Pharmacological Pain Management: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of pharmacological pain management in order to:
- Assess client need for administration of a PRN pain medication (e.g., oral, topical, subcutaneous, IM, IV)
- Administer and document pharmacological pain management appropriate for client age and diagnoses (e.g., pregnancy, children, older adults)
- Administer pharmacological measures for pain management
- Administer controlled substances within regulatory guidelines (e.g., witness, waste)
- Evaluate and document the client's use and response to pain medications
Some orders for pain medications are PRN which means that the client will only receive the pain medication when there is pain or discomfort that can be assessed and documented by the nurse. PRN pain medications can be given using a number of routes including the intramuscular, intravenous, oral, subcutaneous, and topical route as is used for skin irritation and itchiness, for example.
RELATED: Pain Management Nursing Careers
As more fully discussed earlier in the section entitled "Assessing the Client's Need for Pain Management", pain can be classified as acute and chronic, nociceptive and neuropathic, superficial, somatic, radicular, referred or visceral pain, localized or diffuse, and as mild, moderate, or severe.
As also detailed in this same section, pain that is not controlled and managed can lead to severe consequences for the client. For example, the client's psychological and emotional state can be adversely affected with depression, a poor quality of life, and anxiety, and the client's physical status and hemostasis is also affected with things like alterations in terms of their vital signs and perhaps even neurogenic shock.
Despite all the misinformation about pain and pain management, pain must be managed according the external regulatory bodies like the Joint Commission on the Accreditation of Healthcare Organizations, and the American Nurses Association.
There are several ways of assessing pain. These pain assessment methods include:
- The PQRST method of pain assessment which includes precipitating events, the quality of pain (dull, sharp, deep, superficial, burning, aching, or stabbing?), region and location of the pain, the severity of the pain, and the triggers and timing of the pain.
- Using a standardized pain assessment scale specifically for adults, children and infants, such as the CRIES and McGill Pain Assessment tools
- Using a graphic or numerical pain rating scale with faces and on a scale from 0 to 10, for example
- The assessment of behavioral signs and symptoms of pain such as tachycardia, hypertension and diaphoresis
Administering and Documenting Pharmacological Pain Management That is Appropriate for the Client's Age and Diagnoses
Pharmacological pain management medications have some age specific implications along the lifespan and for some diagnoses, conditions and diseases. For example, infants, children, the elderly and clients affected with a normal and expected developmental change, such as pregnancy, have special needs that the nurse must be knowledgeable about before administering a pharmacological pain medication.
Neonates and infants are given dosages of medications based on their weight in terms of kilograms or based on their body surface area. Oral pain medications are given as a liquid using a dropper or a nipple.
Young children are also given pain medications with a dosage as based on their kilograms of body weight or based on their body surface area. Young children may be able to take some oral pills and tablets. The vastus lateralis, rectus femoris and ventrogluteal sites are used for intramuscular injections until the young toddler has been walking for at least one year to develop the gluteus maximus muscle which can now be used for intramuscular injections.
The elderly population and the normal changes of the aging process also have implications in terms of pharmacological pain management medications. The normal changes of the aging process such as decreased renal, hepatic and gastrointestinal functioning place the client at risk for side effects, adverse drug reactions, toxicity and over dosages. Nurses must, therefore, begin a new medication with the lowest possible dosage and then increase the dosage slowly over time until the therapeutic effect is achieved. The initial dosage may be as low as ½ of the recommended adult dosage.
Many pain management medications are contraindicated during pregnancy and lactation. For example, opioids used during pregnancy can lead to premature births, miscarriages, and other complications of pregnancy. The fetus may also have withdrawal symptoms from this medication.
Analgesic pharmacological medications are broadly categorized as opioid analgesics and non-opioid analgesics. They can also be categorized as adjuvant medications and primary analgesic medications.
Opioids are narcotics; they are used for moderate to severe pain; non-opioids are non-narcotic analgesics that are used to treat mild pain and they also to serve as adjuvant medication for the relief of pain.
The non-narcotic, non opioid medications that are used for pain management include those listed below along with their examples and possible side effects.
