Knowledge and Attitude Survey
Andy is 25 years old and this is his second day following abdominal surgery. As you enter his room to check his vital signs, he smiles at you and continues talking and joking with his visitor. Your assessment yields the following information: B/P=120/80; HR=80; RR=18; on a scale of 0-5 (0=no pain/discomfort to 5=worst pain/discomfort) Andy rates his pain as "4" at the surgical site.
1. On the patient's record you must mark his pain on the scale below.
| 0 | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
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No pain/ |
Worst pain/ |
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Answer: The patient's pain rating of 4 is the correct answer.
Rationale
Standards for pain assessment affirm that the patient's self-report of pain, using easily administered rating scales, should be the primary source of assessment (AHCPR Acute Pain Management Panel, 1992; American Pain Society, 1999; Jacox, Carr, & Payne, 1994; Oncology Nursing Society, 1998).Implications for You and Your Institution
Institutions should adopt an easily administered pain rating scale as part of their policies and procedures for pain assessment in patients who are able to communicate. Such scales should be age-appropriate. For non-communicative patients, standards for assessment might include behavioral observations, physiologic cues, data regarding the likely presence of pain based on the history, physical, and procedures administered, and the observations of significant others.Click here for references on pain assessment.
2. Your assessment above, is made four hours after Andy received morphine 10 mg IM. During the three hours following the injection, Andy's pain ratings ranged from 3 to 4 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. His physician's order for analgesia is "Morphine IM 5 to 15 mg Q 3 - 4 hours PRN pain relief."
What action should you take at this time.
Answer: Administer morphine 15 mg IM now.
Rationale
Since the pain had not decreased significantly, the correct answer is to give 15 mg of morphine, 5 mg more than the previous dose. This is known as titrating analgesia to pain intensity and pain relief or individualizing pain management (APS, 1999). Although we are missing an important piece of information (the pain intensity level that represents the patient's goal for pain relief), the assumption is that a rating of 4 is not satisfactory and may be interfering with his activity and recovery.
His behavior may mislead the clinician to believe the acute pain is not "that bad," not a valid assessment since it is not the patient's self-report. The fact that clinicians often infer less pain based on patient's behaviors (such as Andy's joking) is regarded as a myth (McCaffery & Pasero, 1999). In fact, such behavior, particularly with regard to acute pain may be represent the patient's effort to distract himself from pain. It is possible that Andy's pain is worse than the 3 or 4 he has reported and is only that low because he is using distraction effectively.
Implications for You and Your Institution
Numerous studies have documented that clinicians are not knowledgeable about the analgesics most often used to treat pain, particularly opioids. These findings have been affirmed in our own work on PainLink. An institutional policy that establishes the use of patient self-report of pain intensity as the basis for treatment can begin to minimize clinician assessments based on myths and misinformation.
Click here for references on myths that interfere with assessment, individualizing pain management and titration of analgesia.
Bob is 25 years old and this is his second day following abdominal surgery. As you enter his room to check his vital signs, he is lying quietly in bed and grimaces as he turns in bed. Your assessment yields the following information: B/P = 120/80; HR = 80; RR = 18; on a scale of 0 - 5 (0 = no pain/discomfort to 5 = worst pain/discomfort) Bob rates his pain as "4" at the surgical site.
3. On the patient's record you must mark his pain on the scale below.
| 0 | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
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No pain/ |
Worst pain/ |
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Answer: The patient's pain rating of 4 is the correct answer.
Rationale & Implications for You and Your Institution
Same as rationale for question 1.
Click here for references on pain assessment.
4. Your assessment above, is made four hours after Bob received morphine 10 mg IM. During the three hours following the injection, Bob's pain ratings ranged from 3 to 4 and he had no clinically significant respiratory depression, sedation, or other untoward side effects. His physician's order for analgesia is "Morphine IM 5 to 15 mg Q 3 - 4 hours PRN pain relief."
What action should you take at this time.
Answer: Administer morphine 15 mg IM now.
Rationale & Implications for You and Your Institution
Since the pain had not decreased significantly, the correct answer is to give 15 mg of morphine, 5 mg more than the previous dose. This is known as titrating analgesia to pain intensity and pain relief or individualizing pain management (APS, 1999). Although we are missing an important piece of information (the pain intensity level that represents the patient's goal for pain relief), the assumption is that a rating of 4 is not satisfactory and may be interfering with his activity and recovery.
5. Research shows that promethazine (Phenergan) is a reliable potentiator of opioid analgesics.
Answer: False.
Rationale
The combination of promethazine and meperidine, or the combination of meperidine, promethazine and thorazine, are no longer recommended for pain relief; there is no additive relief of pain with these combinations (McCaffery and Pasero, 1999, p. 113). Except for methotrimeprazine (Levoprome, available in parenteral form only), phenothiazines do not relieve pain or potentiate opioid analgesia (APS, 1999, p. 37).
Implications for You and Your Institution
If meperidine and/or promethazine are still routinely used in your institution as a treatment for postoperative pain, you may want to bring the issue to the attention of the QI, Pharmacy and Therapeutics, or other committee that is addressing evidence-based practice.
Click here for references on meperidine and promethazine.
Click here for information on how to obtain resources cited in the discussion of answers to the quiz questions.
Last Updated: April 18, 2000