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Tips for Managing Pain More Effectively
C L I N I C A L N O T E B O O K
Author: Polly Gerber Zimmermann, RN, MS, MBA, CEN,
Chicago, IllSection Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN
Polly Gerber Zimmermann is Assistant Professor, Harry S. TrumanCollege, Chicago, Ill.
For reprints, write: Polly Gerber Zimmermann, RN, MS, MBA, CEN,4200 N Francisco, Chicago, IL 60618; E-mail: pollyzimmermann@msn.com.
J Emerg Nurs 2004;30:470-2.
0099-1767/$30.00
Copyright n 2004 by the Emergency Nurses Association.
doi: 10.1016/j.jen.2004.06.018
470
o nurse wants to see a patient suffer. Beyond
Nobtaining an analgesia order, what can aid in
providing more effective pain relief ? The an-
swer is increased awareness of current f indings and the
following practical tips.
Dispelling the myths
Lingering brulesQ can hinder the application of today’s
advancing knowledge.
MYTH 1: NO ANALGESIA CAN BE GIVEN UNTIL
THE DIAGNOSIS IS ESTABLISHED
Studies have revealed no differences in physical f indings
or diagnostic accuracy between patients who received
morphine and those who received a placebo.123 In addition,
3 major specialty organizations recommend changing the
practice of routinely withholding analgesia during a diag-
nostic workup.
A 2004 American Pain Society guideline states that
pain should be treated as the investigation proceeds and
that withholding all analgesia is rarely justif ied.4 The
American College of Emergency Physicians’ 1994 clinical
policy statement encourages early pain relief in stable
patients with nontraumatic acute abdominal pain.5 The
Canadian Association of Emergency Physicians 1994 con-
sensus statement indicates that there is bno justif ication
to not relieve the (abdominal) pain immediately. Judicious
IV opioid titration used to relieve most of the pain but not
leave the patient somnolent is not only humane but, in
fact, allows a better abdominal examination.Q 6
JOURNAL OF EMERGENCY NURSING 30:5 October 2004
C L I N I C A L N O T E B O O K / Z i m m e r m a n n
MYTH 2: THERE IS A HIGH RISK FOR RESPIRATORY
DEPRESSION AND ADDICTION WITH NARCOTIC
ADMINISTRATION
In a survey of registered nurses published in 2002,7 40%
mistakenly believed that there is a high risk for respiratory
depression and addiction with narcotic administration.
The reality is that clinically signif icant, opioid-induced
respiratory depression occurs less than 1% of the time.
The patients at most risk are the opioid naRve, that is,
those who have not recently received regular daily doses
of opioids (eg, a trauma victim, a young adult with a new
femur fracture). The key assessment is to monitor these
patients for sedation level, because signif icant sedation
precedes respiratory depression.7,8
In the same survey, 46% misperceived the rate of
addiction with the use of narcotics for medical reasons.7
In one study, an addiction disorder developed in only 4
patients of the 12,000 hospitalized patients who received
opioid analgesics, and only 1 of those cases was def ined
as major.7,8
MYTH 3: AN INJECTION OF DEMEROL AND
PHENERGAN IS HIGHLY EFFECTIVE FOR
SEVERE PAIN
Use of meperidine (Demerol) has fallen into disfavor,
especially for elderly patients or when ongoing needs are
anticipated. Its active metabolite, noremerpedine, accumu-
lates and results in neurotoxicity (observe for a f ine hand
tremor). Toxicity was not often noted in past practice
because meperidine traditionally was prescribed in sub-
therapeutic doses. For adequate pain relief, most adults
would require at least 75 to 100 mg (some adults would
require up to 150 to 200 mg) every 2 to 3 hours.7,9
Promethazine (Phenergan) also is no longer recom-
mended as a bpotentiatorQ for any narcotic.5,6 Actually, it
neither relieves pain nor potentiates opioid analgesia; one
study showed that it increased sensitivity to pain and the
amount of opioid needed.1,8
MYTH 4: BIAS HAS BEEN ELIMINATED IN
ANALGESIC ADMINISTRATION
Past studies revealed a discrepancy between analgesia
provided to persons of different races with the same
objective diagnosis. Surely health care has bf ixedQ this
subconscious bias.
