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CONTINUING EDUCATION

Delivering Quality Pain Management: The Challenge for Nurses 1.2 www.aorn.org/CE

KIM HAYES, MSN, RN, CPAN; DEBRA B. GORDON, DNP, RN-BC, ACNS-BC, FAAN

Continuing Education Contact Hours indicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the exami- nation is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.

Event: #15508 Session: #0001 Fee: Members $9.60, Nonmembers $19.20

The contact hours for this article expire March 31, 2018. Pricing is subject to change.

Purpose/Goal To provide the learner with knowledge specific to the peri- operative management of pain.

Objectives 1. Describe how pain affects the surgical patient. 2. Identify the characteristics of quality pain management. 3. Discuss the desired patient outcomes of pain management. 4. Explain the challenges of pain assessment. 5. Identify the implications of pain management for periop-

erative and perianesthesia nurses.

Accreditation AORN is accredited as a provider of continuing nursing ed- ucation by the American Nurses Credentialing Center’s Commission on Accreditation.

Approvals This program meets criteria for CNOR and CRNFA recerti- fication, as well as other CE requirements.

AORN is provider-approved by the California Board of Regis- tered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

Conflict of Interest Disclosures Kim Hayes, MSN, RN, CPAN, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. As a member of the Zogenix Safe Use Advisory Board to the FDA for Zohydro, San Diego, CA, and as a member of the Pacira-health Economics Advisory Board for Exparel, Parsippany, NJ, Debra B. Gordon, DNP, RN-BC, ACNS- BC, FAAN, has declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.

Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.

Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

http://dx.doi.org/10.1016/j.aorn.2014.11.019 ª AORN, Inc, 2015

www.aornjournal.org AORN Journal j 327

Delivering Quality Pain Management: The Challenge for Nurses 1.2 www.aorn.org/CE

KIM HAYES, MSN, RN, CPAN; DEBRA B. GORDON, DNP, RN-BC, ACNS-BC, FAAN

ABSTRACT The delivery of high-quality pain management in the perioperative environment can be challenging and difficult to quantify. Commonly used tools in delivering care, such as pain intensity ratings, indi- vidual pain experience reporting, assessments of individual patients’ expectations, and patient satis- faction scores, have limitations and are not always useful when addressing quality improvement measures. Despite clinical advances in pain management, patients continue to experience inadequate pain control and inconsistent pain management practices. In this article, we discuss the challenges in providing consistent quality pain management, the need for a coordinated plan of care with a goal of meeting desired pain outcomes, and the essential role that perianesthesia and perioperative nurses play throughout the transitions in perioperative care to promote optimal pain management in- terventions based on the patient’s individual needs. AORN J 101 (March 2015) 328-334. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2014.11.019

Key words: acute pain, postoperative pain management, perianesthesia nurse, patient satisfaction.

http://dx.doi.org/10.1016/j.aorn.2014.11.019 ª AORN, Inc, 2015

328 j AORN Journal www.aornjournal.org

Acute pain is a complex condition causing physio- logical and psychological distress. Pain contributes to the surgical stress response, with implications

for the neural-immune-endocrine systems.1 Even brief intervals of acute pain can induce long-term changes in the nervous system, including

� structural remodeling and sensitization of the nervous system,

� chronic pain, and � long-lasting psychological distress.

Recent evidence suggests that providing effective pain man- agement in the early postoperative period may lead to clinically important outcomes with respect to early and long-term re- covery.1,2 Unfortunately, despite heightened awareness of and clinical advances in pain management, evidence continues to suggest that pain is undertreated in the postoperative setting, raising concerns related to this provision of quality patient care.3-5

UNDERSTANDING QUALITY PAIN MANAGEMENT The Institute of Medicine (IOM) defines quality in health care as the extent to which health services provided to individuals and patient populations improve desired health outcomes.6

According to the IOM, quality care should be patient centered and customized to meet patient needs and values and should involve good communication and shared decision making.6 As such, delivering quality care is a systems issue that requires ongoing improvement. Many factors can affect a systems approach to care, including how well care is organized (eg, adequate staffing to safely meet the patient’s needs), how care is delivered (eg, timeliness, efficiency), and the results of care (eg, optimal patient outcomes).7

Gordon et al8 define quality pain management as performing a comprehensive pain assessment that involves clinicians screening patients for the presence of pain, frequently reassessing the patient’s responses to pain treatments, and developing a plan of care that

� is safe, � incorporates patient and family member input, � is culturally and developmentally appropriate, and � provides access to specialty care as needed.

