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“Pain Assessment: It’s More Than Just a Number”

By: Sandra Price, MS, RN, CAPA Secretary for NYSPANA and District 14

I remember listening to a dynamic speaker on multimodal analgesia in treating acute pain at the New York State PeriAnesthesia Nurses Association state conference in White Plains, NY last October. Marty Maresco, past NYSPANA President and Nurse Manager of the Pain Clinic at Phelps Memorial Hospital Center, spoke passionately about pain requiring a complex nursing assessment using a multimodal approach to manage a patient with acute pain. Then, I attended a multimodal pain analgesia lecture again at the American Society of PeriAnesthesia Nurses (ASPAN) 35th national conference in Philadelphia, PA. The topic was current and relevant in nursing practice and I wanted to share what I learned with perioperative nursing colleagues and leadership in my local region of Rochester, NY.

Dr. Esther Bernhofer, Nurse Researcher at Cleveland Clinic, came to the Hilton Garden Inn Hotel in Rochester to present, “The Use of Multimodal Analgesia in Treating Acute Pain: Tools to Implementation.” The interactive nurse-tonurse discussion was a non-branded dinner presentation sponsored by Mallinckrodt Pharmaceuticals. There were a total of 26 Registered Nurses (RN’s) that attended the event, including nursing educators and leadership from Rochester area health care facilities.

Here is a situation that many nurses can relate to when caring for a patient after surgery. The nurse walks in to assess the patient who is sleeping comfortably. The nurse asks the patient to rate their level of pain on a scale 0-10 and the patient states, “my pain is 10/10,” in a groggy voice and falls back to sleep. The nurse knows the patient already received multiple doses of opioids, is on oxygen therapy to maintain adequate oxygen saturation, and the other vital signs are stable. The provider order reads to medicate the patient with two tablets of an opioid for a severe pain rating of >6, as needed. The nurse is faced with a dilemma to medicate for pain based on a provider order that links opioid doses to a pain score or intensity without the consideration of other critical patient factors that may contraindicate what is ordered. The nurse is not going to medicate the patient solely based on the patient’s subjective verbal pain score and compromise patient safety.

The nurse knows that pain is subjective and more than just a number (McCaffery, 1968). The nurse applies critical thinking by having a conversation with the patient, contact the provider if needed, and individualizes the plan of care. Dr. Bernhofer suggests consideration of multimodal pain management alternatives; such as, ice, heat, non-narcotic analgesia, and massage to lessen the need for opioids.

The American Society for Pain Management Nursing (ASPMN) recently issued a position statement that supports a comprehensive pain assessment that includes pain intensity, as well as other patient assessments that influence opioid dosing (www.ASPMN.org).

Adverse outcomes have been published in The Joint Commission (TJC) sentinel event expressing concerns about prescribers linking opioid doses to pain intensity for the management of pain (TJC, 2012); however, many institutions continue to require prescribers to write this type of order and nurses to implement them.

There is an urgent need to address current practice, pain intensity scale, and reform policy to minimize risk to patients and liability to nurses, prescribers and institutions (Lucas, Vlahos, & Ledgerwood, 2007; Pasero, 2014; White & Kehlet, 2007).

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