Crit Care
Nurs Clin North Am 2001 Jun;13(2):243-57
Managing the pain
of traumatic injury.
Alpen M A, Morse C
Department of Surgery,
University of Iowa Hospitals and Clinics, Iowa
City 52242-1086, USA.
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).
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