Archive for the ‘pain control’ Category


The Power of Imagination: Helping Kids with Sickle Cell Disease to Cope with Pain

April 2, 2014

By Sylvia Foley, AJN senior editor

Many people with sickle cell disease suffer from both acute and chronic pain, which can be severe. Although the exact mechanism isn’t known, the pain is believed to result when sickled erythrocytes occlude the vascular beds, causing tissue ischemia. Such pain, which often begins in early childhood, arises unpredictably. Although some pain crises may require ED visits, hos­pitalization, opioid treatment, or a combination of these, most are managed at home. Yet little is known about at-home pain management in people with sickle cell disease, especially children.

Table 2. Changes in Self-Efficacy, Imaging Ability, and Pain Perception in School-Age Children After Guided Imagery Training

Table 2. Changes in Self-Efficacy, Imaging Ability, and Pain Perception in School-Age Children After Guided Imagery Training

Cognitive behavioral therapy (CBT) has shown promise in helping patients with other chronic illnesses to cope with pain. Cassandra Elaine Dobson and Mary Woods Byrne decided to test guided imagery, a form of CBT, among children enrolled at one sickle cell treatment clinic in New York City. They report on their findings in this month’s original research CE, “Using Guided Imagery to Manage Pain in Young Children with Sickle Cell Disease.” The abstract below offers a quick overview; if you click the image above, you’ll see an enlarged view of one table showing key results.

Objectives: The purposes of this study were to test the effects of guided imagery training on school-age children who had been diagnosed with sickle cell disease, and to describe changes in pain perception, analgesic use, self-efficacy, and imaging ability from the month before to the month after training.
Methods: A quasi-experimental interrupted time-series design was used with a purposive sample of 20 children ages six to 11 years enrolled from one sickle cell disease clinic, where they had been treated for at least one year. Children completed pain diaries daily for two months, and investigators measured baseline and end-of-treatment imaging ability and self-efficacy.
Results: After training in the use of guided imagery, participants reported significant increases in self-efficacy and reductions in pain intensity, and use of analgesics decreased as well.
Conclusions: Guided imagery is an effective technique for managing and limiting sickle cell disease–related pain in a pediatric population.

The technique was easily taught in training sessions lasting 15 to 45 minutes, with no child needing more than one session. The authors concluded that “the use of guided imagery in this population assumes that a child’s imagination has the potential to affect health, and our findings support that assumption.” Because this was a small study, they urged further large-scale clinical trials.

To learn more, read the article, which is free online. As always—and especially if you have experience caring for children with sickle cell disease—we welcome your comments.

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Posttonsillectomy Pain in Children: Safer, More Effective Treatment Strategies

February 26, 2014

By Shawn Kennedy, editor-in-chief


One of the CE articles in the February issue is “Posttonsillectomy Pain in Children.” It might seem like a no-brainer—ice-collar, cold fluids, and acetaminophen with codeine, right? WRONG. As the article indicates, there’s a lot more to managing this stubborn, sometimes severe pain.

For one thing, there’s been a big reversal in choice of pain medication. Acetaminophen with codeine, long a mainstay in managing children’s pain, is no longer recommended—in fact, the FDA issued a black box warning last year saying that codeine should not be used because its metabolism rate in one subset of children can cause excessive sedation. Reports of three deaths and a case of nonfatal respiratory depression in children who received appropriate doses prompted the warning. Read the rest of this entry ?


AJN’s February Issue: New Nurses, Children’s Posttonsillectomy Pain, Medication Errors, More

January 31, 2014


AJN’s February issue is now available on our Web site. Here’s a selection of what not to miss, including two continuing education (CE) articles, which you can access for free.

With high hospital turnover rates, keeping newly licensed RNs (NLRNs) continues to be a priority for hospitals. This month’s original research article, “Changing Trends in Newly Licensed RNs,” found that new nurses considered themselves to have fewer job opportunities and to be less likely to work in hospitals and more likely to have a second job than new nurses who were surveyed six years earlier. Earn 2.5 CE credits by reading this article and taking the test that follows.

Tonsillectomy is effective at treating a variety of pediatric disorders, such as sleep apnea and frequent throat infection. But it often results in prolonged, moderate-to-severe pain. “Posttonsillectomy Pain in Children” reviews the causes of posttonsillectomy pain, the efficacy of various treatment interventions, and the recommendations for patient and family teaching regarding pain management. Earn 2.3 CE credits by reading this article and taking the test that follows. If you’re reading AJN on your iPad, you can listen to a podcast interview with the author by tapping on the podcast icon on the first page. The podcast is also available on our Web site.

