Which patients are not getting enough pain relief?

When assessing pain management in the ED, it's important to focus on patients most at risk. "In certain patient populations, pain is often not assessed adequately and simple interventions are routinely not done," says Patricia Padjen, RN, clinical nurse manager for the ED at University of Wisconsin Hospital and Clinics in Madison, WI. Here are some patient populations at high risk for inadequate pain management:

Extremity injuries. Extremity injuries are routinely undertreated, says Paula Tanabe, RN, PhD, CEN, CCRN, clinical nurse specialist and trauma coordinator for the ED at Northwest Community Hospital in Arlington Heights, IL. "The use of ice in acute extremity injury is very underused," she notes. "These patients usually have mild to moderate pain, so nonsteroidals are usually appropriate."

Patients with extremity injuries should be given an analgesic as soon as possible, Tanabe recommends. "We should give them Motrin or Tylenol at triage, and we should treat them in the ED, not give them a prescription to go home with," she says.

Pediatric patients. At Northwest's ED, a policy was implemented to apply EMLA cream at triage for pediatric patients if nurses anticipate that a phlebotomy or IV will be started, reports Tanabe. "We have had good success with that," she says. "The cream takes at least 45 minutes to work, so giving it to them right away buys some time."

Migraines. Non-pharmacological interventions are often extremely beneficial, says Tanabe. "If a patient has a horrendous headache, dimming the lights or putting them in a separate room can be very helpful," she notes.

Nurses should listen to what works for individual patients. At one ED, one patient had a horrible migraine and demanded ice be applied to her head, but nurses were reluctant to abide by her wishes, Tanabe recalls. "If people know what works for them, then we should start with that, unless there is some medical reason why we shouldn't."

Abdominal pain. Many ED clinicians falsely believe they are unable to medicate abdominal pain patients until a diagnosis is made. "A lot of people don't believe you can treat abdominal pain until you know why the patient has it," says Tanabe. "But research shows you can get a better abdominal exam if you relax the patient first, because you are able to [find] a specific location for the pain." Still, some physicians haven't updated their practice, she notes.

Elderly. Nurses may believe elderly patients aren't in pain, because they don't complain of it, but that can be misleading, says Tanabe. "Often, the elderly have the attitude that their doctor gives them all the medication they need, so if they were supposed to have something they would get it," she explains. "They may not ask for pain medication, even though they need it. Sometimes you may have to assume they are in pain based on what they have, and treat them accordingly."

Often, elderly patients have trouble with a 0-10 numerical pain scale, notes Tanabe. "For those patients, we use a verbal descriptor scale, which has six words (pain, mild, distressing, discomforting, horrible, excruciating) on a card," she says. "The two tools correlate really well, so either of them is a reliable and valid tool."

Nurses are often reluctant to give medications because elderly patients can become easily disoriented, says Carolyn Hoover, RN, chair of the task force on pain management at Harborview Medical Center in Seattle, WA. "These patients often fall through the cracks for that reason," she says. "Nurses don't like to give them the big gun drugs because they get confused, and it takes forever to get them out of that. Also, they are already on a lot of different medications that can have effects, so we need to take a very detailed look at everything they've been given."

Substance abusers. If a patient is a substance abuser, that will heavily determine the medications they receive. "If someone is using heroin, you would need a higher amount of analgesic in combination with neuromuscular blocking agent to appropriately treat their pain," says Carol Metcalf, RN, Harborview's pain management clinical nurse specialist. "Alcoholics will need higher doses of sedatives than expected."

Sickle cell patients. It's important to collaborate with the sickle cell patient's primary care physician when possible. "We have developed individualized care plans for these patients, because they are recurrent," says Metcalf. "This way, we can start with a plan which has been effective for them in the past, rather than recreating the wheel every time. Also, patients may have other medical problems such as allergies, or personal preferences, which would impact your choice of treatment."

Cancer patients. Medication history is especially important with cancer patients. "Any patient with a preexisting pain problem will have had a history of medication, and that needs to be addressed," says Metcalf. "If the patient has been on analgesics around the clock or even PRN, we need to know that."