Now that we have reviewed basic concepts related to pain and several disorders requiring analgesic or musculoskeletal medication, let’s consider the nursing process and how it applies to these types of medications.

Assessment

Although there are numerous details to consider when administering medications, it is important for nurses to always first think about what medication you are giving and why the patient is receiving that medication.

Analgesic medications are given to alleviate pain. Nurses perform comprehensive pain assessments, in addition to the patient’s rated pain level, when administering analgesics. Keep in mind the patient’s pain level is what the patient says it is. Many mnemonics are used to ensure comprehensive pain assessment. See Figure 10.4^[1] for various common nursing mnemonics for pain assessment.

Visual pain scales have been developed as a tool of communication about pain with children through patients at the end of life. See Figure 10.5^[2] for the FACES Pain Rating Scale. To apply this scale, use the following evidence-based instructions. Explain to the patient that each face represents a person who has no pain (hurt), some, or a lot of pain. “Face 0 doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.” Ask the person to choose the face that best represents the pain they are feeling.

Figure 10.5 The Wong-Baker FACES Pain Rating Scale. Used with permission from http://www.WongBakerFACES.org.Additional baseline information to collect prior to administration of analgesic or musculoskeletal medication includes inquiring about any history of allergy or previous adverse response. Nurses also ask patients to describe their preferred acceptable pain level while also considering the potential side effects of analgesics.

Implementation

As with all medications, nurses check the rights of medication administration and check for allergies prior to administration. Nurses also consider the best route of administration for this patient at this particular time. For example, if the patient is nauseated and vomiting, then an oral route may not be effective.

When administering opioids, the nurse considers if the prescribed medication is appropriate for the patient’s current level of pain. See Table 10.4 for a list of common opioid medications, ranging from use for moderate to severe pain.^[3]

Table 10.4 Common Opioid Analgesics

A general rule of thumb when administering analgesics is pain control should be based on the pain level indicated by the patient and the least invasive medication should be used to treat the level of pain. The WHO ladder was originally developed for selection of analgesics for patients with cancer but illustrates the concept that pain control should be based on the level indicated by the patient. See Figure 10.6^[4] for an image of the WHO ladder. For example, if a patient reports a pain level of “2,” then it is appropriate to start at the lowest rung of the ladder and administer a nonopioid. However, it may be clinically indicated to start at “Level 3” on the WHO ladder for patients who present with severe, difficult pain.

Nurses anticipate common side effects of analgesics and plan appropriate monitoring as well as potential administration of additional medication if needed. For example, an adverse effects of opioid analgesics is respiratory depression. The nurse plans to monitor the patient’s respiratory rate and pulse oximetry after administration of opioids. Other common side effects of opioids are constipation or nausea. The nurse anticipates administering other medications to treat potential side effects of analgesic medication.

Nurses also teach the patient and their family members about the medications and new symptoms to report that may indicate adverse effects.

When administering opioid medications, recall that controlled substances have special regulations regarding storage, auditing counts, and disposal or wasting of medication. See more information about controlled substances in the “Legal/Ethical” chapter.

Evaluation

Nurses evaluate and document the patient’s response to the administered analgesic based on its onset and peak. With analgesic medications, the nurse typically evaluates the patient for a decreased level of pain 30 minutes after IV administration and 60 minutes after oral medication. If the patient’s pain level is not acceptable, the nurse investigates alternate treatment modalities. These modalities may include, but not limited to, aromatherapy, repositioning the patient, hot or cold treatments, and listening to music.

Because the nurse is the patient’s advocate, the health care provider should be notified if the patient’s pain is not being controlled adequately by the prescribed analgesics.