Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice.

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

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).

Procedural Pain Management: Clinical Practice Recommendations.

Undergoing potentially painful procedures is necessary among patients of all ages. Nurses are responsible to optimize safety and minimize harm for patients. The American Society for Pain Management Nursing (ASPMN) holds the position that all patients undergoing painful procedures have the right to safe and effective pain management throughout the phases of care, and that the interprofessional healthcare team ensures such ethical obligation is fulfilled within a framework of the patients or their designees' goals and preferences. From that position, all nurses, clinicians, and health care organizations are strongly encouraged to offer multimodal pain management that includes integrative interventions when managing procedure related pain.

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.

Position Statement: Acute Perioperative Pain Management Among Patients Undergoing Orthopedic Surgery by the American Society for Pain Management Nursing and The National Association of Orthopaedic Nurses.

Patients undergoing elective orthopaedic surgery may experience pain that is acute, chronic or a combination of the two, with less than half of all surgical patients reporting adequate pain relief. The National Association of Orthopaedic Nurses (NAON) and the American Society for Pain Management Nursing (ASPMN) have partnered to provide evidence-informed guidance to empower nurses to employ effective pain management. Understanding and applying ethical, evidence-informed, patient-focused, interprofessional interventions will improve outcomes for patients, clinicians, and healthcare organizations. Together, we encourage nurses to embrace the guiding principles presented in this Position Statement to provide optimal pain management for the orthopaedic patient.

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.

Procedural Pain Management: Clinical Practice Recommendations American Society for Pain Management Nursing.

Throughout the life span procedures are common within health care and have the potential to cause pain. Nurses have an ethical responsibility involving the care of people with pain. The American Society for Pain Management Nursing holds the position that all patients undergoing painful procedures have the right to safe and effective pain management throughout the phases of care and that the interprofessional health care team ensures such ethical obligation is fulfilled within a framework of patients or their designees' goals and preferences. It is recommended that nurses, other health care providers, and health care organizations offer the use of integrative intervention for managing pain during procedures.

American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions.

OBJECTIVES: This report presents up-to-date evidence and expert consensus-based revisions to the ASPMN 2011 guidelines that inform interprofessional clinical decision-making for hospitalized adults receiving opioid analgesics. DESIGN: Systematic review of the literature. METHODS: A 14-member expert panel was charged with reviewing and grading the strength of scientific evidence published in peer reviewed journals and revising the ASPMN 2011 existing guidelines. Panel members formulated recommendations based on the strength of evidence and reached consensus through discussion, reappraisal of evidence, and voting by majority when necessary. The American Society of Anesthesiologists evidence categories for grading and classifying the strength of the evidence were used. Recommendations were subjected to a critical review by ASPMN members as well as external reviews. RESULTS: The 2011 guidelines were found to still be relevant to clinical practice, but new evidence substantiated refinement and more specific recommendations for electronic monitoring. The revised guidelines present risk factors divided into three categories: patient-specific, treatment-related, and environment of care. Specific recommendations for the use of electronic monitoring are delineated. CONCLUSIONS: All hospitalized patients that are administered opioids for acute pain are at risk of opioid induced advancing sedation and respiratory depression, but some patients are at high risk and require extra vigilance to prevent adverse events. All patients must be assessed for level of risk. Adaptations to the plan of care and monitoring strategies should be driven by iterative re-assessments according to level of risk. NURSING PRACTICE IMPLICATIONS: Opioid medications continue to be a major component in the management of acute pain. Clinicians have the primary responsibility for safe and effective pain management. Evidence based monitoring strategies can improve patient safety with opioids.

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.

Use of the Pasero Opioid-induced Sedation Scale (POSS) in Pediatric Patients.

The Pasero Opioid-induced Sedation Scale (POSS) is a valid, reliable tool used to assess sedation when administering opioid medications to manage pain. The POSS is endorsed by The Joint Commission and the American Society for Pain Management Nursing to help prevent adverse opioid-related respiratory events. Although the POSS is used to assess sedation in pediatric patients at some hospitals, prior to this study, it was not formally evaluated in the pediatric population. This study used a quasi-experimental design with a convenience sample of pediatric patients admitted to a large regional medical center in southeastern North Carolina. The POSS was evaluated from three perspectives. First, the study was designed to compare the documentation of sedation when opioids were administered before (n=25) and after (n=27) implementation of the POSS to assess sedation. Second, the occurrence of respiratory adverse events before and after implementation of the POSS was compared. Third, the appropriateness of using the POSS in the pediatric population was evaluated. When the POSS was used, there was an increase in both the clarity and frequency of documentation when sedation was assessed. There was no incidence of opioid-related adverse respiratory events after implementation of the POSS. Finally, the POSS was found to be appropriate and safe to use in the pediatric population. Through a survey, the majority of registered nurses who cared for the research subjects evaluated the POSS as easy, appropriate and safe to use with pediatric patients. The nurses also noted using the POSS provided standardized communication among staff regarding patients' levels of sedation. No adverse effects, concerns, or objections were reported. Coincidentally, while it was not part of the study, frequency of documentation of assessment of pain also improved with implementation of the POSS.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective.

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.