Pain resource nurse helps ED patients

At University of Wisconsin's ED, a pain resource nurse works with nurses to improve pain management. "The pain resource nurses do retrospective pain assessment monitors and give feedback to individual nurses, so they know where improvement is needed," says Patricia Padjen, RN, the ED's clinical nurse manager.

Pain interventions for various patient populations are monitored on a regular basis, says Robyn Ramsay, RN, BS, pain resource nurse for the ED. "25 charts are audited each month at random," she notes. "If we do an intervention, we look to see if there was any positive result."

At discharge, patients are asked how they are doing compared to when they arrived. "They are asked, do you feel better, worse, or the same?" says Ramsay.

The pain resource nurses teach that pain should be considered a fifth vital sign, along with blood pressure, heart rate, respiratory rate, temperature, says Ramsay. "We have emphasized that when a patient comes in, nurses should check to see if they have any pain component with their chief complaint."

Chronic migraine headache patients are a major focus for the pain resource nurses. "If they come to the ED frequently, it means they are not getting managed adequately with primary care, so we are trying to work with their doctors to set up protocols," says Ramsay. "This way, we can find out that giving 2 mg of Dilaudid works for a particular patient."

The pain resource nurses work closely with physicians to improve pain management. Patients who presented with abdominal pain often weren't treated for pain, because the surgeons didn't want to mask symptoms, says Ramsay. "We explained to the surgeons that these symptoms are going to come back after a couple milligrams of morphine, it's not right for the patient to sit and suffer for hours," she explains. "Now we give minimal amounts to bring their discomfort down until someone can come and evaluate them."

In other cases, it is necessary to update physician's knowledge of current use of medications. "Often, physicians aren't updated with some of the newer drugs, and it's sometimes hard to change the clinical practice of people who are set in their old ways,"says Ramsay.

For example, the nonsteroidal anti-inflammatory torodol has been approved by the FDA for IV use with a different dosage, Ramsay reports. "We point out to the physicians, `If this drug works just as well for long whether given IM or IV, the patient already has an IV, so why should cause him more pain?'" she says.

The pain resource nurses worked with the ED case manager to develop plans for migraine headache patients. "This is done in conjunction with the attending physician for that patient, so we are all working together as a team," says Padjen. Individualized care plans are kept on file in the ED.

Pain resource nurses developed a laminated card with pain management guidelines."We have integrated pain management into our existing pathways," says Ramsay.

Education is a key role for the pain resource nurses, including the fact that pain is subjective. "I teach nurses that everybody won't express pain in the same way-one migraine patient might be experiencing difficulty seeing in the light and vomiting, while another might not look sick at all," says Ramsay. "But the important thing to realize is that pain is whatever the patient says it is."