According to an Institute of Medicine report, at least 1.5 million preventable medication-related adverse events occur in the U.S every year. This month’s Cultivating Quality article, “The Sterile Cockpit: An Effective Approach to Reducing Medication Errors” (abstract only without a subscription or article purchase), describes how nurses on one hospital unit used a commercial aviation industry innovation in an attempt to reduce medication errors. Read the rest of this entry ?


Magnet Hospitals: It’s About the Process, Not the Designation

January 23, 2012

By Shawn Kennedy, AJN editor-in-chief

When I had a recent medical emergency, I went to the local community hospital near my home in northern New Jersey. I had been there before for outpatient testing or to the ER with a child and found the care attentive and efficient and the staff friendly and professional. Besides, it was a Magnet-designated hospital, so I was confident that I’d receive good care.

The ancillary staff was wonderful, but I found myself disappointed with the nurses on the acute med/surg unit where I was located. There was no rounding that I was aware of, and they seemed to only show up when it was time to administer meds. Only a few nurses introduced themselves, and only two nurses over three days really engaged me in any conversation. Nurses seemed to respond to call lights only for those patients to whom they were assigned. The unit clerk who promptly answered the call light intercom would say, “I’ll let your nurse know and she’ll be in soon”—when I asked for pain medication, she told me “your nurse is giving report; I’ll let her know when she’s finished.” I waited uncomfortably for more than half an hour.

There were whiteboards, but often the information—especially regarding the date and the name of the nurse—was unchanged from day to day and no longer accurate. (This was annoying, in that they kept asking me what date it was and I kept getting it wrong!)

The worst, though, was the noise level at night. I’ve worked nights, and I know it’s easy to forget to keep conversations hushed. But this unit was a good example of those that are as “noisy as chainsaws” (see our recent post on this). I was two doors down from the nurses’ station and I could hear every conversation, people singing holiday carols, detailed discussions of patients (forget HIPAA!). Requests that they reduce the noise made no difference. One night, I learned every detail about one nurse’s vacation plans while she and a colleague spoke in normal, conversational tones, occasionally laughing, while providing care to the elderly woman in the bed next to me at 2:30 am.

When I asked if they could speak a bit more quietly, one of the nurses angrily pulled back the curtain and told me that I had to understand that they needed to take care of the woman and would be done shortly. She then resumed talking about her vacation. I barely slept at all the three days I was there. It was exhausting, and I was happy to get home.

A few days later, I was admitted to a large teaching medical center in Manhattan, where I stayed for 10 days. The contrast was startling. The ICU nurses were incredibly attentive and supportive; they made me and my family feel that I was safe and in excellent hands. On the med/surg unit, the nurse manager introduced herself when I arrived. My assigned nurse for each shift would introduce herself and ask me if I needed anything; she came by frequently, even if only to poke her head in the room and say, “Everything OK?” Nursing assistants likewise introduced themselves and would inquire if I needed anything. Read the rest of this entry ?


Toward a Less Painful Death: ICD Deactivation at End of Life

October 14, 2011

By Sylvia Foley, AJN senior editor

A few years ago, in a letter to the editor of another journal, an NP described how one of her patients, a man on home hospice care, had suffered 33 shocks as he lay dying in his wife’s arms. The source of those shocks, his implantable cardioverter-defibrillator (ICD), reportedly “got so hot that it burned through his skin.” The device that had been implanted to save his life caused this man and his wife great distress in his final hours. Device deactivation at the end of life is an option; but in this case, apparently, it had never been discussed.

Stories like this one helped to inspire the research reported in this month’s CE feature, “Deactivation of ICDs at the End of Life: A Systematic Review of Clinical Practices and Provider and Patient Attitudes,” by James Russo.

Lightning by snowpeak, via Flickr

ICDs, standard treatment for people at risk for life-threatening cardiac arrhythmias, work to restore normal rhythm by delivering a high-energy, painful electrical shock. The devices are so effective that people with ICDs often die from causes other than heart disease. But once a person with an ICD begins actively dying, as in the case above, the device may cause needless pain and prolonged suffering. So it’s essential for providers and patients to talk about the possibility of deactivation, well in advance of such crises.

Russo, the coordinator of the pacemaker clinic at the Department of Veterans Affairs Medical Center in New York City, wanted to better understand why providers and patients weren’t discussing this possibility and to find ways to promote more timely discussions. Read the rest of this entry ?


The Five Most Popular Articles at AJN

July 18, 2011

Amanda Geer, AJN administrative coordinator—We look at the statistical views and visits of users at AJN‘s home page to determine our most viewed articles, how many visitors listen to our podcasts, what day of the week we get the most traffic, and a number of other categories to make sure we keep up to date on what matters to our readers. We also look at what our users search for. Some of the most common keyword(s)/phrases are evidence-based practice, research, diabetes, cancer, and stroke. We also look at our most popular articles. For the last few months, the following five articles have dominated our top 10 chart (in an upcoming post, we’ll look at the most popular articles on this blog):


When They Can’t Tell You About the Hurt: Assessing Pain in People with Intellectual or Developmental Disabilities

December 14, 2010

By Sylvia Foley, AJN senior editor

Coffee Time (detail) / by S.M. Drawing used with permission of family.

