Postoperative Nursing Care
Managing Pain
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Safety
- Know your agency’s policy on how frequently to assess patient pain. During the first 24 hours on opioids, assess the patient frequently, at least every 4 hours.
- Evaluate the patient according to your agency’s standardized sedation scale, watching for oversedation and intervening to prevent life-threatening respiratory depression. If it occurs, notify the health care provider immediately and be prepared to administer an antidote, such as an antiemetic, antihistamine, or an opioid-reversing agent, if indicated. Other measures, such as administration of oxygen, may be required.
- Determine the safety of the equipment used in pain management. Correct programming of the patient-controlled analgesia (PCA) pump and correct functioning of the pump are vital for patient safety.
- Advise the patient and his or her family that only the patient should administer pain medication with the PCA pump.
- Never attach a PCA pump to an IV line with blood running or to IV lines with incompatible drugs infusing. If necessary, start another IV site.
Equipment
(Roll cursor over items to see labels)
PCA Pump
PCA control button
PCA medication cartridge
Saline flush
Needleless connector
Alcohol swabs
Clean gloves
Pulse oximeter
Stethoscope
Thermometer
Capnography (CO2) monitoring equipment
PrintableDelegation
The skills of pain assessment and administration of patient-controlled analgesia (PCA) may not be delegated to nursing assistive personnel (NAP). NAP may provide selected nonpharmacological strategies, such as back massage, heat, cold, or elevation, as instructed by the nurse. Be sure to inform NAP of the following:
- Advise NAP to eliminate environmental conditions that aggravate pain, such as excessive heat or noise.
- Remind NAP to provide maximum patient rest periods. A written schedule all staff can follow is ideal.
- Instruct NAP to do the following:
- Remind the patient to turn at least every 2 hours, or turn him or her if the patient is unable to do so
- Encourage the patient to splint his or her incision with a pillow when turning.
- Report promptly if the patient displays any behavior suggestive of pain.
- Inform you immediately of any new symptom or change in patient status, including unrelieved pain or oversedation
- Review behavior that indicates pain in the patient who is unable to self-report.
- Advise NAP never to administer a PCA dose for a patient.
Preparation
- Perform a complete pain assessment. For details, see the Video Skill, “Assessing Pain.” Also assess for other elements that can contribute to pain, such as environmental factors and disorders such as depression, psychosis, and diabetes mellitus.
- Check the accuracy and completeness of each medication administration record (MAR), or check the computer printout with the health care provider’s medication order. Double-check the name of the medication, its dosage, the frequency of administration—including whether it is continuous, on demand, or both—and any lockout settings for PCA.
- Verify that the patient is not allergic to the prescribed medication.
- Assess the following:
- Patient’s cognitive and physical ability to press the button of a PCA device
- Patient’s knowledge of pain management and the efficacy of previous pain management strategies, especially previous PCA use
- Existing IV infusion lines, both peripheral and central. Note signs of infiltration or inflammation
- Character of the patient’s pain, including physical, behavioral, and emotional symptoms
- Environmental factors that could contribute to pain, such as noise and room temperature
- Explain the purpose and demonstrate the function of the PCA to the patient and family.
Follow-up
- Within 1 hour of an intervention, when the drug used has reached its peak effect, ask the patient to describe his or her level of relief, using a scale of 0 to 10.
- Compare the patient’s pain with his or her pain intensity goal.
- Compare the patient’s ability to function and perform activities of daily living before and after pain interventions.
- Observe the patient’s behavior for signs of pain.
- Evaluate the patient for any side effects of analgesia.
- When using a PCA device, have the patient use the pain rating scale to evaluate pain intensity according to your agency’s policy.
- Monitor the patient’s level of sedation, vital signs, and pulse oximetry every 1 to 2 hours for the first 12 hours.
- Observe the patient for adverse reactions, especially excessive sedation.
- Have the patient demonstrate dose delivery.
- Every 4 to 8 hours, or according to your agency’s policy, compare the number of attempts (number of times the patient pushed the button) with the number of doses delivered, including the basal (loading) dose.
Documentation
- Record and report the character of the patient’s pain before intervention. Record the therapies used, and record the patient’s response to interventions.
- Record inadequate pain relief (failure to reach the predetermined pain-intensity goal), any reduction in the patient’s function, adverse effects from pain interventions (pharmacological and nonpharmacological), and any patient or family education performed.
