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Risk Management » Practice Tips
October 2008
Pain Management & Oversedation
Pain – the 5th vital sign to assess
Pain management is a highly individualized type of patient care. It is subjective, therefore, problematic for nurses to measure its intensity. Each patient may have a different response to a particular medication and dose. Undertreatment of acute pain may impair recovery, affect the immune system and progress to a “difficult to treat” chronic pain condition which can lead to anxiety and depression.
The patient’s self-report of pain is the widely accepted standard for pain assessment.
Elements of pain assessment include: location, intensity, duration, description in addition to
aggravating factors, alleviating factors and functional impairment.
Role of Nurses in Pain Management
- Assess pain and conduct regular reassessment of pain according to established criteria.
- Advocate for patients.
- Determine the overall effect of pain for the patient.
- Employ holistic non-pharmacologic methods for pain relief.
- Empower patients in pain control measures.
- Be alert to weight loss or pain that does not resolve at rest.
- Observe for neurological symptoms: incontinence, motor weakness, loss of function in extremities.
- Educate patients and family about their role in pain management, treatment limitation, side effects, pain scale and safety instructions.
- Inform associated healthcare providers, e.g., OT, PT, RT, of the patient’s pain status.
Patient Assessment
Age, diagnosis and communication ability require specific pain scales to be used with adult and pediatric patients. Ensure that assessment for pain occurs in the Emergency Department, with out-patients and patients held for observation. Establish realistic pain relief expectations with the patient. A target level of ZERO provides an opportunity for oversedation and negative consequences to pain management. Pain should be assessed when a medication is given and at regular intervals after administration.
Narcotics Administration
A health care professional should review a narcotic prescription order for appropriateness and dosage accuracy based on the patient’s age, weight and other dose indicators prior to dispensing and administering a narcotic.
A protocol should require one person to ready a solution for administration and a second person to independently verify the following information prior to the infusion of high-alert drugs:
- correct drug
- drug concentration
- rate of infusion
- correct patient and line attachment.
Assure the independent double-check is documented in the patient’s medical record.
IV push drugs must be dispensed in unit dose form to eliminate the potential for error.
Adhere to the policy and processes to address breakthrough pain to assure the level of narcotic is appropriate for the patient’s presenting pain.
- Patient assessment
- Physician consult
- Physician order, pharmacy review of order
- Patient reassessment
- Concurrent documentation of each step in the process
Patient Safety
Use the following parameters to assess patients with IV pain medications and PCA infusions:
Pulse, B/P, Respiratory rate, Pulse oximetry, Pain scale, Sedation score, Level of Consciousness, Activity Level and Capnography. The frequency of reassessment must be delineated in the pain management policy requiring reassessment when the rate of an infusion or dose is adjusted.
- Adhere to the hand-off communication policy that includes pain status and last dose/time of administered medication to be shared between caregivers.
- Drug therapy orders must be rewritten when a patient is transferred to a different level of care within a hospital. Orders “resume the same medications” are unacceptable.
- Preprinted standardized order sets should be available for PCA/epidural orders.
- Establish a QI indicator to monitor compliance with the pain management policy.
- Prescribers must have access to review on a daily basis (for accuracy) a medication profile of current and recently discontinued medications.
The Joint Commission recommends that orders be written with specific doses and time frames in lieu of range orders.
The pharmacy must receive all admitted patient data of medications administered in any department, e.g., ED, cardiac catheterization lab, radiology, PACU to assure no duplicate therapy or potential drug interactions occur with admission medication orders.
- Develop a process where one person prepares the intravenous solution for administration and a second person independently verifies that the correct drug, drug concentration, rate of infusion, patient, and line attachment have been selected before high alert drugs such as IV narcotics, vasopressors,and pediatric/neonatal IV solutions are administered.
Reducing Adverse Drug Events with Programmable Infusion Pumps
- Standardize the selection of PCA pumps in the hospital to maximize competence with their use. “Best practice” is the use of one model of infusion pumps throughout an organization to avoid confusion and programming errors. The use of programmable infusion pumps that prevent free-flow administration of solution help avoid inadvertent overdosing which can lead to a dangerous adverse drug event. Utilize, when available, infusion pumps with full functionality that intercept and prevent wrong dose/wrong infusion rate errors due to misprogramming the pump, miscalculation, or an inaccurately prescribed dose or infusion rate.
- Adhere to established criteria that identifies patient populations, specific medications, and rates of infusion that require delivery of solutions via an infusion control pump.
