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Assessment and managementof patients with post-operative painNS413 Mackintosh C (2007) Assessment and management of patients with post-operative pain.Nursinq Standard. 22, 5,49-55. Date of acceptance: September 3 2007

SummaryEffective pain management is essential in the post-operative periodto ensure that patients do not experience unnecessary distress orsuffering and to minimise potential complications. Post-operativepain management strategies should focus on combiningpharmacological management and comfort measures to ensuremaximum pain relief for each patient.

AuthorCarolyn Mackintosh is senior lecturer, University of Bradford,Bradford. Email: c.mackintosh@bradford.ac.uk

Keywords _^ _Assessment tools; Pain management; Pharmacologicalmanagement; Post-operative pain

These keywords am based on the subject headings from the BritishNursing Index. This article has been subject to double-blind review.For author and research article guidelines visit the Nursing Standardhome page at www.nur5ing-standard.co.uk. For related articlesvisit our online archive and search using the keywords.

Aims and intended learning outcomes

The aim of this article is to assist healthcareprofessionals in the effective assessment andniLHiagement of pain, following surgicalprocedures. Reading this article will enablehealthcare professionals to review current bestpractice in post-operative pain management, witha view to introducing practice changes which maylead to improvements in patientcare.

After reading this article you should be able to:

^ Identify the subjective and personal nature ofthe pain experience.

• Consider the effect that individualcircumstances have on patients' post-operativepain experience.

NURSING STANDARO

> Describe different approaches to painassessment and the relative advantages anddisadvantages.

> Identify different pharmacological methods ofmanaging pain.

> Addressthc importance of basic comfortmeasures and effective communication withpatients.

Introduction

Over the past .30 years., several studies haveidentified poor clinical practice in the assessmentand management of post-operative pain(Schafheutleefa/2001, Manias eM/2005,DihlefM/2006, Schoenwald and Clark 2006).Although the numhcT of patients who complainabout levels of post-operative pain remains low(CarreM/2005, Schoenwald and Clark 2006),this failing is an issue of concern.

The Royal College of Surgeons of England andCollege of Anaesthetists {1990) published aworking document highlighting the failure toeffectively assess and manage pain, stating that;'The treatment of pain after surgery in Britishhospitals has been inadequate and has notadvanced significantly for many years.'Subsequently a number of changes to practice wereinitiated including the establishment of clinicalnursespccialistsaspartof multidisciplinary painteams,thc introduction of standardised painassessment tools and the increasingly routine useof high technology-based pain managementtechniques, most commonly patient controlledanalgesia (PCA) pumpsandepidural infusions.However, in spite of these measures post-operativepain assessment and management continue to beless than ideal (Schafheutle t'M/2001).

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Pain

Pain has long been recognised as a highly personaland subjective phenomenon unique to rheindividual. The most commonK recogniseddefinition of pain is that of the InternationalAssociation for the Study of Pain (1979): 'anunpleasant sensory and emotional experienceassociated with actual or potential damage ordescribed in terms of such damage'. Many factorsare known to affect the experience of pain,includinggender, age, culture, previousexperiences., the meaning rhe pain has to theindividual experiencing it., tempered with a rangeof psychological factors, rhe most predominant ofwhich is individual coping skills (Wakefield 1995,Clarke etal 1996, Briggs 2003, Hall-Lord andLarsson 2006, Shaw 2006}.

This complex combination of factors meansthat it is impossible to either pre-judge or identifybenchmarks for the likely amoiiiit of pain anyindividual willexpericnce fo!lov\'ing any surgicalprocedure. This, when linked to the lack ofcorrelation between tissue damage and physicalpain, means that every experience of pain for eachperson can only be assessed and managedeffectively at an individual level (Middleton 2004,S\omanetal2005).

What does pain mean to you?Reflect on your personalexperiences of pain and askyotirself the following questions:

Could you talk about theexperience easily?

' If so who could you talk about it to?^ What words did you use to describe the pain?