When S.M., a 47-year-old resident at a facility for people with intellectual or developmental disabilities, started hitting himself in the left eye, his caregivers weren’t sure why. S.M., whose developmental quotient is equivalent to that of a two- or three-year-old, couldn’t tell them. Some thought he was frustrated at not being allowed to drink as much coffee as he wanted; others thought a recent decrease in his medication—quetiapine (Seroquel)—might be a factor. But a chart review revealed that both his father and brother had a history of cluster headaches. Was S.M.’s behavior an indicator of headache pain? How could clinicians best assess him?

In this month’s CE feature, authors Kathy Baldridge and Frank Andrasik provide an overview of pain assessment in people with intellectual or developmental disabilities, summarize the relevant research, and discuss the applicability of the American Society for Pain Management Nursing practice guidelines for assessing pain in nonverbal patients. The guidelines describe various behavioral pain assessment tools, some of which might be useful with S.M. and others like him. Other assessment methods include

a search for pathologic conditions or other problems or procedures known to cause pain; the observation of behaviors that might indicate pain; and the use of proxy reports (also called surrogate reports) by people who know the person best, whether family caregivers or professionals.

S.M. was encouraged to draw himself and what the “hurt” felt like; two of these drawings illustrate the article (a detail from one is shown above). The authors also profile one facility’s approach to pain assessment of its patients. And they discuss collaborative team solutions with AJN interim editor-in-chief Shawn Kennedy in this podcast interview.

Have you  faced the challenge of assessing pain in patients like S.M.?

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Maybe Palliative Care SHOULD Go to the Dogs

September 13, 2010

By Shawn Kennedy, MA, RN, AJN interim editor-in-chief

Sam in his hospice quilt

Last week, we took Sam, our ailing 14-year-old Labrador Retriever, on what became his last trip to the vet. Sam had been diagnosed with bone cancer in February after we noticed the right half of his head enlarging. Because of where the tumor was, it was inoperable. We felt that at his age chemotherapy wasn’t a realistic option, and we didn’t want the last few months of his life to be bad ones.

His veterinarian, who’d treated Sam since his puppy days, supported the decision, saying she would make the same choice for her dog. And so we spent the last few months adjusting doses of steroids and pain meds to enable him to live as normally as possible. For Sam, “normal” was being able to greet all comers to our door, to be the leader on his walks, to be smack in the middle of where his family was. (If people were in the basement and on the second floor, he would lie equidistant from where everyone in the house was. If we were in the same room, he sat, front legs crossed in his “elegant dog” pose, where he could see us all.)

So last month, when we saw that he would no longer get up to greet visitors or his family; was reluctant to go on walks (he did, but with a great sigh and lots of panting after even the shortest walk); and, finally, stayed in a corner of the back hallway, no longer making the effort to be part of the family, we realized Sam’s quality of life was diminishing. It became abundantly clear when he wouldn’t eat his normal food or even cookies, his favorite, that Sam was suffering.

When we took him to the vet, secretly my husband and I were hoping the vet would give us a different regimen that would restore Sam to the dog of a few months ago. But the vet pointed out that, at most, any measures we could take would only gain us another few weeks—and there was no guarantee of even that. She also asked us about our motives. Clearly, prolonging Sam’s life meant prolonging his discomfort. It became obvious that “keeping him going” would be only for our benefit and not for Sam’s. And so we decided it was time to say goodbye.

The technician brought out a quilt for Sam to lie on, and we fed him cookies and petted him and talked to him while the vet gave him a large dose, an overdose, of sedative. It was all very peaceful, and we were grateful for the support and guidance of the vet and her staff in helping us let Sam go.

I couldn’t help contrasting Sam’s death with Theresa Brown’s story of her oncology patient in her recent opinion piece, “A Dying Patient is Not a Battlefield.” Yes, I know Sam was a dog, and I’m not advocating euthanasia, but I am advocating that people deserve a good death and shouldn’t be cajoled into decisions for the benefit of others.

I worked as a chemotherapy nurse during graduate school, and I remember discussions with patients who made treatment decisions they really didn’t want to make but made anyway—because they didn’t “get” that things were not going to get much better, or they didn’t want to let their families down or, worse, felt they “owed it” to the physicians and staff who were working hard to keep them alive. What messages are we giving to patients and to families if they feel they owe us anything? What happened to what we learned from the work of Cicely Saunders or Florence Wald in creating hospice care? What happened to those of us who are charged to be advocates for our patients? Brown’s piece is a reminder to make sure our patients have the right information to make informed decisions, and then to listen and support their decisions.