- Adhere to established patient selection criteria for using Patient-Controlled-Analgesia (PCA) that excludes patients unable to deliver the medication themselves, e.g., level of consciousness, physiological condition, limited intellectual capacity, sleep apnea, and/or obesity.
- Validate that infusion pump settings are consistent with provider orders.
- Assure that two RNs verify the infusion pump settings for PCAs at the time of initial set up. Perform two independent staff member double-checks of pump settings, medication and dosage when hanging an intravenous solution each time the dose is changed, the medication concentration is changed and at the change of shift to confirm the settings of patient-controlled-analgesia pumps (PCA).
- Require enhanced monitoring (e.g., capnography, apnea alarms) for patients who receive PCA or other IV infusions to treat pain whenever risk factors such as obesity, low body weight, concomitant use of medications that potentiate opiates, or preexisting conditions such as asthma or sleep apnea exist.
- All electronic infusion control devices (including PCA pumps) undergo inspection and testing (including volumetric testing of rate accuracy) on at least an annual basis.
- Require all infusion pumps in use provide protection from inadvertent free-flow of solutions if the cassette is removed from the pump (without relying on staff to remember to manually clamp the tubing closed).
- Clearly and boldly labeling the distal ends of all tubing on patients who are receiving multiple solutions via various routes of administration (e.g., labeling of the distal end of bladder, IV, central venous, arterial, epidural, and enteral tubing properly identifies relevant access sites).
- Avoid the risk of oversedation and complications that may occur from concomitant use of PCA analgesia and other medications by reconciling the patient’s medications prior to initiation of the PCA. This process will identify potential risk that requires a change in the medication regimen, an increase in the patient monitoring requirements or preclude the patient from PCA usage.
- Prohibit the use of PCA by proxy. Unauthorized activation of the dosing button during PCA by someone other than the patient (a loved one, friend, or even health care provider) can have significant deleterious effects.
- Label the pumps with ”For Patient Use Only” to deter PCA by proxy.
- To avoid oversedation, discourage the use of continuous infusion, where patients receive a small amount of opioid every hour.
- Develop a protocol for management of the signs of oversedation to allow for rapid reversal and potentially improve the patient outcome.
- PCA usage should be documented as determined by policy or physician order, but not less then every four hours. Pump totals should be cleared at the time the PCA usage is documented.
Epidural Catheters in Pain Management
Require that only licensed Independent Practitioners (LIPs) administer the test dose or initial dose of medication and establish analgesic dosage parameters for patients with pain. Avoid the risk of oversedation and complications from concomitant use of epidural analgesia and other medications by reconciling the patient’s medications prior to initiation of the epidural catheter.
- Sensory and motor function must be consistently assessed for patients medicated with an epidural catheter.
- Trace all lines from their origin to the connection port to verify attachments before making any connections, reconnections, or administering medications.
- Include a standardized line reconciliation process as part of handover communications.
- Emphasize to non-clinical staff, patients, and families that devices should never be connected or disconnected by them. Help should always be requested from clinical staff.
- Provide pre-mixed solutions to decrease the likelihood of an error.
- Establish a protocol that identifies who the RN contacts if there is concern regarding the epidural, i.e., pain not managed with current medication order.
- Perform periodic evaluations of the epidural insertion site to insure the integrity of the delivery system and the assessment for complications.
- Assess patients with epidurals for side effects such as pruritis, nausea/vomiting and paresthesia or motor block.
- Assure that two RNs verify the pump settings for epidurals at time of initial set up and whenever there is a rate or dose change or medication concentration change.
- Assure that indwelling catheters are not removed in the presence of therapeutic anticoagulation as this appears to significantly increase the risk of spinal hematoma. http://www.asra.com/consensus-statements/RAPM-Anticoagulation.pdf
- Assure that there is a hand-off communication policy in place and that it includes pain status and last dose/time of medication in the components of patient care to be shared between caregivers.
- Establish triggers for selected drug orders (antidotes) and laboratory test that may be used to enhance detection of potential adverse drug events leading to oversedation via medication error or adverse drug reaction.
Achieving and maintaining nursing competency is vital to successfully manage patients experiencing pain. To practice medication administration safely, new clinical employees must experience a specific pain-management education program. Ongoing annual competency must occur for all nurses to ensure that their knowledge remains current on trends in pain management therapy.
Resources:
- Institute for Healthcare Improvement (IHI) http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/
- Pain Management, Evidence-Based Tools and Techniques for Nursing Professionals Copyright 2007 HCPro, In
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