Clinical studies have linked suboptimal quality pain man- agement to prolonged postoperative recovery, diminished patient well-being, and an increased risk for chronic pain.9,10 Desirable patient outcomes of perioperative pain

management include avoidance of adverse effects from pain and pain treatments, enhanced recovery, and increased pa- tient satisfaction with the results of the treatment (Table 1).11

Beyond the bedside challenges of optimal pain control are the financial implications for health care organizations, which rely on the scores derived from publicly reported performance pain measures associated with the Centers for Medicare & Medicaid Services (CMS) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).12 These scores are a valued component of an institution’s health care report card that consumers use to evaluate hospitals and other care facilities and that institutions use for benchmark information. Driven by a need to increase patient satisfaction in a dynamic health care climate that emphasizes decreasing costs and lengths of stay and increasing patient satisfaction, hospital administrators and bedside clinicians must continue to search for strategies that optimize health care services and promote high-quality pain management. These strategies are particularly relevant in the perioperative area that encompasses preoperative assessment, intraoperative care coordination, and postoperative recovery.

ACHIEVING DESIRED OUTCOMES The quality of pain management depends on a host of complex relationships and processes, including collaborative teamwork and continuity across the continuum of care.13 Achieving the desired outcomes of pain management requires a dedicated interdisciplinary team that engages patients in helping to create their care plans and that is responsive to individuals’ needs. Clinicians should obtain and use patient outcomes at the point of care to adjust the plan of care, and outcome measures should be analyzed over time to guide quality improvement efforts.

Traditionally, quality and safety outcomes for surgery and anesthesia have focused on perioperative mortality and morbidity. The growing field of Enhanced Recovery After Surgery (ERAS�) programs has brought attention to other more immediate aims of improved pain control, such as the resumption of dietary intake, recovery of bowel and bladder function, and resumption of normal physical activities.14

Managing surgical stress and pain are key factors in decreasing patients’ lengths of stay and morbidity, and ERAS programs are being used in several types of postoperative recovery situations.2

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At the bedside, perianesthesia nurses make use of the most obvious pain management approaches, such as assessing the patient’s pain severity ratings and satisfaction with care However,. taken alone, these patient outcomes provide an incomplete picture of quality. A further study by Gordon et al11 identifies four domains of advantageous, measurable, patient-reported outcomes for acute pain management quality

� pain severity and relief; � effect of pain on physical activities, sleep, and negative emotions;

� side effects of treatment; and � patient perceptions of care (Table 2).

UNDERSTANDING THE CHALLENGES OF QUALITY PAIN MANAGEMENT There are many challenges to achieving the desired pain management outcomes, including the fact that quality is multidimensional, dependent on perspective, and often ambiguous. Key challenges include the following:

� Although care should be evidence based and delivered with fair and standardized processes, pain management must be individualized to meet a wide range of patient needs.

� Communicating the pain management goals and the plan of care to the patient and other caregivers is essential to deliv- ering quality care, but can be hampered by the segregation of the phases of perioperative care.

� Staff members and patients may have different knowledge bases about pain management and the skills needed to provide it, or they may hold common misconceptions related to the quality of pain management.

� Some patients and caregivers may view quality pain man- agement as simply meaning access to more or stronger an- algesics, which is important because the focus on pain ratings

and patient satisfaction have, in some situations, resulted in attempts to achieve preselected scores leading to unintended consequences (eg, oversedation as a result of administering additional opioid doses to achieve a lower pain rating; reli- ance on opioids alone rather than using a more multimodal approach, including nonopioids and nonpharmacological methods).