How did the pain make you feel?j How did you get help to relieve the pain?I Looking back what does the experience

mean to you now?

To attempt to simplify the pain experience forscientific and medical purposes, pain has beenclassified into different types, most commonlyacute and chronic pain (McCaffery and Pascro1999). The key differences between chronic andacute pain reflecr the likely duration of pain andits consequent effects. Acute pain usually lasts fora short period of time (less than three to sixmonths), and as a consequence has fewer longerterm effects. Chronic pain tends to extend beyondthe three to six month period of acute pain, orbeyond the normal course of healing, and can

have drastic effects, mcluding long-term absencefrom work, unemployment, consequent loss ofincome and reduction in social contacts (Shaw2006). Post-operative pain is associated with thecharacteristics of acute pain as identified in Box 1.

You are giving care to a patientpost-operatively, and it becomesclear the patient is experiencingpain. However, the patient hasnot mentioned this. List five or sixpossible reasons fot the patient's reluctanceto disclose his or her pain. Consider for eachreason what you could have done to encouragethe patient to mention his or her pain earlier.

Assessment of post-operative pain

Inadequate assessment and management ofpo.sr-operative pain can have profound effects onthe patient, causing raised levels of anxiety, sleepdisturbances and [nobilisation difficulties,restlessness, irritability, aggression, and perhapsmost importantly, unnecessary levels of distress andsu ffering(Sjostrom^/£j/2000., Macintyre andReady 2002, Ca rr et al 2005).

Poorly assessed and managed post-operativepain can also have physiological effects on patients,which may lead to complications and delayeddischarge, including increases in heart rate andblood pressure, delayed gastric emprying resultingin nausea, vomitingand paralytic illeus, and changesin theendtKrine system as a result of increasedadrenaline production. Failure tocough and deepbreath as a result of p(x>rly controlled pain can resultin the development of chest infections., delay inmobilisation and additional problems, such as deepvein thrnnihosis, and pulmonary enibolus(Siostromrtj/200(), Madntyreand Ready 2002).

Accurateasscssmcnrofpost-opcrativt'painisessential to ensure thar pain is managed effectively.Without assessment it is impossible to identify then.nureofpain,theindividuali:haracreristic.sofpainnrtogaugc the effectiveness of pain nuinagcmcntiTUtTventions (Sjostrom ^M/2(H)O, Schafi2(H)4, Heikkinen etallOOS, Mackintosh 2005,

Characteristics of acute pain

• Normally associated with tissue damage, forexample, surgery or trauma.

• The cause of pain is easily recognised.

• Pain can be readily treated.

• The duration of pain can be anticipated.

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Effective communication is fundamental in theaccurate assessment of pain. Healthcareprofessionals should take time to speak and listentt> patients, to respond to them as individuals anJto make due consideration for any limitations incomrnunicatinn. which individuals may have, forexample, deafness or other language barriers(Ciray 2005, Mackintosh 2005). It is a!! toocommon for patients not to report pain or waituntil it has reached a severe level because theybelieve tbat beattbcarc staff are 'too busy', havemore important or seriously ill patients to lookafter, or hecause they do not want to cause trouble(Gray 2005, Mackintosh 2005}.

Effective pain assessment should identify if thepatient hasany other conditions that may also heresponsible for causing pain, hir example, somepatients may have underlying conditions sueb asjoint replacements or rheumatoid arthritis, resultingin citbtT chronic or acute pain in addition to tbatcaused by the surgical procetkire. Ihi patient hasmultiplecausesofpain tben each of these causesshould be assessed and where necessary managedsepanitcly. McC'affery and Pasero (19991 identifiedeight iuiportiUUhiLTors when assessing pain (Box 2).All eight factors should be considered whenassessing the individual's experience of pain, andit is good practice to document these in detail toensure effective communication between thepatient and all members of the bealtbcare team.

on an occasion wnen youcared for a patient oxperioncingpain. List the factofs that couldbave affected that patient'sexperience, then identify how many Wof these factors were mentioned in the mpain assessment tool used in your clinicalarea and in your documentation of the pain.Consider bow you could make your assessmentand documentation more comprebeiisive.

