Pain Module Top Ten Pain Safety Tips
# 1 Monitor Your Patient s Level of Consciousness and Respiratory Status Do not depend on alarms to save your patient s life. You must perform your own assessments of LOC and respiratory status! Do not delegate this responsibility to machines or clinical partners. Sedation usually precedes respiratory depression; therefore opioids should not be administered to lethargic patients unless patient is at end of life and meds are essential to maintain comfort. The combination of opioids or other respiratory depressants can cause death. Do not administer opioids with other medications e.g., sedatives, anxiolytics, benzos, which potentiate the respiratory depressant effects of opioids. PCA pumps make sure only the patient pushes the button unless Authorized Agent Controlled Analgesia (AACA) has been approved (See Tip # 7). See the Respiratory Depression Pain Module for additional information.
# 2 Know that 1.5 mg of Dilaudid(HYDROmorphone) = 10 mg of morphine Risk Control Strategies for Reducing Patient Harm with HYDROmorphone (Dilaudid) Differentiate HYDROmorphone from morphine where both products are available (use tall man lettering on labels, order sets, order entry screens, medication administration records, etc.). Limit the number of strengths available. Avoid stocking HYDROmorphone injection in prefilled syringes in the same strength as morphine prefilled syringes. Include the brand name Dilaudid on order sets, order entry screens, medication administration records, etc., to help differentiate HYDROmorphone from morphine. Employ technology to alert practitioners regarding opioids (e.g., barcode medication verification, hard stops in smart infusion pump libraries for catastrophic doses). Display equianalgesic dosing charts in patient care areas, in computerized prescriber order entry systems and pharmacy information systems, and on medication administration records. Limit the starting doses of HYDROmorphone to 0.5 mg for opioid-naïve patients and those at risk for respiratory depression (obesity, asthma, obstructive sleep apnea).
# 3 Prevent Falls Opioids may cause hypotension and lead to falls. Have patient sit at the side of the bed for a minute or two before having them stand. Make sure patient understands to call for help before getting out of bed. Make sure call light is within reach of patient. Answer call lights promptly when patients need to get up during the night or early am to urinate. Place important items close to patient so that he/she is not temped to get OOB to reach the item.
# 4 Be on alert with the Fentanyl Patch Problem: U.S. health officials are warning of deaths and dangerous side effects related to: Use of patch by opioid-naïve patients. Placing new patch and not removing old one. Changing the patch too frequently. Putting a heat source on the patch, sunbathing or having a fever which increases release of drug. Patches being stolen off of patients, from their homes and from trash receptacles.
# 4 Be on alert with the Fentanyl Patch(2) Inspect patients on admission for the presence of any medication patches. Remove existing fentanyl patch before applying new one. Apply to clean, intact skin on a flat surface such as the chest, back, flank or upper arm Apply patch to a different skin site than the most recent site. After application of the first patch, it can take 12 to 18 hours to reach the peak of pain relief, with some early pain relief occurring at four to six hours after the first administration. Change patch every 72 hours unless otherwise prescribed. Do not cut or use damaged patches as doing so can cause a dangerous increase in the release of the drug. Be aware that serious or life-threatening respiratory depression may occur at any time during the use of the patch especially during the first 24-72 hours after initiation of therapy and following increases in dose. Strategies to Reduce Risks Remove patch immediately if patient has respiratory depression. Due to its 17 hour half-life, the patient must be closely monitored for at least 24 hours after patch removed. A Narcan drip may be necessary. Check for the presence of the patch periodically during your shift. Patches can fall off or be stolen. Abruptly discontinuing opioids, including Duragesic, may cause unpleasant withdrawal symptoms. Know that if patient has a fever or if a heat source is applied to the patch, increased drug absorption will occur. Caregivers should use caution and wear gloves when handling the patch to avoid exposing oneself to the drug. Dispose of old patches by flushing them down a toilet.
