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doi: 10.1097/01.ORN.0000366019.69947.e4

Better Pain Relief in the Pacu

Barone, Claudia P. RN, APN, LNC, CPC, CCNS-BC, EdD; Walthall, Bryn RN, BA; Fenton, Martha RN, BSN; Tinsley, Mary RN; Fikes, Brent D. RN, BSN

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At the College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Ark., Claudia P. Barone is dean and professor, Bryn Walthall is an RN III charge nurse in the PACU, Martha Fenton is an RN III, Mary Tinsley is an RN, and Brent D. Fikes is an RN.

A primary goal of nursing care in the postanesthesia care unit (PACU) is to gain control of pain. Although patients will, of course, prefer complete and total pain relief, managing the pain and getting the pain under control as reported by either a numeric or visual pain scale is the goal. The treatment of pain may vary depending on how the nursing staff is integrated into the postoperative multidisciplinary team. There are a variety of reasons for undertreatment of pain such as those associated with healthcare provider delivery, patients and families, and society.1 Perceptions of the addictive nature of pain medicine may interfere with adequate administration. These perceptions may be on the part of the healthcare provider, patient, or family.

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Understanding pain

By definition, pain is an unpleasant sensation associated with actual or potential tissue damage and mediated to the brain via specific nerve fibers where its conscious appreciation may be modified by various factors.2 The International Association of the Study of Pain also defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.3

There are four factors involved in the transmission of pain. The first is when inflammatory facilitators—such as substance P, serotonin, histamine, and bradykinin—are released at the tissue site of surgery or injury. The facilitators stimulate peripheral sensory afferent nerves. Transmission, the second phase of this stimulus, occurs when ascending nerves from the dorsal horn to the brain are stimulated by the peripheral sensory afferents. Modulation occurs along the descending pathways to the dorsal horn where the activity of the peripheral nerves is affected by the release of enkephalins and endorphins. The brain then perceives the pain (See Nociception system and pain impulse transmission).

To appreciate the management of pain, it's necessary to combine an understanding of what pain is with its implications for patients undergoing surgery. The Agency for Healthcare Research and Quality (AHRQ) guidelines for the assessment of acute pain stress the importance of early recognition and treatment of acute pain episodes.4 Postoperatively, patients may experience a wide range of pain, and self-reports of pain can be inaccurate or inconclusive because of anesthesia and sedation. It's important for practitioners to assess patients accurately and treat them according to each individual's experience when providing pain relief. Some facilities recognize pain as the "fifth vital sign," however, patients often report that their pain is inadequately managed.5

Figure. Nociception ...
Figure. Nociception ...
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Nurses must take into account the sensory, physiological, and behavioral parameters when assessing the presence of painful stimuli. This may include increases in heart rate and BP, anxiety, and attempts to grasp the painful area. The assumption must be made that patients experience pain irrespective of their conscious state and behavioral responses noted in association with noxious stimuli.6 In addition, patients may be unable to communicate the nature of their pain completely. As the importance of pain assessment increases, scores from a pain intensity scale are often included in nursing documentation.7

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Assessment and management of pain

Prior to surgery, it's important to assess the patient's understanding, past experience with painful stimuli, and belief system as they relate to pain. There may be concerns about hospital admission, fear of dying while under anesthesia, or anxiety over facing a life-changing diagnosis. High levels of anxiety can influence the patient's level of pain.8 Previous hospital experiences, family opinions, and current expectations of pain and pain management can also contribute to a low expectation of pain relief and increased anxiety.8

The perioperative nursing assessment for patients undergoing local anesthesia and general anesthesia should include a review of the patient's history, physical assessment, lab results, and other diagnostic results. Reviews of allergies, current medications, past and present substance abuse, preoperative pain levels, and the expectation of intraoperative and postoperative pain control are recommended, as is educating the patient about the expected outcome and the recovery process after the procedure.9

Intraoperatively, pain management depends on many factors, including the type of surgery and the patient's present state of health and medical history. Gabapentin (Neurontin) and ketamine (Ketalar) have been shown to reduce postsurgical or posttraumatic pain.10 Opioids and local spinal anesthestics or epidurals are generally used intraoperatively. In major thoracic, abdominal, or orthopedic surgeries, epidural pain management provides the most effective relief.10