Painassessmenttools A range of standardisedpain assessment tools are also available and canbe used as a framework for assessment. Tbese fallinto two main categories: multi-dimensional anduiii-dimensional. Wben assessing post-operativepain, it is rare to find multi-dimensional toolsused in clinical practice; this is because these tendto be complex and time consuming, for example,tbe McGill Pain Questionnaire (Coll etai 2004,Mackintosb 2005). Tbe most commonly usedtools arc uni-dimensional, focusing specificallyon one or two aspects of pain, most frequently theintensity of pain and occasionally tbe location ofpain through tbe use of a body diagram, whichenahles tbe patient to mark wbere tbe pain is onan outline body diagram (Coll etai 2004).

Key pain assessment factors

• Location,

» Intensity.

• Qitality, for example, throbbing, stabbing orshooting pain,

• Onset duration and variability of pain.

• Words used by the patient to describe pain,

• The patient's preferred method of relieving pain,if known,

• Factors that increase or decrease pain.

• The effect of pain on the patient.

(McCaffei-y and Pasero 1999)

However, uni-dimensional pain assessment toolssbould be used with caution as they only focus onone or two aspects of tbe total pain experience.

Uni-dimensional pain assessmetit tools mayalso be subject to misinterpretation. Soinepatients have difficulty conceptualising tbeir painas a point on a line, or equating a numerical valueto pain intensity. Interpretation difficulties arc-also present when using the verbal rating scale,for example, what constitutes 'moderate pain'?Also, tbe use of particular terms may not beunderstood by patients or have little relevance toindividual descriptions of pain (Heikkinen^-^ii/2005, Mackintosb 2005). Tberc is littleevidenceto support consistency between ratings wbenreporting levels of pain, for example, a patientmay report pain as seven t)n a numerical ratingscale (NRS) and request analgesia. Whenreviewing tbe effectiveness of the analgesia tbepatient may tben report tbat bis or her pain basimproved, but tbe pain level may remain at sevenon tbe NRS (Mackintosh 2005).

There is also no evidence of consistency betweenindividuals in rating tbeir level of pain, for example,a rating of seven by one patient may be completelydifferent to a rating of seven by another patient, andmay also be interpreted differently by healtbcareprofessionals (Maniasc'/i//2002, SlornaiietiT/2005). It is important to note tbat however limitedthe commonly used uni-dimensional pain toolsappear to be, some form of pain assessment is betterthan no assessment. Provided that all staff usingthese tools are awareof their limitations and makeefforts to supplement pain assessment toolstbrough additional individualised enquiry andobservation, for example, using the factorsrecommended by McCaffery and Pasero (1999),tben tbey can use tbis as a starting point for a moreindcpth pain assessment.

When assessing post-operative pain it is alsoessential to recognise tbe likely differencebetween assessing pain at rest and on movement,even limited movement sucb as deep breathing or

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coughing. Although pain may be reported asminimalatrest, pain on movement must also beaddressed to promote effective post-operativerecovery (Mackintosh 2005). Examples of somecommonly used uni-diniensional postoperativepain assessment tools are shown in Figure 1.

A patient is prescribed an opioid drug forpost-operative pain relief but is reluctant to use itbecause of fears of addiction. How would youreassure the patient, and what information couldyou provide to encourage him or her to reconsider?

Management of post-operative pain

There are two main approaches that can be usedwhen managing post-operative pain; the use ofpharmacological interventions and comfortmeasures. These approaches work best when usedtogether, although there is a tendency in clinicalpractice to minimise the importance of comfortmeasures and emphasise the importance ofpharmacological and technological interventions.