# 5 Be careful! Many names, many preparations Problems: Brand names and generic names may look or sound alike. Different formulations of the same brand or generic drug. Multiple abbreviations to represent the same concept. Confusing word derivatives, abbreviations, and symbols. Unclear dose concentration/strength designations. Cluttered labeling small fonts, poor typefaces, no background contrast, overemphasis on company logos. Suggestions: Use tall man lettering on labels, order sets, order entry screens, medication administration records, etc.). Double check drugs and doses because there are several different concentrations and formulations of opioids. See examples at right. Remove duplication products from formulary. Note that IR following a drug name usually refers to immediate release and SR usually refers to sustainedrelease (e.g., long-acting, time-release, controlled-release). Very few drugs have these identifiers however. Regular or Immediate-Release Preparations Oxycodone: OxyFast (concentrated liquid), OxyIR (tablets), Roxicet (Percocet tabs & liquid), Roxycodone Morphine: Morphine sulfate solution/tabs, MSIR, Roxanol, Roxanol 100, Roxananol-T (concentrated solutions) Long-Acting preparations Should not be crushed or chewed! Oxycodone: OxyContin Oxycodone SR Morphine: MS Contin, Oramorph SR, Kadian
# 6 Administer IV Opioids Slowly Speed shock is the result of the rapid introduction of a foreign substance, usually a medication, into the circulation. Patients may experience flushing, severe headache and chest pain. In extreme cases, circulatory and cardiac disturbances, including cardiac arrest, can occur. To avoid this complication, medications for IV push administration should always be diluted to an appropriate concentration and administered over a period of time recommended by published references. Remember, IV means In Very slowly. Substance abusers may demand that the opioid be pushed quickly because they will experience a better high. All patients should be converted to PO pain meds when they are able to tolerate food. Tolerance develops very quickly with the IV route.
# 7 PCA Determine who can push the button If the patient is alert and able to push the button, only that patient should push the button. PCA by Proxy means that unauthorized individuals activate the dosing button of an analgesic infusion pump for a patient receiving Patient Controlled Analgesia. This is not permitted. The term PCA by Proxy should never be used. The proper term when someone other than the patient is authorized to push the button is Authorized Agent Controlled Analgesia (AACA). AACA can be used in a variety of patient care settings where patients are unable to self-administer analgesia; however the facility must have a policy that addresses AACA including the criteria for the use of AACA, guidelines for selection and education of the authorized agent, key prescription and monitoring recommendations during therapy, and quality improvement activities to insure safety and effectiveness. To read the ASPMN Position Paper on Authorized and Unauthorized ( PCA by Proxy ) Dosing of Analgesic Infusion Pumps, refer to the Linked files page of the course.
# 8 Heed the acetaminophen warnings Problems Unintended acetaminophen overdose is the # 1 cause of liver failure in the U.S. Why? Hundreds of products contain acetaminophen (APAP) e.g., cold medicines, pain medicines and sleep medicines. People believe that because the product is available overthe-counter that it is safe. Strategies to Reduce Risks Educate! Inform others that because of deaths, the total daily dose of acetaminophen has been lowered. One should not take more than the recommended dose because doing so will increase the risk of side effects. Avoid taking multiple medications that contain the same active ingredient Emphasize that reading labels is extremely important. Urge people who drink alcohol, take anticoagulants and/or who have liver or kidney problems not to take this drug unless approved by physician.
# 9 Use NSAIDs responsibly. Nonsteroidal anti inflammatory drugs Examples: ibuprofen, naproxen, ketoralac Problems May cause a severe allergic reaction. May cause severe stomach bleeding because NSAIDS deplete prostaglandins responsible for making the mucosal layer that protects the stomach from acid. This risk increases if a person consumes three or more alcoholic beverages every day, is age 60 or older, is taking prescription blood thinners or steroids, has a history of stomach bleeding, ulcers and/or has other bleeding problems, or is taking two or more products containing an NSAID. NSAIDs can cause kidney failure because they deplete prostaglandins needed for renal homeostasis. NSAIDs reduce the blood flow to the kidneys and can aggravate hypertension. Most NSAIDs affect platelet aggregation thereby the potential for bleeding. Taking more than the recommended dose and/or using for longer than directed increases side-effects risk. People have the mistaken belief that these products are totally safe because they can be purchased without a prescription.
# 9 Use NSAIDs responsibly (2) Strategies to Reduce Risks Staff & Patient/Family Education Patients who are pregnant or have asthma, high blood pressure, heart disease, liver cirrhosis, hx stomach ulcers, or kidney disease and or are taking chemo or diuretic, must consult with their doctor before taking an NSAID. Note: NSAIDs are contraindicated in the 3 rd trimester of pregnancy. Avoid taking multiple medications that contain the same active ingredient. Read the label! Many products contain a NSAID. One should not take more than the recommended dose because doing so will increase the risk of side effects. Take the lowest, effective dose unless otherwise advised. Consult a physician if med is needed for longer than a week.
#10 Use your brain! If something doesn t seem right, it probably isn t. Use your common sense, good judgment, and critical thinking skills. Make suggestions to improve safety.