JANNA C. ROOP PhD, RN, CHPN
APRIL HAZARD VALLERAND PhD, RN, FAAN
A Home Care Requisite:
Pain management remains as one of the most important issues in healthcare today. Unrelieved pain can affect the healing process, increase stress, and result in general physical and psychological decline in the sufferer ( McCaffery & Pasero, 1999 ). Home care nurses play a critical role in the assessment and management of pain because economically driven changes in healthcare delivery have placed more patients in the home setting than in acute care settings ( Vallerand, Anthony, & Saunders, 2005 ). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2004) has mandated that healthcare organizations provide adequate interventions to assess and treat pain, and many institutions have responded by identifying pain assessment as a “fifth vital sign.” These efforts have aided in the improvement of pain management, yet pain remains underestimated and inadequately treated ( Vallerand, 2003 ).
What is pain? The “gold standard definition of pain” was developed by McCaffery in 1968 : “Pain is whatever the experiencing person says it is, existing whenever he says it does” (p. 65). Although this definition is widely accepted by home care nurses, data suggest that clinicians are inconsistent in their application of this knowledge. In a study by Vallerand, Hasenau, and Templin (2004) , surveyed nurses reported awareness of McCaffery's definition of pain and could state that pain is what the patient says it is, but further investigation revealed some troubling inconsistencies. Nurses were given 2 vignettes of patients who reported pain scores of 8 on a scale of 1 to 10, with 10 being the worst pain ( Vallerand et al., 2004 ). In the first vignette, the patient was quiet and grimacing, and in the second vignette, the patient was smiling and talking. The survey showed that 91% of the nurses believed the patient's report of pain in the first instance, whereas only 81% believed the smiling patient's report of pain, suggesting that nurses still are reluctant to accept the patient's report of pain in some circumstances.
Comprehensive assessment is the foundation for successful pain control ( American Pain Society, 2003 ). Although multiple factors may contribute to inadequate pain management, consistency in assessment of pain and the patient's response to interventions and proper documentation of these findings are fundamental in pain management.
A comprehensive pain assessment is an essential first step. Multiple rubrics exist for assessing pain, and multidimensional tools are available ( Table 1 ). We believe that the tool is not as important as the thoroughness of the examiner and the subsequent documentation. Lynch (2001) offers 1 framework, the mnemonic PAINED, as a guide for pain assessment:
Table 1. Resources for Pain Assessment and Treatment
The assessment should include not only any pain incurred at the time of the assessment, but also any pain experienced within the recent period or any pain experience that interferes with normal function and activities. This aspect of the assessment is most appropriate for the home care nurse because improving or maintaining adequate function in the home often is the desired goal of care. A simple question such as “What does the pain keep you from doing?” can provide information about the effect of pain on the patient's activities, as well as what activities are meaningful for that individual patient. This information also may direct the type and focus of the interventions for pain management. Assessment of pain should be an ongoing activity to assess changes in the pain experience and new sources of pain.
Several tools are available that assist in the assessment of pain. These tools maintain the patient's place as the primary source of information regarding pain, but they also help quantify the data and afford a measure of consistency among caregivers. The selected tool should be appropriate for the individual patient's age and culture. For the amount or intensity of pain, a numeric scale of 0 to 10 is a common and simple means of consistent assessment that adapts well to home care ( Mercadante, 1999 ). The British Pain Society publishes the numeric pain scale in 17 languages on their Web site ( http://www.britishpainsociety.org/pain_scales.html ). The Outcome and Assessment Information Set (OASIS) from the U.S. Department of Health and Human Services provides a uniform external comparative data set for measuring patient outcomes ( Stadt & Molare, 2005 ).
A thorough assessment will provide a basis for the choice of treatment or treatments of the pain. Home care nurses must be knowledgeable about pain management principles so that they can effectively advocate for adequate pain control ( Vallerand et al., 2004 ).
Although home care nurses encounter many different types of pain, the basic pharmacologic management of most pain types is remarkably similar. As an initial guide, many practitioners refer to the World Health Organization (WHO) 3-Step Analgesic Ladder ( WHO, 1996 ) ( Figure 1 ). This guideline was developed originally to guide practitioners caring for patients with cancer pain, but the same principles can be applied to patients with many types of pain.
