Sujet / Subject: MEDICATION OPIOIDS

Transcription

1 1. POLICY/STANDARD STATEMENT Pain experience is a complex phenomenon and may include acute, chronic pain or cancer pain. Pain is subjective and highly individualized (Perry & Potter, 2010). The patient is the only one who knows whether pain is present and what the experience is like (McCafferey and Pasero, 1999). Patients have a right to the best pain relief possible (Watt-Watson et al., 1999), as pain relief may be a contributing factor in achieving better quality of care and post-operative recuperation. St. Mary's Hospital Center (SMHC) has a responsibility to establish supports to facilitate this outcome. The practice of appropriate pain management includes: the knowledge of pain and clinical assessment, knowledge of standards of care and accountability for pain management. Often times, Opioids will be introduced as a strategy for effective moderate to severe pain management (Perry & Potter, 2010). Safe administration of Opioids must be observed by using SMHC designed tools for assessment, monitoring and documentation sheet in order to anticipate or prevent adverse effects of Opioids usage and achieve optimal pain management. Patients at risk of respiratory depression must be identified. ALERT: Patients excluded: Patients on established Opioids analgesic for seven (7) days or more. 2. PURPOSE To maximize the patient's experience of post-operative comfort or relief from chronic or cancer pain and to minimize the patient's experience of side effects based on the best practice guidelines for Opioids administration. 3. SCOPE Registered Nurses (RN); Graduate Pending Licence (GPL); Licensed Practical Nurses (LPN) (except for IV Opioids); Nursing Externs under supervision of a RN (except for IV Opioids). 4. EQUIPMENT / MATERIAL REQUIRED Corresponding Opioids Observation and Documentation Sheet; Compendium of Pharmaceuticals and Specialties (CPS); Identification (ID) Bracelet; Narcotics Keys or ID Card. Révision Revision Page 1 de/of 10

2 5. PROCEDURE 5.1 Knowledge of Pain Prior to Opioids Administration: The healthcare professional must perform an assessment of the patient's pain experience by using the Pain Characteristics: PQRSTU and using the SMHC Pain Assessment Ruler. Pain Characteristics: PQRSTU Precipitating / P Provocative Factors Q Quality What makes your pain better or worse? e.g. sharp, stabbing, gnawing, aching, burning, etc. R Region/Radiation Where the pain is localized. S Severity Refer to the SMHC Pain Assessment Ruler to accept the patient's subjective pain experience. T Timing and Duration Ask if the pain is constant or intermittent. U How the pain is affecting you The ability to perform the ADL's is reduced by the pain or the pain is amplified by environmental stimuli, e.g. bright lights, loud noises, temperature. SMHC Pain Assessment Ruler: SMHC Adaptation of Wong-Baker Pain Rating Scale Révision Revision Page 2 de/of 10

3 ALERT: If unable to get verbal feedback, use other cues (patient's behaviour and facial expressions). The healthcare professional must be knowledgeable of: o The most likely potential sources of pain (e.g. neurological, muscular, skeletal, visceral). o The pharmacological interventions of Opioids available at SMHC. o The co-analgesic methods (e.g. NSAID) and the CNS Depressants frequently administered (refer to the graph below). o The non-pharmacologic strategies for pain management. Nonpharmacological Strategies for Pain Management Relaxation and Power of the Mind Spirituality and Reflection Self-comfort Enhancing spirituality Music relaxation Humor medicine Autogenics training Set aside time to focus on what is Breathing exercises Share your stress Music relaxation Journaling Visual imagery Put Your Body to Work Exercise Pacing Energy conservation Body mechanics What to Do When Your Pain Flares Cultivating endorphins Cold and hot packs Ball therapy Contrast baths Hand massage Révision Revision Page 3 de/of 10

4 5.2 Knowledge of Clinical Assessment Prior to Opioids Administration: The healthcare professional must be knowledgeable about the patients more at risk of respiratory depression. The healthcare professional must perform a Baseline Assessment following: o The Parameters. o The Sedation Scale. T he Parameters: Révision Revision Page 4 de/of 10

5 T he Sedation Scale: If the sedation status is greater than or equal to 2 on scale, then proceed with: The Glasgow Coma Scale (Refer to the corresponding units Opioids Observation and Recording Sheets. 5.3 Knowledge of Standards of Care and Accountability for Pain Management When Administering Opioids: Every time an Opioid is administered to an Opioid naïve patient or a patient at risk of respiratory depression, the healthcare professional must be knowledgeable about: o The method of administration and peak action. o The surveillance. T he method of administration and peak action: Révision Revision Page 5 de/of 10

6 T he surveillance: The healthcare professional must observe for side-effects such as nausea, vomiting, pruritus, constipation. The healthcare professional must be vigilant in detecting situations requiring immediate interventions such as somnolent state defined as a level 2 or 3 on the sedation scale or a respiratory distress episode and must intervene rapidly as follows (Refer to Annex II): Révision Revision Page 6 de/of 10

