Nursing Spotlight: Profiles in Pain Relief - Crozer-Keystone Health System - PA

Nursing Spotlight: Profiles in Pain Relief

Each of these CKHS nurses devotes a significant amount of time in her practice to helping patients cope with pain. Following is a snapshot of the pain issues they face, their pain management goals, clinical approaches and the rewards and challenges of helping patients manage pain effectively.

To read how these CKHS nurses help their patients manage pain, please click on the name of the nurse below.

Tara Harrell, RN

Jennifer Miller, RN, BSN

Kim Getty, RN

Joanne Schultz, RN, BSN, CMSRN

Ginger Minnick, RN, CHPN

Tara Harrell, RN

Tara Harrell, RN

5 East – DCMH

A 14-year nursing veteran, Tara Harrell, RN, has worked with orthopedic patients at DCMH for 9 years.

Patient pain issues:

Orthopedic – hip and knee replacements, broken bones.

Med/surg patients with post-op pain.

Pain management goal:

Our optimal goal is to help our patients become pain free. We realize that may not always be possible, especially with orthopedic patients. When that is the case, our goal is 2 out of 10 on the pain scale.

Clinical Approach:

We try to help each patient set realistic expectations about managing their pain.  Telling the patient that “the pain won’t be that bad” is not helpful. Patients cope better and recover faster if they know what to expect.

For the first 48 hours after surgery, patient-controlled epidural anesthesia (PCEA) and patient-controlled analgesia (PCA) are generally ordered for our patients. These give patients a better sense of control; we find that they prefer not to have to rely on the nurse every time they need pain medication. Drug choices are limited to morphine and dilaudid for PCA; fentanyl and bupivacaine for PCEA. If the patient can’t tolerate these drugs, we collaborate with the physicians about switching to oral medication or other IV medication.

Challenges: 

Orthopedic patients must get up and move around. If they’ve had joint replacement surgery, they have to use the new joint, which is very painful in the beginning. We usually need to pre-medicate them for pain before they try to move.

Patients may suffer serious side effects from pain medication. Bupivacaine, for example, can cause hypotension. Some patients may experience numbness to the point where it is difficult to move; others may pass out. It’s impossible to tell how a patient will react. Our vigilance about rounding frequently enables us to recognize these side effects early and take action.

Rewards:

It’s great to see a patient on discharge day walking around effortlessly with no pain. Knowing that the patient’s quality of life will be much better than it was before surgery is a great reward. 

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Jennifer Miller, RN, BSN

Jennifer Miller, RN, BSN

Emergency Department, Crozer

Jennifer Miller, RN, BSN, joined Crozer in 2007.  She has been an ED nurse for 2 years.

Patient pain issues:

We deal with a wide variety of pain issues ranging from traumatic injury to chest or abdominal pain to chronic pain.

Pain management goal:

No pain.

Clinical approach:

Recently, pre-emptive guidelines have been implemented by our physicians so ED nurses can start pain meds in certain cases, such as suspected kidney stones or extremity injuries, while waiting to be seen by a doctor. This is definitely improving patient satisfaction. Even if patients have to wait to be seen, they are more satisfied because they are getting pain relief.

Pain can be relieved with many different approaches. I tend to take a conservative approach to pain management, depending on the severity of injury/illness. When collaborating with physicians, I suggest trying non-narcotic pain medication first,  when appropriate. Intravenous narcotics present a major obstacle because they don’t last long – only 20 to 40 minutes – and require frequent dosing. In some cases, oral medication may be a better option.   

In some trauma cases, such as an open ankle injury, no amount of pain medication will provide relief. Most open fractures require surgery, and patients often go straight from the ER to the OR. In some cases, patients are intubated to control pain until the injury can be reduced. Benefits of intubation allow ED nurses and physicians to properly medicate patients for pain while protecting their airway. 

Challenges:

Getting a patient’s pain under control is the hardest part of my job. If I can’t control it in a reasonable amount of time, I start looking for other problems that might not be readily apparent. With an extremity injury, for example, I consider whether the patient may have developed compartment syndrome which occurs when inflammation and swelling is so great that the patient’s circulation is affected. This requires immediate recognition and treatment or loss of a limb can result. It is important to frequently assess these patients and explore all avenues to be sure the pain is not related to a limb-threatening condition.

Rewards: 

It’s gratifying when patients are finally calm and peaceful after their pain has been relieved. They are so grateful that you have helped them, even though it may have been very difficult. I always remember that no one chooses to come to the ED!  

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Kim Getty, RN

Acute Care Center, Springfield

Kim Getty, RN, has been a staff nurse in Springfield’s Acute Care Center for 2 years.

Patient pain issues:

Post-op pain, abdominal pain, pneumonia-related pain.

Pain management goal:

We want our patients to be comfortable enough to get through all activities planned for them that day, such as physical therapy or other types of treatment. A realistic goal is usually 2 out of 10 on the pain scale.

Clinical approach:

I do a complete pain assessment, asking the patient many questions about pain location, what triggers the pain and what relieves it. We talk to our patients about what they can expect in terms of pain relief, helping them to set realistic expectations.