Figure 1. World Health Organization (WHO) three-step analgesic ladder. Developed by WHO and available at: http://www.whoint/cancer/palliative/painladder/en/ .
The WHO 3-Step Analgesic Ladder bases the types of medication used primarily on the intensity of pain. The first level addresses the use of nonopioid analgesics (acetaminophen and nonsteroidal antiinflammatory drugs [NSAIDS]) and possibly adjuvant analgesics for the treatment of mild pain (levels 1–4 on the 0-to-10 scale). Level 2 on the ladder suggests adding opioids for moderate pain (levels 5–6 on the 0-to-10 scale) or a combination of opioids and those analgesics already suggested or used for mild pain. At the third level, for severe pain of 7 or greater on the 0-to-10 scale, strong opioids are used, with nonopioids and adjuvant analgesics added as needed. The following section discusses agents to be used at each level of the analgesic ladder ( WHO, 1996 ).
At the first level of the analgesic ladder, pain is mild and usually controlled with nonopioid analgesics. The choices available include acetaminophen and NSAIDs. Acetaminophen often is chosen because it has a good side effect profile. Most patients can take acetaminophen without experiencing side effects. The biggest concern with acetaminophen is the dose limitation. Doses exceeding 4,000 mg/day are not recommended, and for patients with decreased renal or hepatic function and those with harmful alcohol use, doses should be limited to 2,000 mg/day to prevent renal and hepatic effects ( Deglin & Vallerand, 2005 ; Ferrell et al., 2002 ). Because acetaminophen is found in many over-the-counter medications, the patient must be cautioned not to exceed the total amount recommended. Patients often are unaware that there is acetaminophen in the products they may take for colds, heartburn, and other pain problems.
The choice between acetaminophen and a NSAID should be made according to the type of pain and the patient's history. For pain that has an inflammatory component, such as sprains, postoperative pain, and bone pain, NSAIDs tend to be more effective. Acetaminophen has no antiinflammatory properties and is therefore not as effective for pain with inflammation ( Deglin & Vallerand, 2005 ). Although NSAIDs may be more effective than acetaminophen for analgesia, they also have more side effects, primarily involving in the gastrointestinal system. The use of NSAIDs may upset the stomach and cause ulcers and bleeding. This may be minimized by taking the NSAID with food or milk. Patients also should be advised to stay in an upright position for 20 minutes after NSAID administration to minimize regurgitation. Also, NSAIDs may be taken with antacids, or histamine2 receptor antagonists such as cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), or ranitidine (Zantac). Proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium) also may help to prevent adverse effects ( Ferrell et al., 2002 ).
Bleeding is of particular concern with NSAIDs because NSAIDS prolong the patient's bleeding time. The duration of this effect varies with each NSAID, from minimal to 10 days. It is helpful for the nurse to be aware of the duration of this effect because if the patient is planning to have surgery, he or she may need to stop the NSAID before the surgical procedure.
The second level of the WHO 3-Step Analgesic ladder addresses moderate pain, or pain of 5 or 6 on the 0-to-10 scale. A pain level of 5 or greater has been shown to impair function ( Serlin, Mendoza, Nakamura, Edwards, & Cleeland, 1995 ). Therefore, a stronger analgesic should be considered. Analgesics at the second level of the ladder include opioid analgesics for moderate pain, often in combination with acetaminophen, aspirin, or ibuprofen including propoxyphene (Darvon, Darvocet), codeine, tramadol (Ultram, Ultracet), hydrocodone (Vicodin, Lortab, Lorcet, Norco, Vicoprofen), or oxycodone (Percocet, Percodan, Tylox, Combunox). The dosage of these drugs is limited by the nonopioid analgesic ingredient, such as acetaminophen or ibuprofen. In addition, propoxyphene has a toxic metabolite that accumulates with repeated dosing and may lead to seizures. Propoxyphene is not recommended for elderly patients or those with renal impairment ( American Pain Society, 2003 ).