Postoperative pain management can be challenging because patients are awakening from different types and levels of anesthesia, including general anesthesia using an inhalation agent, total I.V. anesthesia, monitored anesthesia care, and epidural anesthesia with or without sedation. Providers should perform frequent assessments of the nature and intensity of the pain. Monitoring for adequate pain relief, adverse reactions of interventions, and observing patient safety is an ongoing process.11

Pain scales can help document the degree of pain the patient is experiencing.12 There are two commonly used scales. Using the numeric rating scale, patients rate pain from 0 to 10, with 10 being the worst pain ever experienced and 0 being no sensation of pain. Using this scale can be difficult because some patients may not be able to speak coherently due to the effects of anesthesia. The second pain scale is the Wong-Baker Faces pain rating scale, which may be more appropriate. This scale, used for pediatric patients or adults with language difficulties, includes six faces demonstrating varying levels of pain intensity and patients choose the face that most closely depicts their level of pain. (See Examples of pain intensity scales.)13

Postoperative pain occurs through various mechanisms, including acute nociceptive pain from the incision or abnormal body positioning and immobilization, which can lead to musculoskeletal pain. Neuropathic pain associated with stretching of or trauma to peripheral nerves and inflammatory facilitators also play a role. I.V. patient-controlled analgesia (PCA) and epidural analgesics are more effective when compared to I.M. analgesia. The PCA, which is routinely used instead of the I.M. injection or I.V. bolus of opioids, provides more effective relief and avoids barriers to relief, such as time delays of administration. It also has a quicker absorption rate than medication administered I.M.14

Proper management of postoperative pain allows for maximum recovery and also can provide psychological relief to the patient.7 Extended periods of unrelieved pain can result in physiological changes, including pituitary and adrenal activity that can decrease the immune response. There can also be activation of the sympathetic response, which can cause cardiovascular, gastrointestinal, and renal changes. Patients with inadequate pain treatment may avoid movement, coughing, deep breathing, and ambulation, which are key elements to early surgical recovery. The physiological changes can include deep vein thrombosis, pulmonary emboli, myocardial infarction, poor wound healing, and pneumonia. Unrelieved pain can also result in anxiety, depression, and demoralization.

The consequences of undertreated pain can lead to extended hospital stays and readmissions. Not only can inadequate pain management impair the patient's recovery and increase healthcare costs with extended stays or additional treatment, it can also result in poor patient satisfaction reflected in their perception of the care they received at the healthcare facility.15

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PACU pain management

Once the pain has been assessed, pharmacologic and nonpharmacologic interventions can be implemented. A recent study demonstrated that nonpharmacologic interventions were noted in 22% of pain episodes.6 A variety of comfort-producing measures, such as repositioning the patient in bed, oral care, and reassurance can be effective.

In the PACU, drugs used include local anesthetics, nonsteroidal anti-inflammatory agents (NSAIDs), and opioids. Local anesthetics (lidocaine [Xylocaine]) prevent the excitation of nerves to detect painful stimulation. NSAID agents reduce the effect of the inflammatory mediators—prostaglandins not only produce pain, but also cause nerve sensitization to other substances that produce pain—at the site of injury. Nonsteroidal drugs, such as ketorolac tromethamine, are becoming a more common choice in the operative setting.16 Opioids are the gold standard of postoperative analgesics. This class of drugs acts primarily at the level of the spinal cord where it interferes with both the transmission and modulation on the pain pathway.16

Examples of opioids include morphine, which is considered the first-line analgesic, hydromorphone hydrochloride (Dilaudid), or fentanyl citrate (Sublimaze). The choice of drug will depend upon the institutional formulary and the anesthesia provider.