- If using a PCA, record the drug, its concentration, the dosage (basal and/or demand), time started, and lockout time; the amount of solution infused; and the remaining solution. Many agencies have special PCA documentation forms.
- Record your regular assessment of the patient’s response to analgesia on the PCA medication form, in the narrative notes, on the pain assessment flowsheet, and any other documentation, according to your agency’s policy. This includes vital signs, sedation status, pain rating, and status of the vascular access site.
Review Questions
1. What is the nurse’s primary goal for appropriate, effective pain management when considering the patient’s risk for injury?
To minimize the potential for analgesic-induced dependency- To evaluate the effect of pain on the patient’s ability to provide self-care
To maximize pain relief while maintaining the patient’s ability to function- To identify the patient’s need for both physical and emotional pain relief
INCORRECT. Minimizing the potential for analgesic-induced dependency will not reduce the patient’s risk for injury.
INCORRECT. Evaluating the effect of pain on the patient’s ability to provide self-care will not reduce the patient’s risk for injury.
CORRECT. Maintaining patient function is the nurse’s primary goal because it directly affects the patient’s risk for injury.
INCORRECT. Identifying the patient’s need for both physical and emotional pain relief will not reduce the patient’s risk for injury.
2. What is one step the nurse would take if a patient receiving patient-controlled analgesia (PCA) were difficult to arouse?
- Assess the infusion tubing to make sure it has not become occluded.
- Check the infusion site for infiltration and any symptoms of infection.
- Assess respiration, and then notify the health care provider immediately.
- Check the infusion of maintenance fluid to make sure the correct rate is running.
INCORRECT. Assessing the infusion tubing would not help if a patient on PCA were difficult to arouse.
INCORRECT. Checking the infusion site for infiltration or infection would not help if a patient on PCA were difficult to arouse.
CORRECT. If a patient on PCA were difficult to arouse, a possible sign of life-threatening respiratory depression, the nurse would assess respiration (if none, would need to call code) and then notify the health care provider immediately and be prepared to administer an antidote, such as an opioid-reversing agent. The nurse would take other measures as well, such as monitoring the patient’s vital signs and administering oxygen if indicated.
INCORRECT. Checking the infusion of maintenance fluid would not help if a patient on PCA were difficult to arouse.
3. When a patient is using patient-controlled analgesia, which statement is appropriate for the nurse to make to nursing assistive personnel (NAP)?
- “Let me know if the patient has any problems using the PCA pump.”
- “Let me know when the patient’s vital signs indicate that he has pain.”
- “Tell me if the patient is in too much pain to assist with his bath.”
- “The patient is confused and will need your help operating the PCA pump.”
INCORRECT. The responsibility of assessing this aspect of pain management and patient education may not be delegated to NAP.
INCORRECT. The responsibility of assessing this aspect of pain management may not be delegated to NAP.
CORRECT. NAP may assist with the bath and should report to the nurse if the patient is in too much pain to help.
INCORRECT. Neither NAP nor anyone other than the patient may routinely assume responsibility for a PCA pump.
4. Which patient outcome best reflects adequate management for pain originally rated as 8 out of 10 on a pain scale?
- The patient is observed quietly watching television.
- The patient rates current pain as a 4 out of 10.
- The patient tells nursing assistive personnel (NAP) that he is “not hurting as much.”
- The patient is observed sleeping, with a respiratory rate of 20 breaths/min.
INCORRECT. This is not the most definitive indicator of good pain management. The patient may be using distraction as a way to manage pain.
CORRECT. This self-rated improvement is the best sign that pain management is adequate.
INCORRECT. This response is too ambiguous to indicate good pain management.
INCORRECT. Sleep is not always an indication that a patient is pain free.
5. What will the nurse do when discontinuing patient-controlled analgesia?
- Ensure that the main intravenous line is intact.
- Pull the intravenous access device from the patient.
- Tell the patient that pain medication has been discontinued.
- Change the PCA pump infusion rate to keep vein-open status.
CORRECT. The main intravenous infusion should remain intact when discontinuing PCA.
INCORRECT. The main intravenous infusion should remain intact when discontinuing PCA.
INCORRECT. Pain medication has not been discontinued. The PCA delivery approach has been discontinued.
INCORRECT. Changing the PCA pump infusion rate to keep the vein open is not discontinuing the medication.
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