When considering how to address these challenges and achieve desired outcomes, pain severity ratings and patient satisfaction are commonly used pain measures with limitations that war- rant their own discussion.

Pain Severity Ratings Increased attention to measuring and reporting pain through campaigns such as “pain is the fifth vital sign” have led to an overreliance on opioids to relieve pain and an alarming increase in cases of oversedation, as well as significant respiratory depression.15 The lack of a predictable relationship between opioid dose and pain relief led the American Society for Pain Management Nursing (ASPMN) and the American Pain Society (APS) to develop a consensus statement on the use of PRN opioid range orders for acute pain, stating that care providers should not prescribe or administer an opioid dose based solely on pain intensity ratings.16 In addition to considering the patient’s pain intensity rating, decisions should be based on a thorough pain assessment and knowledge of the medication to be administered. This may include an assessment of an individual patient’s risk for adverse effects and the anticipated onset, peak effect, and duration of the opioid to be administered. Little is known about how useful pain severity ratings are in helping to

Table 1.Desired Outcomes of Perioperative Pain Management

� Enhanced recovery from underlying injury or surgery � Reduced neuroendocrine stress response � Controlled and reduced pain � Minimized effect of pain on the physical and emotional recovery process

� Minimized adverse effects associated with pain treatment (eg, pharmacological adverse effects, including respiratory depression)

� Enhanced patient satisfaction � Prevention of chronic pain and disability

Table 2. Patient-Reported Outcome Measures of the Domains of Acute Pain Management1

� Pain severity and relief (eg, least pain, worst pain, percent time spent in severe pain, percent pain relief)

� Effect of pain on activity, sleep, and negative emotions (eg, anxiety, depression, fearfulness, helplessness)

� Adverse effects of treatment (eg, nausea, drowsiness, itching, dizziness)

� Patient perceptions of care (eg, ability to participate in treatment decisions, patient satisfaction with results of pain treatment)

1.Gordon DB, Polomano RC, Pellino TA, et al. Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: preliminary psychometric evaluation. J Pain. 2010; 11(11):1172-1186.

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make decisions about opioid dosages when acute pain is superimposed on patients with pre-existing chronic pain and opioid tolerance. The usefulness of pain ratings as an outcome measure is debatable in the medical literature.15

The data from analgesic trials have revealed that changes in pain intensity from baseline to each postmedication assessment point are distinct from pain relief ratings.17

Treating acute pain can achieve a clinically meaningful outcome ranging from 30% to 50% improvement in pain, but for many patients, this may represent only a one- or two-point change in a pain severity rating on a zero-to-10 scale.17 These findings have implications for how perianesthesia nurses discuss goals of pain management, decide how to administer treatments, and assess patient responses.

Patient Satisfaction Patient satisfaction with pain management does not rely exclusively on pain relief. Patients’ satisfaction with pain management is often paradoxical. For example, some patients may report high levels of satisfaction despite experiencing severe pain at times. Satisfaction with pain management has been associated with patients’ expecta- tions, preoperative fears, and the adverse effects of med- ications.4,18 Studies suggest that a professional and caring environment has a greater effect on positive patient per- spectives than how care is provided.4,18 Patient and family member satisfaction with pain treatment in the early perioperative phase appears to be influenced by a number of factors, including patient involvement and the char- acteristics of the patient-caregiver relationship. The type of anesthesia and pain treatment techniques used may have little direct influence on patient satisfaction, but ultimately may be linked to satisfaction via improved pain relief.

NURSING IMPLICATIONS Perioperative and perianesthesia nurses can help ensure quality pain management (Table 3). A patient’s perioperative experience begins with the primary care provider and progresses to the preanesthesia interview and the surgical specialty team that conducts the comprehensive preoperative assessment. During this assessment, the team and the patient can begin to develop a plan of care that addresses preoperative concerns and postoperative expectations. Team members should partner with patients by engaging them in the plan-of-care process. Nurses should review the coordinated plan of care with patients

and family members and pay attention to their immediate preoperative concerns, such as pain, fear, anxiety, and postoperative expectations. Nurses and other care providers should reinforce that they are concerned about pain control and convey a commitment to doing everything possible to keep their patients comfortable.

