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Therapeutic Nursing Interventions

Therapeutic Nursing Interventions

Rachel Hughes
Old Dominion University
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Therapeutic Nursing Interventions

Therapeutic Nursing Interventions

In nursing school it is often taught that “pain is what the patient says it is.” This common

phrase speaks to the obligation nurses have to both assess and provide interventions based on the

patient's own rating of their pain. Pain is often referred to as the fifth vital sign. Assessing a

patient's pain is often a routine part of nursing practice. Often, adult patients are asked to rate

their pain on a scale of 1-10 and interventions are given based on their response. When caring for

orthopedic post-op patients, assessing and managing pain is key to shorter hospital stays and

quicker recovery times. The practice setting is a 24-bed orthopedic unit in a suburban area

hospital. The unit admits multiple post-op orthopedic patients every weekday. They will stay

only a short period in the hospital before being discharged home. A typical stay is either one to

two nights depending on the surgeon’s preference and the patient’s recovery status. The issue to

be discussed is how to adequately control post op pain in orthopedic patients while attempting to

use the least potent drug ordered when possible. Medications to manage post op pain is strictly

monitored and critical thinking is needed by nursing staff to navigate this issue.

Clinical Problem

Post op pain in orthopedic patients, while it is expected, is an issue for various reasons.

First, pain can be a barrier to mobility. Surgeons expect their post op patients to be up and

walking, with assistance, within hours of their surgery. Frequent ambulation, post op exercises,

and physical therapy are all key elements to a smooth recovery and quick discharge. If a patient

is in unbearable pain, they are less likely to ambulate and be mobile. Second, pain can disrupt

sleep and rest. As most already know, rest is a vital part of the recovery process. Another reason

why pain control is so important for orthopedic patients is that pain control is the first step
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Therapeutic Nursing Interventions

towards recovery. If a patient's pain is not controlled, it could cause a delay in physical therapy

and other interventions that are necessary before discharge. Longer hospital stays put the patient

at a higher risk for developing hospital acquired infections (HAPI’s). Lastly, in a hospital that is

specifically known for its excellence in orthopedic surgery and recovery, positive patient

satisfaction scores are expected and especially valued. Part of the satisfaction score criteria

includes adequate pain control.

Post op pain was chosen because it is an issue that orthopedic nurses face every day.

Each patient has their own pain tolerance and requires unique pain management strategies. As

stated above, pain management can have an effect (whether positive or negative) on other

interventions or therapies. Poorly controlled pain can also negatively affect a patient’s mental

wellbeing. Proper pain control is just one aspect of care that nurses provide in order to contribute

to competent, holistic patient care.

Examples

An example of this issue is shown in the case of a patient “Mrs. K”. Mrs. K underwent a total

right knee replacement in the afternoon. A nerve block was used intraoperatively and by the time

the night shift nurse came on the block had all but worn off. Mrs. K ambulated in the hallway as

well as up to the bathroom multiple times during the day and was feeling very little pain. As the

hours past her pain began to rise slowly. She received one 5mg dose of Roxicodone late in the

afternoon. Per her PRN orders, she could take a 5mg or 10mg dose of Roxicodone every four

hours. She also had PRN Ultram and Torodol for mild pain. At 0900 she rated her pain a 5/10.

She stated that she had a high pain tolerance and declined any pain medications at that time.

Soon Mrs. K was asleep and resting peacefully. When the nurse came in a few hours later to
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Therapeutic Nursing Interventions

assess, Mrs. K awoke and was in extreme pain. She needed to use the bathroom, but her mobility

was extremely limited due to her pain and she refused to get out of bed. She took a dose of 10mg

of Roxicodone to help relieve her pain. For the rest of the night she would only take the highest

dose of medication to manage her pain and was unfortunately unable to go back to sleep at all.

When the day shift arrived and it was time to ambulate to the chair in preparation for physical

therapy, Mrs. K was extremely anxious about getting out of bed and stated her pain was still too

high. In the end, Mrs. K’s pain was not adequately controlled, she got little to no rest, and she

had to result to the highest dose of pain medication instead of using multiple approaches.

Another example is of a patient whose pain was well managed throughout his stay and how it

affected his treatment and goals. Mr. S had a hip replacement done early in the afternoon. Upon

arrival to the ortho unit, Mr. S was stable and in minimal pain. He was able to tolerate his dinner

and even went on a short walk around the halls. Mr. S was educated on the importance of pain

control and that the keys to a successful pain control include positioning, medication, mobility,

and ice. His pain would be assessed every 4 hours throughout the night. Mr. S kept to a schedule

of pain medications every 4 hours throughout the night, his ice pack was changed often, and he

was able to get up to the bathroom twice that night. He consistently rated his pain a 4 or 5/10

throughout the night, stating that a pain rating of 4 was an acceptable level. He was started on

lower doses of pain medications, only using the high dose for breakthrough pain. Since Mr. S

pain was controlled throughout the night and into the next morning, he was able to get dressed

and up in the chair when breakfast arrived. He was able to complete his physical therapy class

and exercises. Mr. S pain remained controlled throughout the day and he completed two rounds

of physical therapy, he was discharged that evening to his home. He stated that he was grateful

for the care he received from all the staff and was satisfied with his experience.
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Therapeutic Nursing Interventions

Current Practice

The first step in pain management is assessment. It is expected that upon admission to the

orthopedic unit, a conversation is had between the nurse and the patient on what to expect as far

as controlling postoperative pain. The nurse will ask the patient on a scale of 1 to 10, what is an

acceptable pain level. This creates a measurable goal that both patient and nurse can aim for.

