IASP Curriculum Outline on Pain for Nursing

Task Force Members: Huda Abu-Saad Huijer, Christine Miaskowski (Chair), Robyn Quinn, Alison Twycross

Every nurse should be able to assess and manage pain. This curriculum is intended to be used to provide the optimal level of education on pain and its management for entry level nurses throughout the world.

Outline Summary

Introduction
Principles
Objectives
Curriculum Content Outline
 I. Multidimensional Nature of Pain
 II. Pain Assessment and Measurement
 III. Management of Pain
 IV. Clinical Conditions
References

Introduction

Pain is a multidimensional and complex phenomenon that requires comprehensive and ongoing assessment and effective management. The multidimensional nature of pain requires an interprofessional approach to assessment and management. All professionals need to serve as advocates for the person in pain and ensure that pain treatment is based on ethical principles and evidence-based standards and guidelines. Nurses play a critical role in effective pain management because they have frequent contact with patients in a variety of settings (e.g., home, hospital, outpatient clinic, community). This frequent contact places the nurse in a unique position to:

1. Identify patients who have pain.
2. Perform a comprehensive pain assessment including its impact on the patient and the patient's family members.
3. Initiate actions to manage the pain and evaluate the effectiveness of those actions.

Nurses' central role and responsibility in the assessment and management of pain means that they are required to be knowledgeable about pain mechanisms, the epidemiology of pain, barriers to effective pain control, frequently encountered pain conditions, variables which influence the patients' perception of and response to pain, valid and reliable methods of clinical pain assessment, and a range of available methods for the alleviation of pain.

Principles

The following principles guide the pain curriculum for entry level nurses:

1. Pain is viewed as a biopsychosocial phenomenon that includes sensory, emotional, cognitive, developmental, behavioral, spiritual and cultural components.
2. Pain may be acute, persistent, or a combination of acute on chronic. The etiology of the pain will guide the development of the pain management plan.
3. Pain must be assessed in a comprehensive and consistent manner using valid and reliable assessment tools.
4. Patients have a right to the best possible pain management. Pain assessment and management are integral aspects of nursing care and should involve patients and their family members.
5. Pain assessment and management should be recorded in a clear and readily accessible manner.
6. Patient and family education about pain and its management are essential components of nursing care.
7. Nurses are essential members of the pain management team.

Objectives

Upon completion of this pain curriculum, the entry-level nurse will be able to:

1. Apply current knowledge of anatomy, physiology, pharmacology, psychology and sociology to the assessment and management of people with pain.
2. Distinguish between different types of acute, recurrent, and persistent (chronic) pain in terms of mechanisms, assessment, and management and understand the consequences of unrelieved pain.
3. Engage in regular evidence-based pain assessment and care planning that takes into account the sensory, cognitive, affective, behavioral, social, cultural, spiritual, and political components of the pain condition.
4. Identify professional, system, patients, family and community barriers to effective pain assessment and management.
5. Recognize individuals who are at risk for undertreatment of their pain (e.g., individuals who are unable to self-report pain, neonates, cognitively impaired).
6. Use valid and reliable pain assessment tools that are appropriate to the needs of the individual patient and the demands of the care situation.
7. Administer prescribed analgesics and evaluate their effects on patients' pain and function.
8. Prevent and manage common adverse effects associated with pain treatment.
9. Describe the differences between physical dependence, psychological dependence (addiction), tolerance, and pseudoaddiction.
10. Identify and deliver a range of basic physical and psychological comfort measures (e.g.,positioning, information, distraction) to decrease patients' pain.
11. Provide patients and family members with information about a variety of pain management interventions.
12. Demonstrate effective collaboration as a nurse-member of the interprofessional team that may include patients and family caregivers, to identify clearly defined, realistic and agreed upon goals for pain management.
13. Ensure accurate record-keeping and communication with patients, family caregivers, and members of the interprofessional team.
14. Practice in accordance with an ethical code that recognizes human rights, diversity, and the requirement to "do no harm."
15. Reflect critically on effective ways to work with and improve care for people with pain.
16. Regularly update personal knowledge on pain and its management.

Curriculum Content Outline

I. Multidimensional Nature of Pain

A. Magnitude of problem – epidemiology

B. Impact of unrelieved pain

1. Impact of acute pain on recovery and on the development of persistent (chronic) pain
2. Impact of persistent cancer and noncancer pain on:
   1. The individual (e.g., physical, psychosocial, spiritual, vocational, socioeconomic)
   2. The family (e.g., roles, relationships, psychological concerns, socioeconomic factors)
   3. Society (e.g., cost, lost productivity)

C. Definitions of pain

1. Types of pain based on duration
   1. Acute pain
   2. Persistent (chronic) pain
   3. Breakthrough pain
2. Types of pain based on mechanism
   1. Nociceptive pain (somatic, visceral)
   2. Neuropathic pain