- Tylenol: The side effects can include hepatotoxicity, renal damage and, in very severe cases, hepatic failure
- NSAIDS: Ibuprofen and Ibuprofen like drugs such as Advil, Motrin, Naprosyn, Naproxen and Clinoril are associated with side effects such as nausea, indigestion, a headache, fecal occult blood and anorexia. Although not that common, some of the severe side effects and adverse effects of these drugs can include aplastic anemia, gastrointestinal tract bleeding, edema, and renal failure.Selective COX-2 (cyclooxygenase 2 ) inhibitors like Celebrex are also associated with both mild and very severe side effects. Some of the commonly occur side effects include abdominal pain, gastrointestinal gas, headache, insomnia, nausea and bloating. Some of the most serious and life threatening side effects of these medications are gastrointestinal hemorrhage, a cerebrovascular accident and a myocardial infarction.
- Salicylate NSAIDS: Salicylate NSAIDS include aspirin and disalcid, for example. Some of the mild side effects include abdominal pain, ulcers and heartburn; more serious side effects and adverse reactions include hemolytic anemia, bronchospasm and anaphylactic shock.
- Centrally Acting Non Opioid Analgesics: Centrally acting non opioid analgesics such as Clonidine are associated with side effects such as oral dryness, drowsiness, sedation, constipation, hypotension and fatigue.The narcotic, opioid medications that are used for pain management include those listed below along with their examples and possible side effects.
- Opioid Agonists: Opioid agonists such as codeine, OxyContin, Darvon, Dilaudid, Demerol and Percocet have the side effects of constipation, sedation, nausea, dizziness, pruritus, and sedation. Some of the more severe side effects and adverse effects of the opioid agonists include respiratory depression and arrest, hepatic damage, an anaphylactic reaction, circulatory collapse and cardiac arrest.
- Opioid Antagonists: Opioid antagonists, also referred to as opioid receptor antagonists, such as naloxone and naltrexone, can have side effects such as hepatic damage, joint pain, insomnia, vomiting, anxiety, headaches and nervousness.
- Opioids with Mixed Agonist – Antagonist effects: Opioids with mixed agonist- antagonist effects include analgesics like Talwin and Stadol can have side effects such as nausea, drowsiness, dizziness, diaphoresis and clammy skin.
Because of the sad realities revolving around the diversion of narcotic drugs by health care professionals, these substances have legal requirements. Some of these requirements when non automated systems are used include:
- The signature of the nurse picking up the narcotics from the pharmacy to confirm that this nurse picked up the medications
- A narcotics sheet which is delivered to the nursing care unit together with the narcotics that were picked up by the nurse at the pharmacy
- Locking and securing controlled substances in a secure manner to prevent diversion and/or theft
- The assignment of the accountable nurse who will count and verify the narcotics count at the beginning and the end of each shift
- The removal of narcotics from the locked cabinet by this accountable nurse and the immediate signature of the nurse removing it for administration to the client
- The witnessing and signatures of two nurses for any wasting and discarding of controlled substances
Nurses assess, evaluate and document all client responses to pain interventions and also their use of pain medications. The responses to pain medications can be evaluated in a number of different ways including the use of pain rating scales, verbal reports of pain, and an objective determination and evaluation of any physical and/or behavioral cues that can be associated with the patient's pain.
The level of pain should be determined prior to the administration of a pain drug and the level of pain must also be determined after the medication was administered in order to determine whether or not it was effective in terms of a decrease in the patient's level of pain.
Some of the expected outcomes and client responses to pain medications can include:
- The client will state that their level of pain has decreased by at least 3 after the administration of a pain medication
- The infant will be free of any behavioral or physiological signs and symptoms of pain
- The client is able to transfer and ambulate without pain after the administration of their pain medication
- The client states that they are able to sleep after they have received their ordered pain medication
- Adverse Effects/Contraindications/Side Effects/Interactions
- Blood and Blood Products
- Central Venous Access Devices
- Dosage Calculations
- Expected Actions/Outcomes
- Medication Administration
- Parenteral/Intravenous Therapies
- Pharmacological Pain Management (Currently here)
- Total Parenteral Nutrition