7 The healthcare professional must document the Opioid administration on the MAR and on the appropriate Opioids Narcotics Sheet. The healthcare professional must evaluate the effectiveness of the strategies and the nursing interventions. The healthcare professional must advocate for the patient's effective pain relief and notify the physician if a change in the treatment plan is required. The healthcare professional must document in the Progress Notes: The pain assessment, the interventions and the patient's response. The healthcare professional must provide information to the patient and their family about pain assessment and the measures used to treat it (pharmacologically and non-pharmacologically, encourage to report it and to observe for side effects (e.g. somnolent, respiratory distress, nausea, constipation). ALERT: All patients receiving intravenous (IV) Opioid and sedatives, must have an IV main line in case of an emergency. Guidelines for patients on infusion devices (PCA pumps, Epidural), refer to the Policy and Procedure Epidural Analgesia Infusion (Continuous) for Surgical Patients, Section II, No. 1.21A. 6. DOCUMENTATION The administration of Opioids must be recorded on: The MAR or the corresponding unit medication recording system; The appropriate Narcotic Sheet; The corresponding unit Opioids Surveillance and Documentation Sheet. 10:00 The patient stated having a throbbing pain to LT knee rated 5/10 on the pain assessment ruler. Medicated with morphine 5 mg S/C. 10:30 The patient stated pain to LT knee 2/10, and is now able to ambulate to chair. 7. CONSENT 8. ENCLOSURE(S) Annex 1: OPIOID Analgesics Comparative Pharmacokinetics. Annex 2: OPIOID Analgesics Adverse Reactions * / Side Effects. Révision Revision Page 7 de/of 10

8 9. SPECIFIC EDUCATION REQUIREMENT 10. OTHER USEFUL INFORMATION 11. REFERENCE(S) Canadian Pharmacist Association (2010). CP S: Compendium of Pharmaceuticals and Specialties, Ottawa: Canadian Pharmacists Association. Durand S. [et al.], Surveillance clinique des clients qui reçoivent des médications ayant un effet nd dépressif sur le system nerveux central, 2 ed., Westmount, Ordre des infirmières et infirmiers du Québec, Hamel, P. [et al.], L'Analgésique à l'urgence: Lignes directrices du Collèges des médecins du Québec. Montréal, Publication du Collèges des médecins du Québec, McCaffery, M. & Pasero, C. (1999). Pain: Clinical Manual, 2 ed., St. Louis, Mosby. Pasero, C. & McCaffery, M. (2002). Monitoring Sedation: It s the Key Respiratory Depression. American Journal of Nursing, 102(2), nd to Preventing Opioid-Induced Potter, P. et Perry A. (2010). Clinical Nursing Skills and Techniques, 7 ed., St. Louis, Mosby Wong, D.L. & Baker, C.M. Pain Rating Scale Taken from Hockenberry, M.J. & other. Wong s th Nursing Care of Infants and Children, 7 ed., St. Louis, Mosby, Watt-Watson, J. & al. (1999). Ca nadian Pain Society Position Statement on Pain Relief. Pain Research Management, 4, th 12. TITLE OF THE PERSON RESPONSIBLE FOR THE POLICY Vice-President, Operations and Nursing. 13. DATE OF NEXT REVISION Révision Revision Page 8 de/of 10

9 ANNEX I OPIOID ANALGESICS COMPARATIVE PHARMACOKINETICS ACTIVITY DRUG HALF-LIFE (h) USUAL DOSAGE RANGE ONSET (min) PEAK (min) DURATION (h) P0: CODEINE mg q h IM/SC: IM: mcg q 1-2 h FENTANYL IV: immediate (severe pain) Transdermal: gradual 24 h mcg/h and + q 72 h PO: mg q h HYDROMORPHONE IM/SC: mg q h IV: mg q h PO: mg q 3-4 h MEPERIDINE IM/SC: mg q 3-4 h IV: immediate mg q 3-4 h METHADONE PO: (acute) mg q 6-8 h > 8 (chronic) (chronic severe pain) PO (liquid): mg q 3-4 h PO (reg tablet): mg q 3-4 h MORPHINE PO (LA tablet): h mg & + q 12 h 2.4 IM: mg q 3-4 h SC: mg q 3-4 h IV: immediate mg q 3-4 h OXYCODONE PO: mg q h PENTAZOCINE PO: IM/SC: IV: mg q 3-4 h mg q 3-4 h 30 mg q 3-4 h Prepared by: Ngoc-My VO Thi, Pharmacist at SMHC January 10, 2005 Révision Revision Page 9 de/of 10

10 IV 13 ANNEX II OPIOID ANALGESICS ADVERSE REACTIONS * / SIDE EFFECTS CNS CV Respiratory GI GU Skin Local Sedation, drowsiness, dizziness, confusion, euphoria, dysphoria, weakness, headache, agitation, nervousness, hallucinations, visual disturbances, convulsions, myoclonus, delirium, insomnia, coma. Palpitations, tachycardia, bradycardia, faintness, orthostatic hypotension, hypertension, cardiac arrest. Respiratory depression, respiratory arrest. Nausea, vomiting, constipation, dry mouth, biliary tract spasm, cramps, anorexia, ileus. Urinary retention, antidiuretic effect. Pruritus, sweating, flushing or warmness of the face, neck and upper thorax. Phlebitis and pain at injection site, local tissue irritation and indurations following repeated SC injections. * See bold characters for adverse reactions. Prepared by: Ngoc-My VO Thi, Pharmacist at SMHC January 10, 2005 Révision Revision Page 10 de/of 10