Commonly used post-operative uni-dimensional painassessment tools

Verbal rating scale

No pain Mild pain Moderate pain Severe pain Very severe pain

Pain intensity scale

0 No pain

1 Mild pain

2 Discomforting

3 Distressing

4 Horrible

5 Excruciating

Visual analogue scate

No pain

Verbal analogue scale

No paifi Mild pain Moderate pain

Numerical rating scafe

1 2 3 4 5

(Mackintosh 2005)

Worst pain imaginable

Severe pain Very severe pain

6 7 8 9 10

Pharmacological management I he principles ofpharmacological management of post-operativepain focus on the use of the World HealthOrganization (WHO) (1996) analgesic ladder(Figure 2), originally designed for use inmanaging pain in palliative care.

When used for managing acute post-operativepam, rather than starting at the bottom of theanalgesic ladder (as in palliative care), it can beused from the top down, starting with strongopioid-based aiialgesic drugs such as morphine,working down to mild non-opioid analgesics suchas aspirin and paracetamol. Morphine is the mostcommonly prescribed opioid for rhe relief ofsevere post-operative pain. It is a safe and effectivedrugand has minimal side effects, niostcummcinlyconstipation caused by decreased bowel motility,nausea, vomiting, sedation, pruritus, urinaryretention, and in rare cases respiratory depression.It is important to recognise that side L-fft'Cts do notaffect all patients and where present can becontrolled with the use of anti-emetics and/orlaxatives. Morphine is well tolerated by patients,and its analgesic henefits outweigh theinconvenience of its side effects (McCaffery andPasero 1999, Weetmanand AllisoEi2006}.'

Morphine is available in a wide range ofpreparations-oral, subcutaneous, intramuscular.Intravenous, and transdermal, as well as slow reliefpreparations, which make it ideal for use in avariety of patients. For post-operative painmanagement morphine is nmst commonly usedintravenously via a l\j\ pump, as part of anepidural Infusion regimen,or less frequently by theintermircent intramuscular route. It is alsoincreasingly being used hy the oral route, providedthat the patient is not nil by mouth. There are anumber of misconceptions cuncerning the use ofopioidanalgesicsamongthe public and healthcareprofessionals. The most persistent of these concernthe threat of addiction. Numerous studies havenow indicated thatthis risk is minimal ((iray2005), and should not inhibit the use of opioidanalgesics, although appropriate patientinformation may need to be provided first.

Compound analgesics or weak opioids canalso be used in the management of post-operativepain. Commonly available drugs include codeinephosphate and dihydrocodeine. These are notcomm<jnly used following major surgicalprocedures, hut are increasingly used followingday-case or short-stay surgery. They can also beused OS a steppisig down point for patientsmoving slowly down the analgesic ladder (WHO1996). Cximpound analgesics have a similar sideeffect profile to morphine, but most drugs arewell tolerated by patients and side effects can hereadily managed.

The third stage ofthe WHO {1996) ladderconcerns the use of non-opioid drugs, most

52 October 10 :: vol 22 no 5 ;: 2007 NURSING STANDARD

commonly aspirin and paracetamol. Althoughthese drugs are at the bottom of the ladder, recentstudii'shaveindicated that paracetamol is ahij hly effective analgesic, in some cases moreeffective than sonic compound preparations, andalso possesses opioid-sparing capacities(Buvanendran and Kroin 2007, Pyati and Gan2007, Remy et.il 2007). This means that if apatient is prescribed regular doses ofparacetamol as well as an opioid, he or she islikely to use less of the opioid drug than a patientwho is only given the opioid drug withoutregular paracetamol. Hence it is now consideredgood practice to routinely prescribe regularparacetamol, alongside stronger opioidanalgesics for effective post-operative pain relief(huvancndranaiul Kroin 2007, Pyati and Gan2007,Rcmyc'/j/2007).