Figure. Examples of ...
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Morphine has several adverse reactions, including pruritus, nausea, vomiting, sedation, respiratory depression, and rare anaphylactic reactions. Patients must be monitored closely for respiratory depression as they recover from anesthesia and receive morphine. Hydromorphone is an alternative for patients who experience pruritus after receiving the first dose of morphine as it's less likely to cause a release of histamine (when changing from one opioid to another, equivalency of the drugs is necessary to maintain the same level of pain control without overmedicating the patient). Hydromorphone is five-to-eight times more potent than morphine, it has a lesser sedating effect than morphine, and causes less nausea and vomiting, which may enhance its ability to provide pain relief.17

Fentanyl and its derivatives are often used in combination with sedatives. It's 100 times more potent than morphine. Because of its short-acting effect, patients who receive it intraoperatively may require pain management intervention sooner than others when arriving in the PACU. Fentanyl requires more frequent titration when compared with morphine and hydromorphone.18 Adverse reactions associated with opioids include respiratory depression, which can result from large doses, rapid infusion, or too frequent administration of the medication. Patients with poor renal or hepatic function can develop excessive drug accumulation. I.V. naloxone (Narcan) can quickly reverse the effects of the opioid.16

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Administering medication

The preferred method of opioid administration is I.V. as it delivers a more rapid onset of analgesia. Opioids can be delivered I.M., but this route is usually not used in the PACU, because of the varied absorption rates from patient to patient and erratic analgesic effects.16 Since the 1980s, the use of epidural and intrathecal analgesia has dramatically improved management of postoperative pain. The use of analgesia via epidural and intrathecal requires smaller amounts of medication and offers longer duration of relief. Sometimes, a combination of opioid and local anesthetic epidural administration is done to maximize pain relief.

The most common adverse reaction is hypotension from action of the local anesthetic on the sympathetic nervous system. It can cause a depletion in the central circulatory system because of vasodilation of the peripheral circulatory system. The patient's BP may decrease, requiring fluid replacement to maintain adequate BP. If the fluid replacement can't maintain the BP, the epidural dose should be reduced or a vasoconstrictor (such as phenylephrine) may be needed to reverse the vasodilation. The patient will need close monitoring for hypovolemia as this can lead to spinal cord infarction and permanent paralysis. The motor fibers of the spinal cord can also be affected resulting in motor block that can cause weakness to the lower extremities, transient neurological symptoms such as pain or dysesthesia in the buttocks, thighs, or lower limbs, or immobilization. If immobilization is persistent, the dose will have to be decreased per the policy of the facility. The patient will need to change body positions to maintain skin integrity on the immobilized areas. Adverse reactions from epidural opioids may include respiratory depression and sedation. Although respiratory depression occurs less frequently than in patients who receive parenteral administration, naloxone should be available for treatment.

Other adverse reactions associated with epidurals include itching, nausea, hematomas at the insertion site, epidural abscess, puncture of the dura mater, dislodgement of the catheter, ineffective pain relief, and equipment malfunction.19

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Pain in the older adult

The number of older adults undergoing surgery is increasing. Managing pain in this population has its own challenges as the cognitively impaired older patient has been shown to receive less analgesia than those who are cognitively intact who have experienced similar painful events. Despite the fact that there's no empirical evidence that the cognitively impaired have decreased pain sensation, research has shown that these older adults report fewer complaints and pain.20

Intervening during the preoperative phase of surgery with older adults improves their ability to report pain—even printed preoperative pain instructions were found to be beneficial. A pain study in which 31 elderly patients were randomly divided into a communication group or a control group demonstrated that pain management skills taught preoperatively, as well as learning the pain-intensity scales, improved pain control in the communication group.21 Patients with a history of previous hospitalizations with poor pain management may also benefit from proactive strategies such as reassurance, simple relaxation techniques, and prescription anxiolytic agents and analgesics prior to surgery.8

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Providing optimal care

The experience of pain is unique to each person and encompasses an individual's physical, psychological, cognitive, and emotional network. To deal with pain effectively, the specific type of pain must first be identified to guide pain reduction. To provide the best and safest care for patients in pain, PACU nurses must be alert to the different types of pain and their manifestations, and the individuality of each person that contributes to the pain experience.

Healthcare professionals must ensure that patients don't experience unnecessary distress or suffering and minimize complications during the postoperative period. Nurses also play a key role as patient advocates. Monitoring patients closely and interpreting their responses to pain intensity scales can offer relief and reassurance during a very difficult and emotional experience.

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