{"id":423,"date":"2019-12-01T20:17:09","date_gmt":"2019-12-01T20:17:09","guid":{"rendered":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-4-applying-the-nursing-process-to-pain-management\/"},"modified":"2025-01-16T22:28:51","modified_gmt":"2025-01-16T22:28:51","slug":"10-4-applying-the-nursing-process-to-pain-management","status":"publish","type":"chapter","link":"https:\/\/pressbooks.ccconline.org\/accnursingpharmacology\/chapter\/10-4-applying-the-nursing-process-to-pain-management\/","title":{"raw":"10.4 Applying the Nursing Process to Pain Management","rendered":"10.4 Applying the Nursing Process to Pain Management"},"content":{"raw":"
\n\nNow that we have reviewed basic concepts related to pain and several disorders requiring analgesic or musculoskeletal medication, let\u2019s consider the nursing process and how it applies to administering these medications.\n

Assessment<\/h2>\nAsking a patient to rate the severity of their pain on a scale from 0 to 10, with \u201c0\u201d being no pain and \u201c10\u201d being the worst pain imaginable is a common question used to screen patients for pain. However, according to The Joint Commission requirements, this question can be used to initially screen a patient for pain, but a comprehensive pain assessment is required for adequate pain management.\n\nNurses perform comprehensive pain assessments before and after administering analgesics. Many mnemonics are used to guide comprehensive pain assessment. See Figure 10.4[footnote]\u201cMnemonics for Pain Assessment\u201d by Julie Teeter is licensed under CC BY-SA 4.0<\/a>[\/footnote]<\/sup> for common nursing mnemonics for comprehensive pain assessment.\n\n[caption id=\"\" align=\"aligncenter\" width=\"598\"]\"Image Figure 10.4 Mnemonics for Pain Assessment[\/caption]\n\nTo adequately manage a client's pain, it is important to also assess potential barriers that may contribute to inaccurate reports of the severity pain by individuals. Optimal pain management can be achieved by gathering subjective and objective data to accurately measure the severity of an individual's pain. A person's health can be negatively impacted if they under-rate or over-rate their pain level. Under-rated severe pain can interfere with an individual's ability to complete activities of daily life and can contribute to anorexia, insomnia, and feelings of depression and anxiety. Additionally, some clients are not able to adequately communicate their pain. For example, for older adults with cognitive impairment, caregivers play an important role in documenting and communicating pain assessments to nurses and health care providers to ensure adequate treatment of pain.[footnote]Boring, B. L., Walsh, K. T., Nanavaty, N., Ng, B. W., & Mathur, V. A. (2021). How and why patient concerns influence pain reporting: A qualitative analysis of personal accounts and perceptions of others' use of numerical pain scales. Frontiers in Psychology, 12<\/em>. https:\/\/doi.org\/10.3389\/fpsyg.2021.663890<\/a>[\/footnote],[footnote]Horgas, A. L., Bruckenthal, P., Chen, S., Herr, K. A., Young, H. M., & Fishman, S. (2022). Assessing pain in older adults. American Journal of Nursing 122(12)<\/em>, 42-48. https:\/\/doi.org\/10.1097\/01.NAJ.0000904092.01070.20<\/a>[\/footnote]<\/sup>\n

Visual Pain Rating Scales<\/h3>\nVisual pain scales are commonly used as tools for assessing pain, especially with children and adults who have difficulty using the numerical pain rating scale. See Figure 10.5[footnote]Wong-Baker FACES Foundation. (2020). Wong-Baker FACES\u00ae pain rating scale<\/em>. Retrieved [2020] with permission from http:\/\/www.WongBakerFACES.org<\/a>[\/footnote]<\/sup> for the FACES Pain Rating Scale. To apply this scale, use the following evidence-based instructions. Explain to the client that each face represents a person who has no pain (hurt), some, or a lot of pain. \"Face 0 doesn't hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to have this worst pain.\" Ask the person to choose the face that best represents the pain they are feeling.\n\n<\/div>\n \n
[caption id=\"\" align=\"aligncenter\" width=\"1321\"]\"Image Figure 10.5 Wong-Baker FACES Pain Rating Scale. Used with permission from http:\/\/www.WongBakerFACES.org<\/a>.[\/caption]<\/div>\n
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Additional baseline information to collect prior to administration of analgesic or musculoskeletal medication includes obtaining a history of allergies or previous adverse response to medications. Additionally, nurses ask clients to describe their preferred acceptable pain level while also considering the potential side effects of analgesics.<\/div>\n
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Read additional information about pain assessment and pain scales in the \"Comfort<\/a>\" chapter of Open RN Nursing Fundamentals<\/em>.<\/p>\n\n<\/div>\n

