with minimal limitations due to pain.

For more information on managing acute pain, see Evidence-Based Nursing Monographs: Acute Pain in Mosby’s Nursing Consult

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