ASPAN pain and comfort clinical guideline.

Preoperative Phase

Assessment

Vital signs including pain and comfort goals (e.g., 0 to 10 scale)
Medical history (e.g., neurologic status, cardiac and respiratory instability, allergy to medication, food and objects, use of herbs, motion sickness, sickle cell, fibromyalgia, use of caffeine/substance abuse, fear, and anxiety)
Pain history (e.g., preexisting pain, acute, chronic, pain level, pattern, quality, type of source, intensity, location, duration/ time, course, pain effect, and effects on personal life)
Pain behaviors/expressions or history (e.g., grimacing, frowning, crying, restlessness, tension, and discomfort behaviors [e.g., shivering, nausea, and vomiting]. Note that physical appearance may not necessarily indicate pain/ discomfort or its absence.)
Analgesic history (type [i.e., opioid, non-opioid, and adjuvant analgesics], dose, frequency, effectiveness, adverse effects, other medications that may influence choice of analgesics [e.g., anticoagulant, antihypertensive, muscle relaxants])
Patient's preferences (e.g., for pain relief/comfort measures, expectations, concerns, aggravating and alleviating factors, and clarification of misconceptions)
Pain/comfort acceptable levels (e.g., patient and family [as indicated] agree to plan of treatment/interventions postoperatively)
Comfort history (i.e., physiological, sociocultural, psychospiritual, and environmental [e.g., spiritual beliefs/symbols, warming measures, music, comfort objects, privacy, positioning, factors related to nausea/vomiting])
Educational needs (i.e., consider age or level of education, cognitive and language appropriateness, and barriers to learning)
Cultural language preference, identification of personal beliefs, and resulting restrictions
Pertinent laboratory results (e.g., prolonged prothrombin time [PT], partial thromboplastin time [PTT], and abnormal international normalized ratio [INR] and platelet count to determine risk for epidural hematoma in patients with epidural catheter)

Interventions

Identify patient, validate physician's order and procedure (i.e., correct name of drug, dose, amount, route, and time, and validate type of surgery and correct surgical site as applicable)
Discuss pain and comfort assessment (i.e., presence, location, quality, intensity, age, language, condition, and cognitively appropriate pain rating scale [e.g., 0 to 10 numerical scale or FACES scale] and comfort scale. Assessment method must be the same for consistency.)
Discuss with patient and family (as indicated) information about reporting pain intensity using numerical or FACES rating scales and available pain relief and comfort measures (include discussion of patient's preference for pain and comfort measures; implement comfort measures)(i.e., physiological, sociocultural, spiritual, environmental support as indicated by patient)
Discuss and dispel misconceptions about pain and pain management
Encourage patient to take a preventive approach to pain and discomfort by asking for relief measures before pain and discomfort are severe or out of control
Educate purpose of intravenous or epidural patient-controlled analgesia (PCA) as indicated; educate about use of nonpharmacologic methods (e.g., cold therapy, relaxation breathing, music)
Discuss potential outcomes of pain and discomfort treatment approaches
Establish pain relief/comfort goals with the patient (e.g., a pain rating of less than 4 [scale of 1 to 10] to make it easy to cough, deep breathe, and turn); premedicate patients for sedation, pain relief, comfort (e.g., non-opioid, opioid, antiemetics as ordered; consider needs of chronic pain patients)
Arrange interpreter throughout the continuum of care as indicated
Utilize interventions for sensory-impaired patients (e.g., device to amplify sound, sign language, and interpreters)
Report abnormal findings including laboratory values (prolonged PT/PTT and abnormal INR and platelet count among epidural patients)
Arrange for parents to be present for children

Expected Outcomes

Patient states understanding of care plan and priority of individualized needs
Patient states understanding of pain intensity scale, comfort scale, and pain relief/comfort goals
Patient establishes realistic and achievable pain relief/comfort goals (e.g., a pain rating of less than 4 [scale 0 to 10] to make it easier to cough, deep breathe, and turn upon discharge)
Patient states understanding or demonstrates correct use of PCA equipment as indicated
Patient verbalizes understanding of importance of using other nonpharmacologic methods of alleviating pain and discomfort (e.g., cold therapy, relaxation breathing, music)