Multiple care transitions can take place during a patient’s peri- operative experience. In 2006, The Joint Commission addressed the topic of communication during the transfer of care in the health care setting in the published National Patient Safety Goal 2E.19 A revision to this document was published in 2008, bringing attention to persistent transfer-of-care communication discrepancies.19,20 In the perioperative arena, accurate hand- over communication is an essential component that helps ensure quality through a patient’s multiphase surgical experience. As a member of the interdisciplinary team, the perioperative nurse has information that must travel from the preoperative area into the OR or procedure room. For example, addressing a patient’s preoperative concerns related to surgical positioning in the OR reinforces that patients are a part of the perioperative plan. In addition, coordinating the patient transfer from the OR to the postoperative environment requires a team approach that recognizes the need for accurate information specific to expected or unexpected perioperative events. Ideally, this information provides the postanesthesia

Table 3. Actions for Perioperative and Peri- anesthesia Nurses to Help Ensure Quality Pain Management

� Partner with patients to individualize care � Manage patient expectations and help develop realistic goals of pain treatment

� Use words that convey care (eg, “I want to do everything I can to make you as comfortable as possible”)

� Communicate the plan of care, including when and how to ask for pain medicine and the frequency and methods of pain monitoring

� Alleviate anxiety through explanations and reassurance � Provide complete clarifications of new and modified interventions

� Augment analgesic strategies with basic comfort methods (eg, positioning, temperature control, and nonpharmacological strategies such as ice and music)

� Address pain and the pain management plan during transfer of care and hand overs

� Collaborate effectively as a member of the interdisciplinary team

� Participate in quality improvement activities

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care unit (PACU) nurse with knowledge that supports an individualized postoperative plan of care.

Perianesthesia nurses are members of a coordinating surgical team whose work begins when a patient accepts the proba- bility of surgical intervention and continues through the continuum of care. For example, a patient who presents to the orthopedic spine clinic with reports of persistent low- back pain exacerbated by supine positioning, such as lying in bed for any length of time, is assessed by the surgical clinician. Does the pain interfere with normal daily activities or does it interrupt sleep? After a surgery is scheduled, the preanesthesia interview, often performed by an RN sup- ported by an anesthesia professional, gathers detailed infor- mation related to the individual’s health history and communicates this information to other team members. At this point in time, team members learn more about the presentation, location, duration, and intensity of the patient’s pain and personal issues that might affect pain care

on the day of surgery. The day of surgery involves care co- ordination. Beyond the standard preoperative chart review, it is imperative that the admitting hospital clinician discuss the patient’s perianesthesia course, especially as it relates to preoperative and postoperative pain management expecta- tions. The admitting clinician is the information conduit for the OR team. The preoperative checklist, although thor- ough, does not necessarily address unique intraoperative considerations, such as the patient who does not tolerate supine positioning. In this situation, the perioperative nurse plays a pivotal role in quality patient care. After learning that the patient does not tolerate lying supine for any length of time, the OR nurse can implement a positioning plan aimed at avoiding additional strain or stress. The transition from the OR to the PACU is a critical time for accurate communication and information transfer. Learning that the patient does not tolerate lying on his or her back gives the PACU nurse essential information that can affect quality

patient care and improve individual pain manage- ment outcomes.

When the transfer of care is complete, the PACU nurse as- sumes the role of the intervening patient care coordinator. The approach to pain management in the PACU relies on the knowledge of available pain treatment modalities. Multimodal and nonpharmacological evidence-based in- terventions in the PACU setting are well supported. Multi- modal analgesia is defined as combining pain medications that have different mechanisms of action to increase anal- gesia quality, decrease analgesic consumption, and avoid adverse medication reactions. Multimodal therapies can include preoperative and postoperative administration of acetaminophen (IV or PO), nonsteroidal anti-inflammatory drugs, gabapentinoids, and nonpharmacological in- terventions such as cold, heat, music, and meditation.10 The knowledge and ability to develop an individualized plan of care and effectively communicate and carry out

that plan supports high-quality care delivery in the perianesthesia area.