A study published in 2003 of 64,487 patients seen
in US emergency departments over 3 years found no overall
October 2004 30:5
difference in the receipt of some analgesia by race. How-
ever, blacks and Hispanics were 28% less likely than were
whites to receive an opioid analgesic for the same severity of
pain. The discrepancy was particularly noted in conditions
where the severity was more dependent on a patient’s sub-
jective report, such as a migraine or back pain, compared
with an objective condition, such as a long-bone fracture.10
MYTH 5: REQUIRING LARGE DOSES OF
OPIOIDS FOR RELIEF IS INDICATIVE OF A
PHYSICAL DEPENDENCE
The amount of opioids required to provide relief varies
widely between patients. Pain Consultant Margo McCaff-
ery, MS, RN, FAAN, notes that someone who has taken
opioid analgesics regularly (someone who is bopioid
tolerantQ) may require 100 times more opioid than an
opioid-naRve patient (that is, someone who has not received
opioids regularly) (personal communication, June 24,
2004). Some conditions, such as sickle cell crisis, can
require more opioids than are normally given postopera-
tively for major surgery. There is no bceilingQ effect on
the analgesia with morphine and morphinelike opioids
(eg, Hydrocodone), unlike other classes of opioids, non-
opioids, and adjuvants. If a dose of morphine fails to
relieve pain, and there are no adverse reactions, the dose
should be increased by 25% to 50%.1,8
Tricks of the trade
Try these hints to enhance your patient’s pain management:
TURNING THE HORIZONTAL SCALE VERTICALLY
Some older children or adults have diff iculty using
horizontal, left-to-right classic pain scale presentations,
such as a numeric rating scale (0Q10) or Wong-Baker Faces
Pain Rating Scale.11 This phenomenon may be seen more
often in persons who speak a language that is read vertically
or from the right to left.
Turn the scale vertically instead.12 The scale should be
positioned so that the b10Q is at the top because sequences
that progress upward are more universally recognizable
than those that progress downward.
MANUAL PRESSURE PRIOR TO AN
INTRAMUSCULAR INJECTION
Applying manual pressure to the site of an intramuscular
injection for 10 seconds prior to administering the
JOURNAL OF EMERGENCY NURSING 471
C L I N I C A L N O T E B O O K / Z i m m e r m a n n
injection reduces patients’ sensation of pain.13 It is
hypothesized that this research-validated technique works
because the pressure stimulates multiple nerve endings so
the body does not sense the new needle prick. Anecdotally,
when I apply manual pressure before tetanus immunization
administration, the patients compliment me for giving a
bgood shotQ that did not hurt.
ORAL GLUCOSE FOR INFANT ANALGESIA
Oral glucose (1 mL of 30%) was compared with the use of
EMLA cream (lidocaine 2.5% and prilocaine 2.5%) during
venipuncture on infants. Only 20% of infants in the oral
glucose group were scored as having pain (using PIPP
[Premature Infant Pain Prof ile]), compared with more
than 40% of the infants in the EMLA group. The glucose
solution also had the advantage of taking effect almost
immediately.14 It is hypothesized that that the glucose
activates endorphins and includes a more central analgesic
effect than does the topical response.
From the available research, it also appears that both
EMLA and ELA-Max (an over-the-counter 4% lidocaine
cream) have similar eff icacy in both children and adults,
with or without occlusive dressings. EMLA must be
applied for a minimum of 60 minutes, but ELA-Max has
the advantage of being effective in 15 to 30 minutes.15217
Future trend: Increased administration of
prehospital analgesia?
