Position Statement: Range Orders in the Management of Pain.

American Society for Pain Management Nursing (ASPMN) supports safe medication practices and the appropriate use of pro re nata (PRN) range orders for analgesics in the management of pain within the scope of nursing practice. Although range orders may apply to many medications prescribed as PRN, the focus of this ASPMN position statement is on PRN analgesic medication. PRN range orders are commonly used to provide flexibility in dosing to meet the analgesic requirements of an individual patient. There are many patient-specific factors that require professional clinical assessment when administering medications to patients. Unfortunately, several myths persist regarding The Joint Commission's (TJC) standard around the implementation of range orders leading many to assume that range orders are not supported or safe. On the contrary, if utilized in a consistent and appropriate manner, PRN range orders can allow nurses to provide optimal pain management while still providing safe administration (Paquette et al., 2022).

Prescribing and Administering Opioid Doses Based Solely on Pain Intensity: Update of a Position Statement by the American Society for Pain Management NursingⓇ.

Prescribing and administering opioid doses based solely on pain intensity is inappropriate and potentially unsafe for many reasons, including that pain intensity ratings are completely subjective, cannot be measured objectively, are dynamic as the experience of pain is dynamic, and may be describing a construct other than intensity (i.e. suffering). Many factors, in addition to pain intensity, influence opioid requirements and subsequent dosing. The American Society for Pain Management Nursing (ASPMN) holds the position that the practice of prescribing and administering doses of opioid analgesics based solely on a patient's pain intensity should be prohibited because it disregards the relevance of other essential elements of assessment and may contribute to negative patient outcomes.

Prescribing and Administering Opioid Doses Based Solely on Pain Intensity: Update of A Position Statement by the American Society for Pain Management Nursing.

The foundation of safe and effective pain management is an individualized, comprehensive pain assessment that includes, but is not limited to, the intensity of pain if the patient is able to report it. An unforeseen consequence of the widespread use of pain intensity rating scales is the practice of prescribing specific doses of opioid analgesics based solely on specific pain intensity ratings. Many factors in addition to pain intensity influence opioid requirements. To date there is no research demonstrating that a specific opioid dose will relieve pain of a specific intensity in all patients or even in the same patient at different times. The official position of the American Society for Pain Management Nursing (ASPMN) maintains that the practice of prescribing doses of opioid analgesics based solely on pain intensity should be prohibited because it disregards the relevance of other essential elements of assessment and may contribute to untoward patient outcomes.

Assessing the Impact of the Position Paper "Prescribing and Administering Opioid Doses Based Solely on Pain Intensity".

BACKGROUND: A task force of members of the American Society for Pain Management Nursing (ASPMN) authored a position paper "Prescribing and Administering Opioid Doses Based Solely on Pain Intensity." Some of the authors of this ASPMN position paper presented a concurrent session at the September 2016 ASPMN National Conference discussing the content of the position paper. As a follow-up, the authors designed a research study to identify the impact of the position statement in facilitating change in institutional practice of dosing analgesics based solely on pain intensity. AIMS: Our aim was to ascertain the effect of the American Society for Pain Management Nursing ASPMN position paper "Prescribing and Administering Opioid Doses Based Solely on Pain Intensity" (2016) on changes in institutional practices. DESIGN: The study used an online anonymous questionnaire that included open-ended questions. SETTINGS: An anonymous electronic questionnaire was used to assess the impact across the United States. PARTICIPANTS/SUBJECTS: Participants were members of the American Society for Pain Management Nursing. METHODS: An eight-question anonymous questionnaire created through Survey Monkey was sent to members of the American Society for Pain Management Nursing via an e-mail listserv and the monthly e-newsletter. RESULTS: Of the 142 members who consented to participate in the study, 120 members answered one or more questions. Those who responded to the question about changes in practice, only 13 (11.1%) reported that the position paper had influenced a change in practice at their institution. The majority, 89 (75%), reported that practice had not changed in their institution. CONCLUSIONS: Among those clinicians who participated in this study, the position paper "Prescribing and Administering Opioid Doses Based Solely on Pain Intensity" reportedly had minimal impact on changing institutional practices.

''As-Needed'' Range Orders for Opioid Analgesics in the Management of Pain: A Consensus Statement of the American Society for Pain Management Nursing and the American Pain Society.

Effective pain management requires careful titration of analgesics and evaluation of individual patient's responses to treatment using valid and reliable pain and pain relief assessment tools, and evidence-based patient monitoring for adverse treatment effects. A registered nurse, competent in pain assessment and analgesic administration, can safely interpret and implement properly written ''as-needed'' or ''PRN'' range orders for analgesic medications. The American Society for Pain Management Nursing (ASPMN) and the American Pain Society (APS) support safe medication practices and the appropriate use of PRN range orders for opioid analgesics in the management of pain.

Quality Improvement Project: Replacing the Numeric Rating Scale with a Clinically Aligned Pain Assessment (CAPA) Tool.