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Notes from the Nursosphere, Plus a Great Palliative Care Discussion

April 9, 2010

First: Twitter delivered a treasure this morning, from @abbrody (Ab Brody, an RN — and PhD — in San Francisco):

Wow,just wow! RT @DianeEMeier Pallimed:Post from husband of Dr. Pardi Do not miss this discussion! #hpm #palliative

What’s the big deal? Well, the New York Times ran a piece this week about Dr. Pardi, a palliative care doctor who fought it out against her cancer up to the end. The article was fascinating, disturbing, powerful, and we posted about it—and a related article we’d run in AJN not long ago—at this blog a few days ago.

What Brody’s Twitter message alerts us to today is an ensuing post and discussion at the palliative care blog Pallimed. The discussion has none of the harshness of tone one sometimes gets on Web discussions. Many of the people in the palliative care community seem to know each other, which always helps keep things civil (you don’t typically insult people you’re likely to meet in person).

A big question in the discussion is whether the Times story oversimplified the issues, creating an “either/or”  scenario out of something much more complex, and in the process made palliative care look like it’s all about convincing people to give up and die. But it really gets interesting when Dr. Pardi’s husband pops up in the comments section and attempts to clarify some of the questions and misperceptions raised by the Times story. You’ll have to scroll down below the Pallimed post to find it, but it’s well worth it.

Also this week, on the nursosphere: JParadisi has a thoughtful post that points out a certain jarring feeling she sometimes experiences when shifting between her work as a nurse and her work as an artist. Read it for the great list of things she did this week. And Change of Shift, the “nursing blog carnival,” went up on April Fool’s Day at the ambitiously named Millionaire Nurse Blog. It’s always worth a read.

Many blogs by nurses flower quickly and fade fast (several of the blogs on our blogroll have been silent for quite some time). Others pop up to take their places. Some endure, grow, prosper. Ecologists may soon undertake a study, but in the meantime A Nurse Practitioner’s View draws our attention to a few new or newish blogs by NPs and PAs. May they prosper. –Jacob Molyneux, senior editor/blog editor

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Some Observations In Response to the NY Times Article on Palliative Sedation

January 7, 2010

By Judy Schwarz, PhD, RN*  

The NY Times article of 12/26/09 that described use of palliative sedation in hospice institutional settings provided helpful and clinically accurate informative—for the most part. These few notes are meant to address those issues raised by the article that may unduly alarm dying patients, their families, and their clinical caregivers.

There is a consensus among palliative care clinicians that “palliative sedation to unconsciousness” (a descriptive term that eliminates some of the visceral reaction elicited by use of the term “terminal sedation”) is an intervention used only when other therapies that do not compromise patient consciousness have failed and the patient continues to experience intolerable and intractable suffering that cannot otherwise be relieved.

2) Use of palliative sedation to unconsciousness has NOT been shown to cause a hastened death. Research showing that patients at the very end of life who receive palliative sedation do not die more quickly than patients who are not sedated has been published in such peer-reviewed journals as Annals of Oncology, Journal of Palliative Medicine, Journal of Pain and Symptom Management, Archives of Internal Medicine, and Palliative Medicine. (In response to the Times article, the National Hospice and Palliative Care Organization has made available a bibliography of these articles.)

This intervention is generally only provided when patients are “imminently” dying (a condition the recognition of which requires experience and clinical judgment) and is distinct from “respite sedation,” which is used when clinicians plan to awaken a patient from the unconscious state to determine if their suffering has been relieved. It would be clinically inappropriate to awaken a dying patient whose suffering was deemed intractable and intolerable to them.

3) The Times article mentions an article published by Billings and Block in 1996 in the Journal of Palliative Care (vol 12, pp 21-30), an article intended to highlight the inappropriate use of morphine drips that were ordered by some physicians with the intention of causing a merciful death. These two very skilled and experienced palliative care clinicians were attempting to highlight the difference between the appropriate use of palliative sedation, in which the infusion of opiate and sedative is titrated and set to relieve suffering and cause unconsciousness, and “hanging a morphine drip,” in which the infusion rate is continuously increased in order to cause obtundation, respiratory depression, and death.

4) Finally, the one issue that was not addressed in this generally excellent article was the difficulties faced by dying, suffering patients whose symptoms merit use of palliative sedation to unconsciousness but who want to be able to die at home. In my experience, most hospices are unable or unwilling to provide this intervention to suffering patients who want to die comfortably and peacefully in their own homes.

*Schwarz, the author of “Stopping Eating and Drinking,” published in the September 2009 issue of AJN, is a regional clinical coordinator at Compassion and Choices, a nonprofit end-of-life advocacy and consultative organization.

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