A patient’s pain experience and the choice of quality pain treatment modalities are never straightforward.21 Clinicians must have an appreciation for a patient’s prior surgical procedures and opioid use, which can contribute to preconceived pain perceptions and postoperative exp- ectations. Pain after surgery is expected, but reinforcing that care providers will do everything possible to manage the patient’s pain is an essential component of the conversation between the PACU RN or the receiving floor RN and the patient and family members in the postoperative phase. The goal of the perioperative clinician is to minimize suboptimal pain relief outcomes during the continuum of care. Beyond the multimodal pharmacological interventions that can be implemented throughout the perioperative course, the use of nonpharmacological strategies is attracting the attention of

” “Perioperative nurses play a key role in developing and following through with a plan of care that incorporates individualized pain management strategies.

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health care organizations, bedside clinicians, and individual consumers. In addition to the application of heat or cold, attending to basic comfort measures during all phases of care (eg, positioning, maintaining normothermia) can have an enormous effect on an individual’s perception of how well he or she was cared for. For example, simply turning down the lights has been shown to affect a person’s pain and opioid requirements.22

Nurses, as frontline clinicians, are often in a position to identify targets for improvement in processes and outcomes of care when advocating for quality patient care and optimal patient care systems. Nurses also can participate in identifying systems errors and implementing potential systems solutions through the development and coordination of quality improvement activities.

CONCLUSION Achieving high-quality pain management in the perioperative setting is an essential component of successful postoperative recovery and supports the AORN mission and vision state- ment that promotes optimal patient care outcomes related to surgical or procedural interventions.23 Optimal perioperative pain management is an important health care focus that benefits patients and families, bedside clinicians, third-party payers, and health care organizations. Although pain severity and patient satisfaction measures are the most visible outcomes associated with quality pain management, they are limited in scope and represent only a small piece of the puzzle.

Perioperative nurses play a key role in developing and following through with a plan of care that incorporates preoperative assessment, intraoperative interventions, and individualized postoperative pain management strategies. A supportive part- nership with patients and the interdisciplinary team that re- inforces individualized care, effective communication, and realistic treatment goals is critical to promoting quality pain management and achieving optimal patient outcomes. � Editor’s note: Enhanced Recovery after Surgery ERAS is a registered trademark of the ERAS Society, Kista, Sweden.

References 1. Layzell M. Current interventions and approaches to postoperative

pain management. Br J Nurs. 2008;17(7):414-419. 2. Kehlet H. Fast-track surgerydan update on physiological care

principles to enhance recovery. Langenbecks Arch Surg. 2011; 396(5):585-590.

3. Hutchison R. Challenges in acute post-operative pain manage- ment [serial online]. Am J Health Syst Pharm. 2007;6(Suppl 4): S2-S5.

4. Ward SE, Gordon DB. Patient satisfaction and pain severity as outcomes in pain management: a longitudinal view of one set- ting’s experience. J Pain Symptom Manage. 1996;11(4): 242-251.

5. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: results for a US national Survey. Curr Med Res Opin. 2014;30(1): 149-160.

6. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.

7. Mitchell PH, Lang NM. Framing the problem of measuring and improving healthcare quality: has the Quality Health Outcomes Model been useful? Med Care. 2004;4(2 Suppl): II4-II11.

8. Gordon DB, Dahl JL, Miaskowski C, et al. American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005;165(14): 1574-1580.

9. Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth. 2008;101(1):77-86.

10. Pyati S, Gan TJ. Perioperative pain management [serial online]. CNS Drugs. 2007;21(3):185-211.

11. Gordon DB, Polomano RC, Pellino TA, et al. Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: pre- liminary psychometric evaluation. J Pain. 2010;11(11): 1172-1186.