CAPA is a multifaceted pain assessment tool that was adopted at a large tertiary Midwest hospital to replace the numeric scale for adult patients who could self-report their pain experience. This article describes the process of implementation and the effect on patient satisfaction scores. Use of the tool is supported by the premise that pain assessment entails more than just pain intensity and that assessment is an exchange of meaning between patients and clinicians dependent on internal and external factors. Implementation of the tool was a transformative process resulting in modest increases in patient satisfaction scores with pain management. Patient reports that "staff did everything to manage pain" had the biggest gains and were sustained for more than 2 years. The CAPA tool meets regulatory requirements for pain assessment.

American Society for Pain Management Nursing Position Statement: Prescribing and Administering Opioid Doses Based Solely on Pain Intensity.

The foundation of safe and effective pain management is an individualized, comprehensive pain assessment, which includes, but is not limited to, determining the intensity of pain if the patient is able to report it. An unforeseen consequence of the widespread use of pain intensity rating scales is the practice of prescribing specific doses of opioid analgesics based solely on specific pain intensity. Many factors in addition to pain intensity influence opioid requirements, and there is no research showing that a specific opioid dose will relieve pain of a specific intensity in all patients. The American Society for Pain Management Nursing (ASPMN) holds the position that the practice of prescribing doses of opioid analgesics based solely on a patient's pain intensity should be prohibited because it disregards the relevance of other essential elements of assessment and may contribute to untoward patient outcomes.

American Society for Pain Management Nursing position statement: pain management at the end of life.

Pain at the end of life continues to be of great concern as it may be unrecognized or untreated. While nurses have an ethical obligation to reduce suffering at the end of life, barriers remain regarding appropriate and adequate pain management at the end of life. This position statement from the American Society for Pain Management Nursing contains recommendations for nurses, prescribers, and institutions that would improve pain management for this vulnerable population.

Pain in critically ill patients with substance use disorder or long-term opioid use for chronic pain.

Opioid tolerance resulting from long-term opioid consumption for chronic pain or from substance use disorder adds a layer of complexity to managing pain in the critical care setting. This article discusses similarities and differences of these 2 conditions. The phenomenon of tolerance and opioid-induced hyperalgesia are presented. Prevention of opioid withdrawal, when patients are on methadone or buprenorphine, is described. An overview of the neurophysiology of pain and substance use disorder is presented. Practical clinical suggestions are given to assist the critical care nurse in caring for these complex patients.

A qualitative approach to understanding patients' diagnosis of Lyme disease.

OBJECTIVES: The purpose of this study was to explore the lived experience of becoming diagnosed with Lyme disease. DESIGN: A qualitative, phenomenological study was conducted to investigate the experience of becoming diagnosed with Lyme disease. SAMPLE: A purposive sample of 10 participants diagnosed with Lyme disease were interviewed and tape-recorded. Data saturation guided the size of the sample. METHODS: The interviews were transcribed verbatim. Key words or phrases were extracted and clustered; clusters were interpreted into themes. Analyzed data were confirmed with the participants for trustworthiness and reliability. RESULTS: Six themes emerged from the interviews. Participants expressed feelings of frustration during the long road to diagnosis. They endured multiple diagnostic tests and were seen by numerous health care providers. Participants voiced financial stress. They expressed the need for self-advocacy and felt validation when a diagnosis was made. Despite the chronicity of their illness, the participants voiced a sense of hopefulness for their future. CONCLUSION: A deep understanding of the lived experience of becoming diagnosed with Lyme disease allows for nurses to prioritize health care interventions and strategize ways to implement quality improvement systems as clients enter the health care environment.

Decision analysis as a tool to support an analytical pattern-of-reasoning.

Decision analysis is offered as a tool to aid nurses' decision-making in complex and troublesome situations where there are mutually exclusive actions and time is available for deliberation. Decision analysis can be formal or informal. Formal decision analysis provides a structure for representing the decision situation and a mathematical procedure for prescribing the alternative action that is most consistent with what is known and what one values. Informal decision analysis uses the concepts and sometimes the structure of decision analysis, but usually does not include the mathematical calculations. In the present paper, the authors illustrate how formal and informal decision analysis might be used by nurses to: (i) enhance their own decision-making; (ii) assist patients or family caregivers with decision-making and; (iii) promote informed health care policy development. Finally, the advantages and limitations of decision analysis are discussed.

Comparison of normal saline and heparinized saline for patency of IV locks in neonates.

In this randomized double-blind experiment of 49 neonatal intensive care unit patients, probable time to catheter failure was significantly longer (p =.0358) for catheters flushed with heparinized saline (median = 127) compared with those flushed with normal saline (median = 39). This is in contrast to the nonsignificant difference (p =.841) in mean scores for six heparin-flushed catheters (M = 41.5 hours, SD = 44.0) compared with 18 saline-flushed catheters (M = 30.4 hours, SD = 20.8) discontinued for reasons other than completion of treatment. We concluded that survival time analysis is necessary when evaluating results of time-dependent studies in which the end point may not be elective.