Postanesthesia Phase I

Assessment

Refer to preoperative phase assessment, interventions, and outcomes data
Type of surgery and anesthesia technique, anesthetic agents, reversal agents
Analgesics (i.e., non-opioid, opioid, adjuvants given before and during surgery, time and amount at last dose, and regional [e.g., spinal/epidural])
Pain and comfort levels on admission and until transfer to receiving unit or discharge to home (Reassess frequently until pain or discomfort is controlled. During sedation procedure, assess continuously.)
Assessment parameters
1. Functional level and ability to relax
2. Pain: type, location, intensity (i.e., using self-report pain rating scale whenever possible [age, language, condition, and cognitive appropriate tools], quality, frequency [continuous or intermittent], and sedation level; patient’s method of assessment and reporting need to be the same during the postoperative continuum of care for consistency.) Note pain level at rest and during activity.
3. Self-report of comfort level using numerical scale (0 to 10 scale) or other institutional approved instruments
4. Physical appearance (e.g., pain/discomfort behaviors [Note: Pain behaviors are highly individual and the absence of any specific behavior (e.g., facial expression, body movement) does not mean the absence of pain.])
5. Other sources of discomfort (e.g., position, nausea and vomiting, shivering, environment such as noise, noxious smell, anxiety)
6. Achievement of pain relief/comfort treatment goals
Age, cognitive ability, and cognitive learning methods
Status/vital signs
1. Airway patency, respiratory status, breath sounds, level of consciousness, and pupil size as indicated and other symptoms related to the effects of medications
2. Blood pressure
3. Pulse/cardiac monitor rhythm
4. Oxygen saturation
5. Motor and sensory functions post– regional anesthesia technique

Interventions

Identify patient correctly; validate physician's order; implement correct drug, dose, amount, route, and time; include type of surgery and surgical site as applicable
Pharmacologic (medicate as ordered)
1. Mild to moderate pain—use non-opioids and may consider opioids (e.g., acetaminophen nonsteroidal anti-inflammatory drugs [NSAIDs], cyclooxygenase 2 [Cox-2] inhibitors). All the patient's regular non-opioid prescription medications should be made available unless contraindicated and per institutional approval.
2. Moderate to severe pain—use multimodal therapy (e.g., combine non-opioid and opioid)
3. Utilize the 3 analgesic groups appropriately (consider multimodal therapy)
  1. Non-opioids (e.g., acetaminophen, NSAIDs, Cox-2 inhibitors); adjuvants non-opioids (acetaminophen and NSAIDs, such as aspirin, ketorolac, ibuprofen, Cox-2 inhibitors).
  2. Mu-agonist opioids (e.g., morphine, hydromorphone, fentanyl)
  3. Adjuvants
    1. Multipurpose for chronic pain (e.g., anticonvulsants, tricyclic antidepressants, corticosteroids, antianxiety medication)
    2. Multipurpose for moderate to severe acute pain (e.g., local anesthetics, ketamine)
    3. Neuropathic continuous pain— antidepressants, tricyclic antidepressants, oral or local anesthetic
    4. Neuropathic lancinating pain- (stabbing, knifelike pain) anticonvulsant, baclofen
    5. Malignant bone pain—corticosteroids, calcitonin
    6. Post–orthopedic surgery—consider muscle relaxants if patient experiences muscle spasm
Initiate and adjust IV and regional infusions (PCA) as indicated and ordered, and based on hemodynamics status (Refer to institutional permissive procedure.)
Nonpharmacologic intervention use to complement, not replace, pharmacologic interventions
Administer comfort measures as needed
1. Physiological (e.g., positioning, pillow, heat and cold therapies, sensory aids [e.g., dentures, eye glasses, hearing aids]; use meperidine [Demerol] for shivering, antiemetics, e.g., Reglan, Zofran as ordered)
2. Sociocultural (e.g., family/caregiver, interpreter visit)
3. Psychospiritual (e.g., chaplain or cleric of choice, religious objects/symbols)
4. Environmental (e.g., confidentiality, privacy, reasonably quiet room)
Cognitive behavioral (e.g., education/instruction, relaxation, imagery, music, distraction, biofeedback)