At all stages of the WHO (1996) analgesicladder it is also possible to add some form ofadiiivaiu analgesia such asnon-steroidalanti'inflammatory drugs (NSAIDs). NSAIDsprovide analgesia as a side effect of theiranti-inflammatory properties, helping to reducethe inflammatory response at rhe site of traumaor surgery. Where patients report minimal levelsof pain, they may be effective when used inisolation, but are generally considered mosteffective for pain relief when prescribed regularlyin combination with an analgesic preparation.However, not all patients wilt heable totolcrarfdrugs from this group, for example, patients witha history of gastric ulceration. A range of sideeffects have also been reported from this druggroup although most usually occur followinglong-term use. Side effects may include uppergastrointestinal tract complications, nausea andvomiting, and renal impairment {NationalInstitute for Clinical Excellence 2001}.

The use of local anaesthetic agents or sodiumchannel blockersin the management of post-operative pain is also increasing. These are usedin two ways, the first is by infiltration of thewound during the final stages of surgery,ensuring that the wound area will appear 'frozen'for some hours after surgery has finished. Thistechnique is most commonly used in day casesiirgL'ry or following invasive investigativeprocedures, it is important to be aware that,although the patient may report minimal painimmediately following surgery, the localanaesthetic effect will fade quickly once it startsto wear off and another form of analgesia shouldbe provided before this occurs.

The second common use for local anaestheticsis as part of the solution used inanepiduralinfusion (Wcctmaii and Allison 2006). Side effectsfrom the use of local anaesthetic preparations areminimal. However, specific issues warrant carefuland specific observations when these preparations

are used as part of an epidural infusion, forexample, hypotension, increased gut motility,motor block, urinary retention and possible toxiceffects (Weetman and Allison 2006).

Find out If your hospital has anyprotocols or procedures for theuse of patieut controlled analgesiapumps or epidural infusions. Arethese protocols evidence based? Arethey clear? Is the itiforniation adequateto provide optimum care fof patients in yourclinical area? Discuss any questions you mayhave vj\th the pain team.

Patient controlled analgesiaThc[\dm\mstranonof post-operative drugs is becoming moretechnological, with the routine use of PCA pumpsand the increased use of epidural infusions. PCApumps usually use a solution of niDrphine, ormorphine in combination with an anti-emeticdrug, to deliver a smail patient controlledintravenous (IV) dose. Because they are self-

The analgesic ladder

Moderate tosevere pain

Administer opioidplus non-opioid ±adjuvant

to

moderate pain

Administer opioid

plus non-opioid ±

Adniinistecnon-opioidmedication ±adjuvant

(Adapted from WHO 1996)

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administered by the patient it is possible forindividuals to titrate the dose much more accuratelyto his or her pain level, thusovercoming many ofthedifficulties associated with the subjective and highlyvariable nature of pain (McCaffery and Pasero1999). It has been shown that PCA pumps provideimproved post-operative pain relief for the majority.of patients (Chumblcy etal 1998, Chen etal200\ ].However, it is important to remember that asignificantminority of around 12% of patients findthem difficult to use. This is a consequence of poorunderstanding, or lack of manual dexterity, and canlead to ineffective pain relief [Chen i-ru/2001). Asaresult, patients using PCA devices require routinepain assessment to ensure that the device is workingwell and that pain relief is effective.Epiduralinfuslons Epidiir.il infusions arc onlySLiitiibie for certain types of surgery, usuallyinvolving the lower abdomen and legs. However,for suitable surgical procedures they provideeffective analgesia with minimal systemic effects.An epidural has a specific cannula or catheterwhich is inserted into the epidural space., intowhich an infusion, usually an opioid analgesicand/or local anaesthetic drug, is infused slowlyusing an electronic pump. Occasionally the rateofthe infusion can he patient controlled, butmore routinely the infusion runs at a set rateprescribed hy the physician, although this can bealtered according to the patient's need. Analgesiais provided by blocking the transmission ofmessages hy the spinal nerves and theeffectiveness of this can vary depending on theposition of the catheter in the epi Jural space, the

prescribed drug combination and rate of infusionprescribed. Patients with epidural infusionsrequire careful monitoring, as althoughcomplications art not common, when they occurthey can be serious.

