Pharmacological intervention As a result of a nationwide effort to reduce unnecessary opioid use and reduce incidents of patient abuse, clinicians are encouraged to carefully assess their patients’ pain through assessment, limit the number of prescribed narcotic analgesics and limit further prescribing by evaluating the patient’s/resident’s pain relief and increased functional ability. The Healthcare Association of New Jersey’s Pain Management Guideline recommends the WHO pain management ladder as its pharmacological recommendation for pain management. The WHO ladder centers on five key principles: ● “By Mouth”: Use the oral route whenever possible, even for opioids. ● “By the Clock”: For persistent pain, provide medication at regular intervals (around the clock) rather than PRN (as needed). ● “By the Ladder.” Step 1: a. For mild to moderate pain, start with a nonopioid (e.g., acetaminophen, ibuprofen) and increase the dose, if necessary to the maximum recommended dose. b. Use an adjuvant such as an anti-depressant or anticonvulsant, if indicated. c. If the patient presents with moderate or severe pain skip Step 1. Step 2: a. If or when non-opioids do not adequately relieve pain, add an opioid intended for moderate pain such as hydrocodone (combined with acetaminophen). b. Add or continue adjuvants, if appropriate. Step 3: a. If or when the non-opioid for mild to moderate pain no longer adequately relieve the pain, switch to an opioid that is not combined with another agent such as acetaminophen, and one that is effective for moderate to severe pain (e.g., morphine, oxycodone, hydromorphone). b. Add or continue adjuvants, if appropriate for the individual: Individualize the pain management program according to the patient’s goals to incorporate person-centered criteria to meet the patient’s pain needs. Other notable recommendations under this guideline a. Before starting opioid therapy for chronic pain, it is recommended, based on person-centered care, that a clinician work to establish pain management goals that utilize nonpharmacological methods that will increase the patient/resident’s daily functional abilities at a comfortable level. What is a comfortable level? The level of pain that is tolerated by the established enables a degree of independence in activities of daily living. With continuing assessment, and evaluation and as increase This guideline was developed to update the principles of acute pain management in adult burn patients and present a reasonable approach to the management of the complex pain associated with burn injury based on a review of the literature and expert opinion. For easy comprehension, this guideline was subdivided into different sections of recommendations with each recommendation graded accordingly. Grades of recommendations include: a. Consistent level 1 studies. b. Consistent level 2 or 3 studies or extrapolations from level 1 studies.
independence, there is a continued reduction in the necessity for narcotic analgesics. b. Clinicians should establish treatment goals with all patients/residents and understand at what level on the selected pain scale the patient/resident feels they are comfortable and able to function. Every person’s tolerance to pain is subjective. If a patient says they have pain, they do have pain. If they say they have pain at an 8 they do. A 5 on the pain scale may be uncomfortable for someone else. c. At what level is the pain manageable for this patient? Once that is established, person-centered goals can be set including realistic goals for pain and function and should consider how opioid therapy will be discontinued if the benefits do not outweigh the risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient/resident safety. d. Reduced renal function and medication clearance even in the absence of renal disease, in patients/residents aged ≥65 years might have increased susceptibility to accumulation of opioids and a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose (contextual evidence review). Some older adults suffer from cognitive impairment, which can increase the risk of medication errors and make opioid-related confusion more dangerous. In addition, older adults are more likely than younger adults to experience co-morbid medical conditions and more likely to receive multiple medications, some of which might interact with opioids (such as benzodiazepines). Clinicians should use additional caution and increased monitoring to minimize the risks of opioids prescribed for patients/residents aged ≥65 years. e. Monitor for safety and side effects of medications. ○ Utilize the Four As of pain treatment outcomes, which are: 1. Analgesia (pain control). 2. Activities of daily living (patient/resident functioning and quality of life). 3. Adverse events (medication side effects). 4. Aberrant drug-related behavior (addiction-related outcomes). f. Administer medication routinely, not PRN (as needed). PRN analgesic may be administered for breakthrough pain or when resident/staff identifies circumstances when pain may be anticipated, On-going communication is recommended with the healthcare provider for optimal pain management before wound treatment or skilled therapy.
g. Pain assessment findings shall be documented in the resident’s medical record. This shall include, but not be limited to, the date, pain rating, pain rating tool, treatment plan, and patient/resident response. American Burn Association Guideline on the management of acute pain in adult burn patients
c. Level 4 studies or extrapolations from level 2 or 3 studies. d. Level 5 evidence or troublingly inconsistent or inconclusive studies of any level. This course covers the different sections of this guideline relevant to its theme. Pain Assessment ● Guideline 1 : Pain assessments should be done repeatedly during the day during different activities. This would allow assessment of pain during all phases of care and capture fluctuations that occur throughout
Page 151
Book Code: PYCA2725
EliteLearning.com/Psychology
Powered by FlippingBook