At level three of the 3-Step Analgesic Ladder, severe pain of 7 or greater on a 0-to-10 scale is treated with opioid analgesics for severe pain. The analgesics at this level include morphine (MSIR, MS Contin, Oramorph, Kadian, Avinza), hydromorphone (Dilaudid), oxycodone (Roxicodone, OxyIR, OxyFAST, OxyContin), fentanyl (Sublimaze, Duragesic, Actiq), and methadone. These opioid analgesics are available in many forms, which can be administered by different routes. They vary in onset and duration.
Opioid analgesics at both the second and third levels may be given concurrently with nonopioid analgesics. Differences in the mechanism of action between opioids and nonopioids allow pain to be treated simultaneously at different receptor sites. Concurrent administration of nonopioids also may decrease the amount of opioid required to control the pain ( Deglin & Vallerand, 2005 ).
Adjuvants are drugs that may not be considered analgesics based on their mechanism of action, but have analgesic effects in certain pain conditions ( Foley, 2006 ). For example, neuropathic pain characterized by burning or lancinating pain may require the use of tricyclic antidepressants or anticonvulsants. Corticosteroids may be useful for the treatment of inflammatory pain, and benzodiazepines and muscle relaxants can be helpful in treating pain associated with muscle spasm. Adjuvants may be added at any level of the WHO 3-Step Analgesic Ladder based on the type of pain the patient is experiencing. The use of adjuvants illustrates the need for a comprehensive assessment of the quality of pain to determine the need for these drugs.
Use of the WHO 3-Step Analgesic Ladder can be enhanced by the application of 5 key principles: by mouth, by the clock, by the ladder, for the individual, and attention to detail ( WHO, 1996 ). “By mouth” focuses on the use of the oral route for analgesic administration. The oral route is the preferred route and proves effective, even for strong analgesics such as morphine.
“By the clock” emphasizes that for persistent pain, analgesics should be taken at regular intervals and not “as needed.” Dosing as needed (PRN) requires the patient to make the decision that the pain is severe enough to take the medication, often allowing a higher level of pain to occur before the medication is taken. This delay often results in the need for a higher dose of medication to control the pain. Dosing at regular intervals around the clock prevents the pain from becoming severe and may require lower doses. In addition, doses should be scheduled to allow the patient to sleep through the night without waking up with an increase in pain.
“By the ladder” directs the clinician to use the WHO 3-Step Analgesic Ladder and the pain intensity to guide the prescription of analgesics. Unless the pain is severe, a nonopioid should be prescribed initially and adjusted to the maximum recommended dose before an opioid is used. An opioid, such as morphine, for moderate to severe pain should be added if the nonopioid no longer adequately relieves the pain. However, if the patient initially has severe pain, an analgesic for severe pain rather than a nonopioid from step 1 should be used.
“For the individual” addresses the variability in patient responses to analgesics. Factors such as pain severity, previous opioid exposure, age, and concurrent diseases may affect the patient's response to analgesics. Because individuals vary in their requirements for analgesics, each drug has a wide range of doses that may be effective for relieving pain in different patients. The underlying principle is that “the correct dose of an analgesic is the dose that relieves the pain. There are no standard opioid doses” ( Foley, 2006 , p. 2). In addition, opioid analgesics have no ceiling effect. The dose of an opioid can be increased as needed to control pain, unless there are unmanageable side effects. It is important to remember that doses should be increased by percentages (50–100%) rather than by predetermined milligrams. For example, a morphine dose of 5 mg could be reasonably increased to 7.5 or 10 mg, but a dose of 50 mg would need to be increased to 75 or 100 mg to achieve additional relief.
“Attention to detail” focuses on the importance of monitoring the patient's response to the analgesic regimen. Reassessment of pain at the peak of the analgesic allows the nurse to determine whether the medication is effective, whether a higher dose is needed, or whether side effects are present. The focus is on ensuring that the patient obtains the maximum benefit with as few adverse effects as possible ( Foley, 2006 ).
Studies have demonstrated that the WHO 3-Step Analgesic Ladder can provide relief to between 77% and 100% of advanced cancer patients with pain ( Foley, 2006 ). The principles from the WHO analgesics ladder also can assist the nurse in determining options for managing pain in other populations of patients.