12. HCAHPS: Patients’ Perspectives of Care Survey. CMS.gov. Centers for Medicare & Medicaid. http://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityIni ts/HospitalHCAHPS.html. Accessed November 17, 2014.

13. Gordon DB, Dahl JL. Quality improvement challenges in pain management. Pain. 2004;107(1-2):1-4.

14. Guidelines. ERAS� Society. http://www.erassociety.org/index.php/ eras-guidelines. Accessed November 17, 2014.

15. Vila H, Smith RA, Augustyiak MJ, et al. The efficacy and safety of pain management before and after implementation of hospital- wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings? Anesth Analg. 2005;101(2):474-480.

16. Drew D, Gordon D, Renner L, Morgan B, Swensen H, Manworren R. The use of “as-needed” range orders for opioid analgesics in the management of pain: a consensus statement of the American Society of Pain Management Nurses and the American Pain Society. Pain Manag Nurs. 2014;15(2): 551-554.

17. Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain. 2003;4(7):407-414.

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18. Schwenkglenks M, Gerbershagen HJ, Taylor RS, et al. Correlates of satisfaction with pain treatment in acute postoperative period: results from international PAIN OUT registry. Pain. 2014;155(7): 1401-1411.

19. National Patient Safety Goals; 2014 National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/standa rds_information/npsgs.aspx. Accessed November 13, 2014.

20. Johnson F, Logsdon P, Fournier K, Fisher S. SWITCH for safety: perioperative hand-off tools. AORN J. 2013;98(5): 495-504.

21. Rejeh N, Vaismoradi M. Perspectives and experiences of elective surgery patients regarding pain management. Nurs Health Sci. 2010;12(1):67-73.

22. Malenbaum S, Keefe FJ, Williams AC, Ulrich R, Somers TJ. Pain in its environmental context: implications for designing envi- ronments to enhance pain control. Pain. 2008;134(3): 241-244.

23. Batti�e R. The IOM Report on the Future of Nursing: what periop- erative nurses need to know. AORN J. 2013;98(3):227-234.

Kim Hayes, MSN, RN, CPAN is a clinical educator at Harborview Medical Center, Seattle, WA. Ms Hayes has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Debra B. Gordon, DNP, RN-BC, ACNS-BC, FAAN is a teaching associate in anesthesiology and pain medicine at the University of Washington, Seattle. As a member of the Zogenix External Safe Use Advisory Board to the FDA for Zohydro, San Diego, CA, and as a member of the Pacira-health Economics Advisory Board for Exp- arel, Parsippany, NJ, Dr Gordon has declared affiliations that could be perceived as potential conflicts of interest in the publication of this article.

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EXAMINATION

Continuing Education: Delivering Quality Pain Management: The Challenge for Nurses 1.2 www.aorn.org/CE

PURPOSE/GOAL To provide the learner with knowledge specific to the perioperative management of pain.

OBJECTIVES 1. Describe how pain affects the surgical patient. 2. Identify the characteristics of quality pain management. 3. Discuss the desired patient outcomes of pain management. 4. Explain the challenges of pain assessment. 5. Identify the implications of pain management for perioperative and perianesthesia nurses.

The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www .aorn.org/CE.

QUESTIONS 1. Pain contributes to the patient’s surgical stress response

by inducing long-term changes, including 1. remodeling and sensitization of the nervous system. 2. chronic pain. 3. long-lasting psychological distress. 4. hyporesponsiveness to the presence of a potentially

injurious environmental stimulus. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

2. Recent evidence suggests that providing effective pain management in the early postoperative period may lead to clinically important outcomes with respect to early and long-term recovery. a. true b. false

3. The characteristics of quality pain management include 1. performing a comprehensive pain assessment. 2. ensuring safe care. 3. including patient and family member input. 4. providing culturally and developmentally appropriate

care.