The use of epidurals is limited to areas wherethere are sufficient numbers of suitably trainednursingstaff available to provide the frequentmonitoring required. Potential side effects areeither as a consequence of the drugs beinginfused orasa result of the epidural and theequipment accompanying it (WeetmanandAllison 2006) (Box 3).

Considei- a patient who hasrecently undergone surgery, listthe physical and psychologicalcomfort measures you might useto ensure any discomfort is minimised.

Comfort measures Comfort measures areimportant when managing post-operative pain.Generally, a combination of pharmacologicalinterventions and comfort measures will be mosteffective in relieving the patient's pain. Comfortmi;asLires focus on different strategies, somephysical and some psychological, which mayprovide relief to patients. Reassurance as a meansof reducing anxiety is essential for all patientsregardlessofthenatureofsurgery.lt is importantto remember that, for most patients, undergoingsurgery is not a routine occurrence and the level ofexplanation and assurance required may vary. Thismay also be linked to the need to educate patientsabout what to do if they have unacceptable levelsofpain.Regardlessofthe method of analgesia

References

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Carr EC, Thomas Nicky V,Witson-Bamet J (2005) PatJenfexperiences of anxiety, depressionand acute pain after surgery:J longitudinal perspective.Internationa! Journal af NursingStudies. 42, 5, 521-530

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Gray A (2005) Barriers to effectivepain management. In Banks C,Mackrodt K (Eds) Chronic PainManagement. Whurr Pubiishers,London, 113-128.

Haii-Lord ML, Ursson BW (2006)Registered nurses' and studentnurses' assessment of pain anddistress related to specific patientand nurse characteristics. NurseEducation Taday. 26, 5. 377-387

Heiifkinen K, Saiantera S,Kettu M, Tatttonen M (2005)Prostatectomy patients'postoperative pain assessment inthe recovery room. Journal ofAdvanced Nursing. 52, 6, 592-600,

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Time out 7Complications of epidural infusions

Drug related:

• Hypotension

• Motor biock

• Nausea and vomiting

• Respiratory depression

• Pruritus

Epidural related:

h Eptdurai haematoma

• Epidural abscess

• Puncture of tfie dura mater

• Catheter dispiacement

* Equipment risks

(Weetman and Allison 2006)

prescribed, patients should be informed thatanalgesia is available and can be provided onrequest. Itisvital that the individual's pain is wellcontrolled to prevent unnecessary suffering and tominimise possible post-operative complications(Brigj s 2003, Oliver and Ryan 2004).

Physical comfort measures should focus onbasicnursingcare, ensuring that the patient iscomfortably positioned, that IV infusions ordrains are not rubbing or pulling at the patientand that wound dressings are adequate. It mayalso be appropriate to provide patients with coldor hot packs and elevate the patient's limbs.Patients with other underlying painful conditionsmay have alternativecomfort-promotingstrategies which they routinely use at home and itmay he appropriate to incorporate these into theircare while they are inpatients (Briggs 2003,Oliver and Ryan 2004).

After reading this article, reflecton your own clinical situationand then write a summary of allthe key points which are essentialto provide best practice for effectivepain management. Once you havedecided on your criteria for best practice,reflect on the nLirsing care in your clinicalarea, highlight any areas of concern, discussthese with colleagues and then consider whataction you could take to improve it. •

Conclusion

Effecrive pain management is essential in thepost-operative period to ensure that patients donot experience unnecessary distress or sufferingand to minimise potential complications andpromote recovery. Post-operative painmanagement strategies should focus onpharmacological and comfort measures.Pharmacological management should beappropriate to rhe patient's needs, using the WHOanalgesic ladder forgiiidance. Ciood nursing careat all levels is fimdamentiil roprovido effectivepost-operative pain relief and it is a key functionofthe nurse's role to ensure that unnecessarydiscomfort is minimised NS

Time out 8Now that you liave completedthe article you might like towrite a practice profile. Guidelinesto help you are on page 60.

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