In 2000, the Joint Commission on Accreditation of Healthcare Organizations first included pain as a vital sign. Nurses have always been educated in using nursing measures/interventions (also known as nursing orders) to treat patients with non-pharmacological and first aid as the first line of treatment. These include such things as cooling measure to treat a fever, simple wound cleansing and bandaging to prevent further damage, applying cooling measures to burns, ice and elevation to minor injuries, etc.
Beyond these initial nursing assessment and treatments, a physician’s assessment, diagnosis and order or direction is required. However, nursing measures/interventions can and should always be used in conjunction with the physician’s orders. In the treatment of pain for instance, the nurse uses a PAIN or PAINAD scale to asses for the level of pain and provides care as directed by the physician. In addition to pharmacological orders, the nurse should be using and teaching the patient methods to reduce and manage pain that don’t require the use of medications.
Pain: the 5th vital sign
The philosophy adopted with JCAHO’s pain as the 5th vital sign included the understanding that pain is subjective, and it is what it is to the patient. Pain is totally to be taken as what the patient perceives it to be. What might be a 5/10 to one person might be a 2/10 to another. Medication orders began to be written for specific levels of pain medication at specific parameters. For instance, pain at 0-3/10 should be treated with Tylenol; 3-6/10 pain would warrant Norco 5/325 and pain 7-10 might warrant something even stronger such as oxycodone or even morphine or Dilaudid. These would be given q 4-6 hours prn and might overlap if the pain is not managed and worsens.
Staying ahead of the pain became the rule and taking a patient’s word for the level of pain as standard practice. Astute nurses as patient advocates began to question the advisability of this in light of behaviors that didn’t match the numbers patients were providing in an assessment, but the standard said the patient’s perception is the guideline and nurses were bound to follow doctor’s orders. Patients would state their pain was 6/10, but they could ambulate easily and didn’t exemplify any guarding or grimacing or calling out with movement.
Documenting subjective and objective data
Things weren’t adding up. So, nurses were advised to document a full assessment of objective data including appearance and behavior along with other signs and symptoms such as increasing respirations, elevated heart rate and blood pressure when patients were requesting pain medication. (“Patient states pain is 6/10 but no elevated VS, smiling and no grimacing or guarding, moves freely. PAINAD score 1.”) This thrust the burden of proof back onto the physician to manage pain appropriately. However, patients who had already become accustomed to the feeling and sense of well-being the medication provided were demanding and reluctant to deal with any level of pain; not understanding the ramifications of continuing a pain management plan that wasn’t really necessary.
Along with administration of medication, nurses are expected to use and educate patients on nursing measures to manage any symptoms, not just pain. These include measures for pain such as repositioning, elevating, using pillows for guarding and support, cooling measures, ice or heat therapy, light massage, mild stretching as allowed as well as using techniques such as imagery, meditation and distraction.
In the daily stressful rapid-response environment with expectations for immediate gratification, administering medication as requested and ordered has become the simpler solution. In reality, nurses don’t have time to provide all of the patient education and implementation of non-pharmacological methods needed. Patients just want to feel better quickly and not experiment with measures that might just be as effective but might take longer to work.
As the situation has grown into a crisis with opioid use out of control, the pendulum has swung back the other direction. For some, it’s gone back too far and honestly there are patients who do need some medication beyond the over the counter meds such as Tylenol, Advil and Motrin. Pharmacies and Insurance companies are working hard to deny them this and prevent physicians who abuse the system from continuing to write never-ending prescriptions. Things need to balance out and they will eventually.
Meanwhile, nurses can help tremendously by educating patients in how pain works, and managing their pain and expectations of instant gratification by using nursing measures in conjunction with the medications ordered to reduce the frequency and requirement of controlled drugs as well as exceeding recommended doses of OTC meds. Patients also need education to fully understand the physical ramifications of using opioid drugs and abusing OTC meds as well.
Use continuing education
Nurses can educate themselves through continuing education courses to gain a better understanding of Safe and Effective Prescribing of Controlled Substances, the use of palliative care to help those with acute and chronic pain issues and those dealing with end-of-life care pain management issues. Nurses can also provide education in the use of medical marijuana and CBD for chronic and acute pain issues.
As the most trusted and ethical professionals, nurses can make a difference for all patients as they educate and advocate for effective and appropriate pain management. Nurses need to stand and take a fully active role in educating patients in the pain process and how to use non-pharmacological methods in addition to medications in order to achieve the best quality care and outcomes.