Implementation<\/h2>\nAs with all medications, nurses check the rights of medication administration and consider the best route of administration for this client at this particular time. For example, if the client is nauseated and vomiting, then an oral route may not be effective.\n\nWhen administering opioids, the nurse considers if the prescribed medication is appropriate for the client's current level of pain. If there are concerns about appropriateness of the medication based on the client's current status, the prescribing provider should be notified. See Table 10.4 for a list of common opioid medications used to treat moderate to severe pain.[footnote]This work is a derivative of DailyMed<\/a> by U.S. National Library of Medicine<\/a> in the Public Domain<\/a>.[\/footnote]<\/sup> Notice that many opioids are combined with acetaminophen, so the maximum daily dosage of acetaminophen must be monitored.\n\nTable 10.4 Common Opioid Analgesics Used to Treat Mild to Severe Pain\n\n\n\n\n\n\n\n\n\n
\n
Generic Name<\/strong><\/h5>\n<\/th>\n
\n
Brand Name(s)<\/strong><\/h5>\n<\/th>\n
\n
Pain Level<\/strong><\/h5>\n<\/th>\n
\n
Route<\/strong><\/h5>\n<\/th>\n
\n
Adult Dosage<\/strong><\/h5>\n<\/th>\n<\/tr>\n
Codeine\/Acetaminophen<\/strong><\/th>\nTylenol #3<\/td>\nMild<\/td>\nPO<\/td>\n30 mg\/300 mg<\/td>\n<\/tr>\n
Fentanyl<\/th>\nDuragesic\n\nSublimaze<\/td>\nSevere<\/td>\nTransdermal\n\nIM\n\nIV<\/td>\n12 mcg-100 mcg\/hr\n\n0.5-1 mcg\/kg\n\n0.5-1 mcg\/kg<\/td>\n<\/tr>\n
Hydrocodone\/Acetaminophen<\/strong><\/th>\nLortab\n\nNorco\n\nVicodin<\/td>\nModerate<\/td>\nPO\n\nPO\n\nPO<\/td>\n5 mg\/300 mg or 325 mg\n\n10 mg\/320 mg or 325 mg\n\n <\/td>\n<\/tr>\n
Hydromorphone<\/th>\nDilaudid<\/td>\nSevere<\/td>\nPO\n\nRectal\n\nSubQ, IM, & IV<\/td>\n4-8 mg\n\n3 mg\n\n1.5 mg (may be increased)<\/td>\n<\/tr>\n
Morphine<\/th>\nDuramorph, MS Contin, Oramorph SR, & Roxanol-T<\/td>\nSevere<\/td>\nPO & Rectal\n\nSubQ, IM, & IV<\/td>\n30 mg (may be increased)\n\n4-10 mg (may be increased)<\/td>\n<\/tr>\n
Oxycodone<\/strong>\n\nOxycodone\/<\/strong>Acetaminophen<\/strong><\/th>\nOxy IR, Oxycontin, & Oxy-FAST\n\nPercocet & Roxicet<\/td>\nSevere<\/td>\nPO\n\nPO<\/td>\n5 mg-10 mg (may be increased)\n\n5 mg\/325 mg<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

WHO Ladder<\/h3>\nA general rule of thumb when administering analgesics is pain control should be based on the pain level reported by the client and the least invasive medication with the least side effects should be used to treat that level of pain. The WHO ladder was originally developed for selection of analgesics for clients with cancer. It illustrates the concept that pain control should be based on the level indicated by the client. See Figure 10.6[footnote]World Health Organization. (1996). Cancer pain relief <\/em>(2nd ed.). Geneva. [\/footnote]<\/sup> for an image of the original WHO ladder.\n\n[caption id=\"\" align=\"aligncenter\" width=\"584\"]\"Image Figure 10.6 WHO Pain Ladder. This diagram below shows the stepwise approach to cancer pain management recommended by the World Health Organization (WHO)[\/caption]\n\n \n\nThe original WHO ladder consisted of three steps[footnote]Anekar, A.A., Hendrix, J.M., & Cascella, M. (2023). WHO Analgesic Ladder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK554435\/<\/a>[\/footnote]<\/sup>:\n