Although successful pain management strategies have been available for decades, many lay people and clinicians alike cling to outdated and inaccurate ideas. Most healthcare curricula devote little or no time to pain management. Therefore, tradition rather than scientific evidence often guides professional practice ( Furrow, 2001 ; McDonald, Thomas, Livingston, & Severson, 2005 ). The home care nurse can be a valuable resource for educating patients, families, and other professionals on the interdisciplinary team. See Table 2 for more information about some of the most common misconceptions regarding pain.
Table 2. Misconceptions About Pain and Corrections
Successful pain relief strategies rely on a partnership between the patient, family, doctor, nurse, and pharmacist. Communication among all members of the partnership is essential if good pain control is to be achieved. Unfortunately, with so many people involved, there are multiple places for breakdown. In the following sections, we offer suggestions for improving the communication among all the partners.
Successful treatment of pain always starts with the patient and family, and a comprehensive baseline assessment of pain is the essential first step ( American Pain Society, 2003 ; Passik et al., 2004 ). Because pain is a subjective experience, the patient is the expert regarding his or her pain. The nurse must elicit the best possible understanding of the patient's experience to obtain a meaningful assessment, and the nurse must believe the patient's report of pain ( American Pain Society, 2003 ). Objective signs of pain are inadequate and unreliable assessment data. Both families and clinicians may be misled by the absence of objective signs such as changes in vital signs, facial grimacing, or a decrease in activity, yet patients can experience severe pain without showing any outward signs. Many patients, however, may not know how to talk about their pain or may be reluctant to do so. They also may have misguided or outdated ideas about pain and pain medicines, so the nurse should be prepared to educate both patients and families. It is particularly important that the patient and family understand a few key points:
The healthcare professional who has the most contact with the patient in his or her home environment will most likely be the home care nurse. One of the most important tasks for the nurse is to make the pain visible to other members of the interdisciplinary team ( Wilke et al., 2001 ). The most effective way to achieve this aim is through thorough documentation and efficient oral communication. Passik et al. (2004) developed the Pain Assessment and Documentation Tool. It was designed for physician's to use to document pain assessment, the treatment plan, and outcomes, but it also is appropriate for nursing. Passik et al. (2004) suggested that documentation should include 4 broad categories, the “4 A's” of pain control: analgesia, activities of daily living, adverse events, and aberrant drug-related behaviors.
When the assessment indicates a change in the plan of care, the nurse should contact the physician. The nurse is well advised to have a planned suggestion in mind when the call is made and to base requests and suggestions on published professional guidelines. An excellent resource is Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (5th edition), available from the American Pain Society ( www.ampainsoc.org ). Clinicians unfamiliar with the most recent advances in pain management may be more willing to prescribe adequate pain medication if they know that their prescriptions are consistent with national interdisciplinary guidelines. It also is appropriate in this situation to ask the primary doctor for a referral to a physician specializing in palliative care because these physicians are experts in pain and symptom management.
Pharmacists also are important partners in the pain management plan of a patient at home, and like other professionals, they may have misconceptions about appropriate pain management. Patients have reported pharmacists chastising them for taking so much opioid because “you don't look like you're in pain.” Other patients have been given inaccurate counsel about pain control (you can't take a long- and short-acting opioid at the same time) or have had difficulties because the pharmacy has resisted stocking enough medication to allow for seamless refills.
In our experience, if a patient will be taking large doses of opioids, it can be very helpful for the home care nurse to call the pharmacist directly to collaborate on the plan of care. Communicating that the treatment plan includes thorough assessment using the 4 A's of pain control and interventions based on national guidelines can help to ease the pharmacist's concerns.
Home care nurses play a pivotal role in the management of pain for their patients. Their skills in assessment and their promotion of communication between the patient, the caregiver, the prescribing professional, and other professional members of the team are crucial to high-quality patient care. An accurate, consistent, and comprehensive assessment provides the cornerstone of this process. Nurses who accept the patient's report of pain, have knowledge about basic pharmacologic management of pain, and promote communication among all members of the interdisciplinary team are powerful agents in the quest for optimal pain management.
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