The patient localises her pain over the wound incision. She reports it is severe, sharp with a score of 8 out of 10 at rest. She has vomited twice overnight.
Abdominal examination does not reveal any significant findings and her observations are normal apart from a slight tachycardia.
- What is the cause of the pain?
- Incisional pain? , New or different pain suggests a new pathology? Is further investigation required?
- Has any analgesia been given yet? Is the charted medication been used appropriately? Has it worked?
- Severity
- May be moderate/severe
- Use Visual Assesment Scale (VAS) or Faces pain scale if appropriate
- Classify the pain
- Acute, nociceptive, non-cancer pain?
- Other factors contributing to the pain?
- Physical - new pathology? , post op complication? Unable to tolerate the oral route - vomiting? In trauma - other injuries? Physiological effects of untreated pain - respiratory, cardiovascular etc.
- Psychological - anxiety? worried about the post-operative course or what has been found during the operation? worried about social supports
- Use SOCRATES??
- Can help 'diagnose' what is causing the pain?
- Colic? Constant?
SOCRATES assessment
- Site
- Onset
- Character ….. Dull, sharp, ache, burning, pins and needles, shooting
- Radiation
- Associations
- Time course
- Exacerbating/relieving factors
- Severity …. Mild, moderate, severe…….”out of 10”
NOTE: Nurses may use OLDCART for pain assessment (onset, location, duration, characteristics, aggravating factors, relieving factors, treatment)
Treat cause if possible
The patient is reassured that all went well with the operation and she is transferred to a more comfortable bed.
Her pain is managed with regular IV paracetamol and a morphine PCA (Patient Controlled Analgesia) is started by the Acute Pain Service as she is currently unable to tolerate oral medication. She is charted a regular anti-emetic.
Her pain resolves quickly.
Note: Non drug and drug treatments are equally as important and can be initiated at the same time
Non-Drug
Psychological treatment options:
- Listen to patient concerns.
- Identify patient beliefs about cause of pain and address these
- Reassurance
- Consider calm environment
- Manage sleep
- Also...use regular medication schedule rather than PRN for baseline (reduces anxiety around next dose)
Physical treatment options:
- Position of patient and assistance with mobilising - good nursing care
- Wound care
- Physiotherapy
Drug
- Multi-modal analgesia - combine analgesics e.g. paracetamol, tramadol and strong opioids for post-operative pain
- IV morphine and IV fentanyl protocols
- The Acute Pain Service (APS) should be contacted for advice - they may use:
- Patient controlled analgesia (PCA)
- Other modalities - e.g. epidurals, nerve blocks
- Ketamine infusions
- The intravenous route for pain relief should be changed to the oral route as soon as the patient is eating and drinking
- Careful prescribing for discharge planning includes reducing the doses of, for example, oral opiods as the acute pain resolves
- Do not prescribe on-going long term opioids for the patient to take home if they have non-malignant related pain - a short 5-10 day course of oral opioids may be required for major surgery and this would require a careful plan to be made with the GP to stop the opioids completely
Refer to Important Medication and Safe Opioid Prescribing for more information
How would you manage her pain?
