1. Rowland, Emily Brooke BSN, RN

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Postoperative pain is an expected outcome of surgery. Due to various factors, such as physical and emotional stimuli, pain is subjective for each patient. Because of this, pain management needs to be individually tailored. Factors such as age, coping strategies, chronic conditions, previous experiences with pain, and multiple surgeries may dictate how aggressive pain management techniques need to be. The issue isn't that patients don't expect some degree of pain; rather, it's that they don't feel their pain is being managed properly. Studies have found that inadequate post-op pain management occurs in 75% of patients. Inadequate pain control directly relates to increased lengths of stay and post-op complications. And with the Hospital Consumer Assessment of Healthcare Providers and Systems survey posing questions about patient satisfaction with pain control, the issue of post-op pain management has been placed even more in the spotlight.


Not only does inadequate pain control impact physical healing, it also affects the emotional health of both the patient and his or her family. Because multiple aspects of the patient's life are affected, it's important that we pay particular attention to managing post-op pain. Unfortunately, managing pain from a postoperative perspective can be challenging. Differences between nursing judgment and post-op treatments can cause unpredictable pain regulation for the patient. And no single factor has been shown to increase patients' satisfaction with their pain control.


So, what can we do? There are several areas that can be improved to increase patient satisfaction with pain control regimens. This doesn't necessarily mean giving the patient more or different pain medications; rather, it means improving systems that we already have in place.


Rethinking the pain rating scale

The use of the numeric rating scale (NRS) has helped quantify patients' pain levels, providing insight into what interventions need to be performed. Both providers and patients have placed a tremendous amount of trust in this tool. When attempting to provide optimal pain control and increased patient satisfaction, our goal is to decrease the patient's reported pain level. However, studies have indicated that low pain scores alone don't directly increase patient satisfaction with pain management. This means that the goal of a low pain score isn't enough to impact patient satisfaction.


Another issue with the use of the NRS is patients' understanding of the scale itself. Simply put, they know the difference between a pain score of 0 and 10, but they don't know how we translate the pain level into a treatment plan. Overall, the NRS is viewed as an easy way to express patients' perception of pain; however, if patients don't know how nurses use this information, the process may be futile.


We need to educate our patients about what the NRS is and what their pain score describes to us. We can then define our actions based on the rating that they provide. Ideally, we should discuss the NRS with the patient during the preoperative period. This allows ample opportunity to explain nursing assessment techniques while setting an acceptable pain goal for the patient. By providing education about the assessment and options to relieve pain, we create a more empowered patient.


Boosting communication

Hourly rounding to assess the 5 Ps (pain, potty, positioning, possessions, and pumps) can be utilized to increase communication between patients and staff. In addition, specific communication about pain medications prescribed (onset, peak, and duration), the administration times of these medications, and the frequency at which they're available allows the patient to feel involved with his or her care, which can lead to increased satisfaction.


Participating in open forms of communication, such as script-based communication or providing a chart outlining pain medication times, demonstrates to the patient that the nurse takes a genuine interest in his or her concerns. If patients believe that their opinions are valued, they're more likely to express their concerns, ultimately increasing their satisfaction with their hospitalization.


Creating an expectation of open communication between the patient and nurse encourages the formation of a positive relationship, which allows us to create individualized assessment techniques to evaluate pain management more or less frequently depending on patient needs. Patients should also be instructed that pain changes throughout the day and they should communicate any change to the nursing staff.


Utilizing adjunct therapies

Explaining both pharmacologic and nonpharmacologic options to patients allows them to understand that opioid medications aren't the only option. Nonopioid medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), specifically toradol, have been proven to be effective for post-op pain. There has been some reluctance to use these medications because of potential complications such as impacting bone regeneration. Newer studies indicate that short-term use of NSAIDs doesn't impact how fractures heal. And the integration of nonpharmacologic therapies can decrease pain levels in a simple, cost-effective manner while reducing the complications related to excessive or frequent opioid use.


For example, both ice and heat have been proven to reduce pain from acute injuries. Unfortunately, the use of these options is often limited in the hospital setting despite their known effectiveness. The literature indicates that ice reduces pain levels, which in turn reduces the amount of opioids used by patients. From a cost perspective, the use of ice and heat requires minimal spending and preparation.


More recently, music therapy and relaxation techniques have been explored to reduce both acute and chronic pain. Music has proven to reduce the pain intensity and distress of individuals experiencing pain related to abdominal surgery during pain-inducing actions such as changing positions. The use of psychological interventions, such as mindfulness and relaxation techniques, has been shown to improve the pain levels of individuals experiencing fibromyalgia.


Satisfaction ahead

Managing post-op pain is a challenge, but aiding our patients to become informed participants in their own care goes a long way. Redesigning current tools, such as the NRS, and creating open forms of communication are key. Encouraging patient participation in all aspects of care will decrease anxiety and confusion, which ultimately leads to increased satisfaction for both patients and the nursing staff providing their care. Incorporating family members into this communication process will further increase patient satisfaction.


consider this

One of your post-op patients calls for pain medication. You enter the room, administer a medication through the I.V., and tell the patient that it's to help with his pain. The same patient calls for pain medication later in the day and is handed pills in a cup by a nurse on a different shift. The patient is confused and questions the nurse. That's why it's important to educate the patient about the different options for pain relief, how each medication is administered, and how long each will last.

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consider this

A post-op patient is asked to rate her pain on a scale of 1 to 10 during the nurse's morning assessment. She rates her pain as a 5 and is expecting to receive pain medication for relief. The nurse's previous patient expressed that a 5 is a tolerable level, so the nurse leaves the room at the end of the assessment. The patient calls stating that she needs pain medication, but the nurse hasn't returned with it. A communication breakdown has occurred because the nurse and patient haven't discussed a tolerable pain level. That's why it's important to understand that the NRS is subjective and used differently by each individual patient.

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Alaloul F, Williams K, Myers J, Jones KD, Logsdon MC. Impact of a script-based communication intervention on patient satisfaction with pain management. PainManag Nurs. 2015;16(3):321-327.


Eriksson K, Wikstrom L, Arestedt K, Fridlund B, Brostrom A. Numeric rating scale: patients' perceptions of its use in postoperative pain assessments. Appl Nurs Res. 2014;27(1):41-46.


Kurmis AP, Kurmis TP, O'Brien JX, Dalen T. The effect of nonsteroidal anti-inflammator drug administration on acute phase fracture-healing: a review. J Bone Joint Surg. 2012;94(9):815-823.


Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Phys Ther. 2011;91(5):700-711.


Oh J. Average cost per inpatient day across 50 states in 2010.


Phillips S, Gift M, Gelot S, Duong M, Tapp H. Assessing the relationship between the level of pain control and patient satisfaction. J Pain Res. 2013;6:683-689.


Theadom A, Cropley M, Smith HE, Feigin VL, McPherson K. Mind and body therapy for fibromyalgia. Cochrane Database Syst Rev. 2015;4:CD001980.


Vaajoki A, Pietila AM, Kankkunen P, Vehvilainen-Julkunen K. Effects of listening to music on pain intensity and pain distress after surgery: an intervention. J Clin Nurs. 2012;21(5-6):708-717.


Watkins AA, Johnson TV, Shrewsberry AB, et al. Ice packs reduce postoperative midline incision pain and narcotic use: a randomized controlled trial. J Am Coll Surg. 2014;219(3):511-517.


Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet. 2011;377(9784):2215-2225.


Zusman EE. HCAHPS replaces Press Ganey survey as quality measure for patient hospital experience. Neurosurgery. 2012;71(2):N21-N24.