Managing the pain of traumatic injury.

Management of pain in the trauma patient is a complex issue requiring the ability to selectively match different injuries and patient situations with the most optimal pain management methods. Having an understanding of the various stages of trauma care helps clinicians to best support the goals of patient care while decreasing the detrimental effects of the stress response through good pain control interventions. When nurses have a good understanding of the various pain management interventions they are better able to assess the effectiveness, potential side effects, and goals of therapy. The following is a list of clinical pearls to help guide nurses to better manage the pain of traumatic injuries: Encourage your trauma team to standardize pain medications (particularly opioids). A protocol that uses a couple of opioids with varving routes of administration, onset, duration, mechanism of action, and side effects helps the team to become extremely familiar with them and better able to assess effectiveness and side effects. Frequent motor and sensory assessments are necessary in the injured-patient (especially with extremity and head injuries), and drug therapy choices must allow for a thorough baseline assessment and periodic checks to follow. Patients with multiple rib fractures or flail segments (particularly elderly patients) and no contraindications deserve serious consideration for treatment with an epidural. When using various pain management techniques, the nurse needs to be prepared to treat complications if they should arise. Airway equipment, drugs (i.e., oxygen, opioid antagonists, pressors), and resuscitation means must be immediately available. Nurses need to be extremely careful when receiving pain medication and other central nervous system depressant orders from various doctors involved in patients' care. If a pain management specialist is involved, all pain medication therapies should be supervised and ordered by that individual, particularly when spinal analgesia is employed. Nurses must be knowledgeable regarding the effects of spinal medications (local anesthetics and opioids) at varying spinal levels so as to assess therapeutic as well as untoward effects. Institute a diligent bowel protocol when using opioids. Opioid administration combined with the immobility and altered nutrition often associated with trauma can easily result in constipation, abdominal distention, and bowel obstruction. It is not uncommon for epidural blocks to need supplementation with other drug therapy, and this should not be considered a failure of the epidural. Any addition needs to be ordered and closely supervised by one primary team of doctors. Use of nonopioid drugs, if not contraindicated should be considered in all trauma patients. This is especially true for patients sustaining trauma and being discharged to home within 24 hours. They need to be educated about the pain they can expect the next day and how to judge if it is normal and expected or possibly the sign of a missed injury or developing complication (i.e., compartment svndrome infection).

Implementation of the Agency for Health Care Policy and Research Pain Guidelines.

Implementation of clinical practice guidelines in a large setting is a complex process. This article describes the many issues encountered in trying to implement Agency for Health Care Policy and Research acute pain and cancer pain guidelines in an academic medical center. Issues addressed include the membership of the task forces involved, incorporation of the guidelines into the institution-specific standards of care, selection and implementation of self-reporting tools for assessment of pain throughout the institution, issues involved in standardizing documentation of pain throughout the institution, measurement of the current status of pain control and integration into the existing quality assessment and improvement program, various analgesic interventions addressed throughout the hospital, educational strategies used and planned, and how multidisciplinary involvement was obtained.

Pain management in the critically ill: what do we know and how can we improve?

Pain management in the critically ill is a challenge and a problem of great concern for critical care nurses. The authors review research on pain in the areas of pain assessment, nurses' knowledge and attitudes, pharmacologic interventions, and nonpharmacologic interventions for the management of pain. Although the research base is not completely developed in the critically ill population, implications for practice are provided, based upon the findings in populations akin to the critically ill. Strategies are outlined for achieving improved pain control in critical care units through education, adoption of standards on pain management, and quality improvement activities.

The impact of technology on patients and families.

The continuing evolution of the highly specialized, technologic manner in which we provide care in critical care units has potentially hazardous effects on the physical and psychological well-being of patients and family members. Although the ICU environment possesses characteristics that make patients and families prone to undesirable sequelae, critical care nurses can employ creative strategies to minimize the impact of bedside technology that is so important for the survival and recovery of the critically ill patient. Strategies to reduce the psychological impact of the ICU environment begin with a psychosocial assessment of the meaning patients and families attach to bedside technology. This assessment will strengthen nurse, patient, and family interactions, as well as guide patient and family education and sensory information to reduce fear and anxiety often associated with threatening procedures. Facilitating touch and family involvement in the patient's care during visitation is another strategy to humanize the technologic environment. Managing the environment is essential to reduce the physical impact of the ICU environment. Nurses can manipulate the use of equipment to reduce crowding and noise at the bedside, foster familiar activities to stimulate the patient's other senses, and facilitate sleep patterns by structuring nursing activities and providing comfort measures. These nursing interventions will reduce the effects of sensory overload/deprivation and sleep deprivation and, it is hoped, prevent ICU psychosis.

Family needs: an annotated bibliography.

Hospitalization for a critical illness is not only a crisis for the patient, but also his family. This annotated bibliography can be used as a resource for nurses dealing with the family members of such patients.