5. providing access to specialty care if needed. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, and 5

4. Quality perioperative pain management includes 1. avoiding adverse effects from pain and pain

treatments. 2. relying solely on pain rating scales. 3. enhancing recovery. 4. increasing patient satisfaction with the results.

a. 2 and 3 b. 1, 2, and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

5. Quality and safety outcomes for surgery and anesthesia are focused on 1. improved pain control. 2. perioperative mortality and morbidity. 3. recovery of bowel and bladder function. 4. resumption of dietary intake. 5. resumption of normal physical activities.

a. 1 and 3 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, and 5

www.aornjournal.org AORN Journal j 335

6. According to Gordon et al, the domains of advantageous, measurable, reported outcomes for acute pain manage- ment are 1. pain severity and relief. 2. effect of pain on physical activities, sleep, and negative

emotions. 3. adverse effects of treatment. 4. physician perceptions of care. 5. patient perceptions of care.

a. 1, 2, 3, and 5 b. 2, 4, and 5 c. 4 and 5 d. 1, 2, 3, 4, and 5

7. Carrying out quality pain management can be challenging because 1. segregation of the phases of perioperative care can

hamper communication of pain management goals and the plan of care.

2. nurses may have different knowledge bases about pain management and the skills needed to provide it.

3. nurses may have common misconceptions related to the quality of pain management.

4. patients and caregivers may view quality pain man- agement as simply meaning access to more or stronger analgesics.

5. nurses may have misguided attempts to achieve pre- selected pain ratings and patient satisfaction scores.

6. pain management efforts can have unintended consequences. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

8. Care providers should prescribe or administer an opioid dose based on 1. the patient’s pain intensity ratings. 2. assessment of an individual patient’s risk for adverse

effects.

3. determination of the anticipated onset and peak effect.

4. duration of the opioid to be administered. a. 2 and 3 b. 1, 2, and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4

9. To provide quality pain management, nurses should 1. review the coordinated plan of care with the patient

and his or her family members. 2. allow the patient to control the type and dose of pain

medication. 3. reinforce that they care about pain control. 4. convey a commitment to doing everything possible to

keep the patient comfortable. 5. screen patients for substance abuse. 6. pay attention to the patient’s immediate preoperative

concerns, such as pain, fear, anxiety, and post- operative expectations. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 3, 4, and 6

10. As a member of the interdisciplinary team, the periop- erative nurse 1. determines what information is pertinent and whether

to include it in the hand-over report. 2. has information that must travel from the preopera-

tive area into the OR or procedure room. 3. is responsible for coordinating the patient transfer

from the OR to the postoperative environment. 4. understands that a team approach, which recognizes

the need for accurate information specific to expected or unexpected perioperative events, is necessary.

5. provides the postanesthesia care unit (PACU) nurse with knowledge that supports an individualized postoperative plan of care. a. 1, 3, and 5 b. 1, 2, and 4 c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5

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LEARNER EVALUATION

Continuing Education: Delivering Quality Pain Management: The Challenge for Nurses 1.2 www.aorn.org/CE

This evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed

here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.

OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe how pain affects the surgical patient.

Low 1. 2. 3. 4. 5. High

2. Identify the characteristics of quality pain management. Low 1. 2. 3. 4. 5. High

3. Discuss the desired patient outcomes of pain manage- ment. Low 1. 2. 3. 4. 5. High

4. Explain the challenges of pain assessment. Low 1. 2. 3. 4. 5. High

5. Identify the implications of pain management for peri- operative and perianesthesia nurses. Low 1. 2. 3. 4. 5. High

CONTENT 6. To what extent did this article increase your knowledge

of the subject matter? Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No

9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.)

9A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why

change is needed. 2. I will work with management to change/implement

a policy and procedure. 3. I will plan an informational meeting with physicians

to seek their input and acceptance of the need for change.

4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice.

5. Other: __________________________________

9B. If you will not change your practice as a result of reading this article, why not? (Select all that apply) 1. The content of the article is not relevant to my

practice. 2. I do not have enough time to teach others about the

purpose of the needed change. 3. I do not have management support to make a

change. 4. Other: __________________________________

10. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: _______________

www.aornjournal.org AORN Journal j 337

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