I reevaluate pain an hour after giving the patient medication. If it isn’t helping, I discuss alternative pain medication with the patient’s physician. I also use diversion activities to help my patients. This may include repositioning and/or helping them use guided imagery to relax and take their minds off their pain. 

Our unit frequently audits patient charts to determine which pain management practices are working most effectively.

Challenges:

Some patients can’t tolerate any pain medication because of the side effects, such as nausea, vomiting and excessive sleepiness. This makes it difficult for them to get up and move around, which is often essential to their recovery. In these cases, I try to help them with diversion activities.

Rewards:

Watching people recover and become pain free. 

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Joanne Schultz, RN, BSN,
CMSRN

Joanne Schultz, RN, BSN, CMSRN

Oncology, Taylor

Joanne Schultz, RN, BSN, CMSRN, has been a staff nurse on Taylor Hospital’s Oncology unit for 9 years.

Patient pain issues:

Cancer-related pain – bone and deep pain

Post-op pain

Pain management goal:

We want our patients to be comfortable enough to be ambulatory and able to do the activities necessary for their recovery. We would like them to be pain free, but that isn’t always realistic, especially when a patient has just had surgery.

Clinical approach:

I believe that pain is what the patient says it is, and I collaborate with the physician to manage the pain accordingly. A combination of long-acting and short-acting pain medications and patches are generally ordered for our patients. In addition, I try to spend time just sitting and talking with my patients. When they are feeling scared about a cancer diagnosis, this can help alleviate their fears and, as a result, reduce their pain.

Challenges:

Some patients, especially older ones, fear that they will become addicted to pain medication. I try to reassure them that we are monitoring their medication and only giving them the dose they need to be comfortable. I also emphasize that being pain free will enable them to be more active, and that, in turn, will help them recover. 

Rewards:

It’s rewarding to help cancer patients return to a level of normalcy in their lives. Even in cases where the long-term prognosis isn’t good, I’m happy when I can help manage their pain so they feel well enough to enjoy their lives and their families. 

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Ginger Minnick, RN, CHPN

Ginger Minnick, RN, CHPN

CKHS Hospice Care

Ginger Minnick, RN, CHPN, has been a hospice nurse for 16 years.

Patient pain issues:

Cancer-related pain, bone pain

Neuropathic pain related to chemotherapy

Pain related to respiratory illnesses, i.e. emphysema, COPD

Pain management goal:

We ask our patients what their pain goals are. Ideally, we would like them to be in no pain, but many patients are willing to accept 3 or 4 on the pain scale because they’ve become used to living with it and they’d rather not take more pain medication. In hospice care, our ultimate goal is to enable our patients to experience a comfortable and peaceful death, and this is usually attainable.

Clinical approach:

Pain is a very personal issue. Some people don’t want to admit that they’re in pain or take pain medication. Patients in hospice care have lost so much control over their lives that they want to take control of any aspects that they can, such as how and when to take pain medication. We can recommend the best way to manage their pain, but ultimately it is their decision.

We take a multidisciplinary team approach to pain management. CKHS Hospice nurses meet weekly with physicians and pharmacists to discuss the pain management plan for each patient. Long-acting drugs are usually ordered, sometimes combined with short-acting medication for breakthrough pain. For bone pain, narcotics alone don’t control the pain, so a steroid or anti-inflammatory drug is usually ordered in addition. For patients with neuropathic pain, medications such as Neurontin, Elavil or Nortriptyline are usually ordered. If a patient can’t swallow, a patch may be ordered instead of oral medication. Morphine is often ordered to relieve shortness of breath.

Challenges:

People often have misperceptions about hospice care. One man who signed his wife into hospice care asked me, “Are you going to give her the shot now?” He thought that we were going to euthanize her. We had to explain that our goal was to keep her comfortable by managing her pain. We’ve also had cases where the family thinks that the hospice nurse is going to move in with the patient and provide around-the-clock care. They don’t understand that they need to partner with us to manage their loved one’s pain. It is very important to spend time educating patients and their families about what hospice care is and isn’t. 

In an increasing number of cases, we have discovered that the patient has family members who are using the pain medication intended for the patient. This has become a big problem and it continues to grow. We become suspicious when the only time the family asks us to come is when the patient needs more medication. You have to trust your instincts.  In these cases, we consult with the physician about switching the patient from oral medication to patches.

It is harder to deal with the patient’s emotional or spiritual pain than with physical pain. We sit and talk to our patients, listening carefully for any clues that they may need counseling. One patient who was in a great deal of pain asked, “Is there enough morphine here for me to take my life?” When we hear that kind of desperation, we suggest emotional or spiritual counseling in addition to helping them manage their physical pain. Of course, all hospice patients are entitled to receive visits and support from a spiritual counselor and social worker, but sometimes they refuse those visits.

Rewards

Pain control clearly contributes to quality of life. I once had a patient who was talking about suicide because her pain was so acute. Once we got it under control, she stopped talking about suicide.

We can’t fix patients in hospice care but we can make them comfortable and help them die peacefully. This also makes the process of letting go and saying goodbye easier for the patients’ families.

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