Expected Outcomes

Patient maintains hemodynamic stability including respiratory/cardiac status and level of consciousness
Patient states achievement of pain relief/ comfort treatments goals (e.g., acceptable pain relief with mobility at time of transfer or discharge)
Patient states he/she feels safe and secure with the instructions (e.g., use of PCA machine)
Patient shows effective use of at least one nonpharmacologic method (i.e., breathing relaxation techniques)
Patient shows effective use of PCA as indicated and discusses expected results of regional techniques
Patient verbalizes evidence of receding pain level and increased comfort with pharmacologic and nonpharmacologic interventions

Postanesthesia Phase II/III

Assessment

Refer to preoperative phase and Phase I assessments, interventions, and outcomes data
Achievement of pain/comfort treatment goals and level of satisfaction with pain relief and comfort management
Pain relief/comfort management plan for discharge and patient agreement
Educational and resource needs, considering age, language, condition, and cognitive appropriateness

Interventions

Identify patient correctly; validate physician's order; implement correct drug, dose, amount, route, and time
Pharmacologic interventions (medicate as ordered): non-opioid (e.g., acetaminophen, NSAIDs, Cox- 2 inhibitors), Mu-agonist opioids (e.g., morphine, hydromorphone, fentanyl), and adjuvant analgesics (e.g., local anesthetics).
Continue and/or initiate nonpharmacologic measures from Phase I
Educate patient and family/caregiver
1. Pain and comfort measures
2. Untoward symptoms to observe
3. Regional or local anesthetic effects dissipating after discharge (e.g., numbness, motor weakness, or inadequate relief) and potential adjustments as applicable
4. Availability of resource as needed
Discuss misconceptions, expectations and implement plan of action satisfactory to patients
Address nausea with pharmacologic interventions or other techniques and discuss expectations

Expected Outcomes

Patient states acceptable level of pain relief and comfort with movement or activity at time of transfer or discharge to home
Patient verbalizes understanding of discharge instruction plans
1. Specific drug to be taken
2. Frequency of drug administration
3. Potential side effects of medication
4. Potential drug interactions
5. Specific precaution to follow when taking medication (e.g., physical limitation, dietary restrictions)
6. Name and telephone number of the physician/resource to notify about pain, problems and other concerns
Patient states understanding or shows effective use of nonpharmacologic methods (e.g., cold/heat therapy, relaxation breathing, imagery, music)
Patient states achievement of pain/ comfort treatment goals and level of satisfaction with pain relief and comfort management in the perianesthesia setting

Complete Summary

GUIDELINE TITLE

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

FDA WARNING/REGULATORY ALERT

COMPLETE SUMMARY CONTENT

DISEASE/CONDITION(S)

GUIDELINE CATEGORY

CLINICAL SPECIALTY

INTENDED USERS

GUIDELINE OBJECTIVE(S)

TARGET POPULATION

INTERVENTIONS AND PRACTICES CONSIDERED

MAJOR OUTCOMES CONSIDERED

METHODS USED TO COLLECT/SELECT EVIDENCE

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

NUMBER OF SOURCE DOCUMENTS

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

METHODS USED TO ANALYZE THE EVIDENCE

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

METHODS USED TO FORMULATE THE RECOMMENDATIONS

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

COST ANALYSIS

METHOD OF GUIDELINE VALIDATION

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

MAJOR RECOMMENDATIONS

CLINICAL ALGORITHM(S)

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

POTENTIAL HARMS

QUALIFYING STATEMENTS

DESCRIPTION OF IMPLEMENTATION STRATEGY

IOM CARE NEED

IOM DOMAIN

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

DATE RELEASED

GUIDELINE DEVELOPER(S)

SOURCE(S) OF FUNDING

GUIDELINE COMMITTEE

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

GUIDELINE STATUS

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

NGC STATUS

COPYRIGHT STATEMENT

NGC DISCLAIMER

Search

Summary

Browse

Compare