Research on the topic of increased administration of
prehospital analgesia reveals that accurate pain assess-
ments can be done in the f ield but field analgesia is often
not provided, even with obvious etiologies. In cases where
analgesia was given, patients obtained signif icant pain
relief earlier (up to 2 hours earlier), and no serious
adverse effects were evident.18220 For example, one EMS
system allows paramedics to administer up to 0.1 mg/kg
morphine sulfate (except for standard contraindications,
such as a closed head injury) in addition to the tradi-
tional nonpharmacologic measures (ie, ice, elevation,
and immobilization).
Conclusion
Pain relief is a patient’s right. With current knowledge and
tricks of the trade, ED nurses can help ensure the best relief
possible is available for their patients.21
472 J
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2. Thomas SH, William S, Cheema F, Reisner A, Aman S,Goldstein JN, et al. Effects of morphine analgesia on diagnosticaccuracy in emergency department patients with abdominalpain: a prospective, randomized trial. J Am Coll Surg 2003;196:18-31.
3. Vermeulen B, Morabia A, Unger PF, Goehring C, Grangier C,Skljarov I, et al. Acute appendicitis: inf luence of early pain reliefon the accuracy of clinical and US findings in the decision tooperate—a randomized trial. Radiology 1999;210:639-43.
4. American Pain Society. Principles of analgesic use in thetreatment of acute pain and cancer pain. 5th ed. Glenview (IL):American Pain Society; 2004.
5. American College of Emergency Physicians. Clinical policy forthe initial approach to patients presenting with a chief complaintof nontraumatic acute abdominal pain. Ann Emerg Med 1999;23:906-22.
6. Ducharme J. Emergency pain management: a Canadian Associ-ation of Emergency Physicians (CAEP) consensus document.J Emerg Med 1994;12:855-66.
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9. McDermot PA. Recognizing normeperidine toxicity. Nursing2003;33(3):24.
10. Tamayo-Saver JH, Hinze SW, Cydulka RK, Baker DW. Racialand ethnic disparities in emergency department analgesicprescription. Am J Public Health 2003;93:2067-73.
11. Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML,Ahmann E, Divito-Thomas PA. Whaley and Wong’s nursingcare of infants and children. 6th ed. St. Louis: Mosby; 1999.p. 1153.
12. McCaffery M. Using the 0-to-10 Pain Rating Scale. Am J Nurs2001;101:81-2.
13. Chung JWY, Ng WMY, Wong TKS. An experimental study onthe use of manual pressure to reduce pain in intramuscularinjections. J Clin Nurs 2002;4:457-61.
14. Gradin M, Eriksson M, Holmquist G, Holstein ASA, Schollin J.Pain reduction at venipuncture in newborns: oral glucosecompared with local anesthetic cream. Pediatrics 2002;110:1053-7.
15. Wong D. Topical local anesthetics. Am J Nurs 2003;103:42-5.16. Kleiber C, Sorenson M, Whiteside K, Gronstal BA, Tannous R.
Topical anesthetics for intravenous insertion in children: arandomized equivalency study. Pediatrics 2002;110:758-61.
17. Eichenf ield LF, Funk A, Fallow S, Lander F, Cunningham BB.A clinical study to evaluate the eff icacy of ELA-Max (4%liposomal lidocaine) as compared with eutectic mixture of localanesthetics cream for pain reduction of venipuncture in children.Pediatrics 2002;109:1093-9.
18. McEachin CC, McDermott JT, Swor R. Few emergency medicalservices patients with lower-extremity fractures receive prehospi-tal analgesia. Prehosp Emerg Care 2002;6:404-10.
19. DeVeelis P, Thomas SH, Wedel SK, Stein JP, Vinci RJ.Prehospital fentanyl analgesia in air-transported pediatric traumapatients. Pediatr Emerg Care 1998;14:321-3.
20. Chambers JA, Guly HR. Prehospital intravenous nalbuphineadministered by paramedics. Resuscitation 1994;24:153-8.
21. Zimmermann PG. Pain assessment and management. InZimmermann PG, Herr RD. Nursing triage secrets. St. Louis:Mosby (in press).
OURNAL OF EMERGENCY NURSING 30:5 October 2004
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