D. Multiple dimensions of Pain

1. Physiological dimension – neural mechanisms of pain
   1. Transduction
   2. Transmission
   3. Modulation
   4. Perception
2. Sensory dimension
   1. Location
   2. Intensity
   3. Quality
   4. Temporal pattern
   5. Relieving and exacerbating factors
3. Affective dimension
   1. Influence of negative and positive emotions
   2. Affective consequences of pain, including suffering
   3. Impact of pain on mood, sleep, socialization
4. Cognitive dimension
   1. Personal beliefs, attitudes, and meanings attached to the pain experience and/or the disease condition associated with pain
   2. Spiritual beliefs, community, culture, family, and social networks related to cognitive responses to pain
5. Behavioral dimension
   1. Response to stressors (e.g., situational, developmental)
   2. Pain expression behaviors
   3. Pain control behaviors
   4. Usual behaviors prevented by pain
6. Social, cultural, ethical and political dimensions
   1. Social and cultural variations in conceptualizing pain, its meaning, and management
   2. Access to resources, including availability and costs of treatment

II. Pain Assessment and Measurement

A. Evaluate the feasibility, validity, reliability, sensitivity, and clinical utility of different pain assessment methods for specific groups (e.g., age groups, cognitively impaired, diagnostic groups) and clinical settings

B. Conduct an initial comprehensive pain assessment using valid and reliable comprehensive multidimensional pain assessment tools

C. Perform ongoing pain assessments using valid and reliable unidimensional measures

1. Intensity/severity
2. Pain relief
3. Impact of pain on function
4. Improvement in pain intensity

D. Identify patients at risk for inadequate pain assessments and effective pain management and use valid and reliable tools to assess pain in these high risk patients

1. Infants and children
2. Older adults
3. Cognitively impaired or developmentally disabled individuals
4. Individuals with a history of addictive disease or current use of illicit substances
5. Individuals who speak a language other than that spoken by the healthcare professionals
6. Patients who are unable to communicate effectively due to disease or treatment

E. Communicate verbally and record initial and ongoing pain assessments in the patient's health care record so that these assessments are accessible to all members of the pain management team

III. Management of Pain

A. Establish the goals of pain management with the patient and their family caregivers

B. Identify patient, family caregiver, system, and clinician barriers to effective pain management

C. Utilize appropriate pharmacologic interventions for pain management

1. Nonopioid analgesics
   1. Mechanisms of action
   2. Indications
   3. Onset and peak duration of action
   4. Adverse effects
   5. Interactions with other drugs
2. Opioid analgesics
   1. Types of opioid analgesics
      1. Short-acting
      2. Long-acting
   2. Mechanisms of action
   3. Indications
   4. Onset and peak duration of action
   5. Equianalgesic dosing
   6. Adverse effects
   7. Interactions with other drugs
   8. Definitions of tolerance, physical dependence, and psychological addiction
3. Adjuvants
   1. Mechanisms of action
   2. Indications
   3. Onset of action, titration, and duration of an adequate analgesic trial
   4. Adverse effects
   5. Specific drugs
      1. Anticonvulsants
      2. Antidepressants
      3. Local anesthetics
      4. Corticosteroids
      5. Other agents
   6. Interactions with other drugs
4. Methods of drug delivery
   1. Oral/enteric
   2. Parenteral (intravenous or subcutaneous, infusion devices, patient-controlled analgesia)
   3. Transdermal
   4. Transmucosal
   5. Topical
   6. Spinal (epidural or intrathecal)
   7. Regional
5. Age-specific issues
6. Disease-specific therapies (e.g., anticancer therapies)

D. Utilize appropriate nonpharmacologic interventions for pain management

1. Therapeutic use of oneself (e.g., active listening, acknowledging and valuing the individual's and/or family's perspective, being empathic)
2. Physical strategies (e.g., exercise, turning and positioning, wound support, massage, heat, cold, hydrotherapy)
3. Psychological and behavioral strategies (e.g., cognitive-behavioral strategies, stress management, patient and family education and counseling)
4. Neurostimulation (transcutaneous nerve stimulation, acupuncture, epidural stimulation, brain and spinal cord stimulation)
5. Neuroablative strategies (neurolytic nerve blocks, neurosurgical techniques)
6. Palliative radiotherapy (cancer pain)

E. Multimodal and interprofessional pain management

1. Role of each profession
2. Unique contribution of nursing
3. Patient and family members as integral members of the pain management team
4. Palliative care, including hospice, home care, and long-term care
5. Patient and family education
6. Integration and coordination of care; discharge planning
7. Health promotion to prevent persistent pain (e.g., back pain)

F. Monitoring of pain relief and improvements in function and prevention and management of adverse effects

1. Follow-up evaluation of therapeutic effects
2. Follow-up evaluation of patients' and family members' responses to the pain management plan

IV. Clinical Conditions

A. Acute pain associated with trauma, surgery, or acute medical conditions

B. Common chronic pain conditions

1. Low back pain
2. Arthritis
3. Headache
4. Cancer pain
5. Pain associated with HIV disease
6. Neuropathic pain conditions

References

American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older P. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. Aug 2009;57(8):1331-1346.

Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. Feb 2009;10(2):113-130.

Cleeland CS, Farrar JT, Hausheer FH. Assessment of cancer-related neuropathy and neuropathic pain. Oncologist. 2010;15 Suppl 2:13-18.

Cruccu G, Truini A. Neuropathic pain and its assessment. Surg. Oncol. Jan 5 2010.

Dworkin RH, O'Connor AB, Audette J, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clin Proc. Mar 2010;85(3 Suppl):S3-14.