Every patient's answer will vary. Some will reply that a 3 or 4 is acceptable, others will choose a

0. Patient’s pain assessment should be done routinely with vital signs and at least every four

hours. It is also expected that a follow up assessment be done 1 hour after pain medication is

administered. This is to find out if the dose given was enough to relieve their pain to an

acceptable level. Another formal mechanism used for pain management is the WHO analgesic

ladder. The three-step ladder gives an outline for what type of analgesics should be used based

on a patient's pain rating (Anekar, 2020). Step 1 in the ladder is to use a non-opioid, if pain

persists, then step 2 is to use an opioid for mild to moderate pain such as codeine (2020). If a

patient's pain continues to be uncontrolled, then step three is an opioid for moderate to severe

pain such as morphine (2020). Most orthopedic surgeons at this hospital will order the following

pain medications, Tylenol q8 for mild pain, Tramadol q6 for mild pain, Toradol q6 for mild pain,

Roxicodone 5 or 10mg q4 for moderate to severe, and an IV narcotic such as dilaudid or

morphine q4 for moderate, severe or breakthrough pain.

There are multiple informal mechanisms in place to help solve the problem of pain

control. For example, experienced ortho nurses will know that certain orthopedic surgeons prefer

their patients pain medication management done a certain way. Some surgeons will have the

tylenol, tramadol, and/or toradol scheduled while others will list them all as PRN. Additionally,
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Therapeutic Nursing Interventions

some surgeons prefer their patients to only use IV narcotics if absolutely necessary while others

don’t care what is used, only that the pain is controlled. Surgeons preferences of pain

medications are not the problem, in fact it is helpful to know what their preferences are as it can

be used as a guide. However, for new orthopedic nurses, it can be a challenge to remember what

approach is preferred while keep It is difficult at times to ensure the patient is not

undermedicated or overmedicated. A study conducted shows that the unit culture plays a major

factor in nurses’ attitudes regarding pain management in their patients (Denness, 2017). If the

unit has an overbearing culture of efficiency, productivity, and good ratings, the nurse is more

likely to be focused on getting all her tasks and charting done in a timely fashion even if this

takes away face-to-face time with patients. Informally, patients' pain is usually only assessed

with vitals or when the nurse has a task to complete in the room. While hourly rounding is ideal,

more often than not it is unrealistic and seldom accomplished with consistency. Nurses will rely

on the call bells to alert them if the patient is in increased pain instead of preemptively assessing

their pain.

There can be discrepancies between the formal methods of pain control and informal

methods. When it comes to assessment, sometimes a patient's pain is not assessed as often as it

should. The biggest discrepancy is the follow up assessment that needs to be completed 1 hour

after a pain medication dose. This is typically due to a lack of time management by the nurse or

the busyness of their patient load during that shift. Another discrepancy is whether the WHO

analgesic ladder is followed. Often, some nurses will skip over the less potent analgesics and go

straight for the high dose Roxicodone or even IV opioids. Their intent is not wrong, these

medications will certainly relieve the patient’s pain and even help with sleep during night shift,

but it can often make it harder for the pain to be controlled as they are weaned off the more
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Therapeutic Nursing Interventions

potent drugs. When a patient is complaining of pain it is easy to simply administer the dose of

analgesic that will eliminate pain the fastest. Nurses can be quick to forget to use other

therapeutic techniques such as ice packs, positioning, guided imagery, or other distractions to aid

in pain relief.

Nursing Interventions

An easy intervention to add to the nursing routine that is not commonly in practice is

simply to make a habit of assessing a patient's pain at every encounter using the double/triple

check system. Ideally it is expected that nurses are rounding on their patients hourly during day

shift and every 2 hours during night shift. An article published in MedSurg Nursing linked

consistent hourly rounding with higher patient satisfaction scores (Ford, 2010). Whether the

nurse is simply placing eyes on the patient, helping them to the bathroom, passing scheduled

medications, or carrying out other orders, pain should be assessed every time. This will help the

nurse better understand if a patient’s pain is being adequately managed or if adjustments need to

be made. It also relays to the patient that their pain control is important, and their goals are a

priority to the nursing staff. The double/triple check system refers to “using a verbal scale to

assess pain, judging patients’ pain based on appearance and mobility, and consulting the

patients’ documentation” (Chatchumni et al., 2016) A study conducted in Thailand found that the

double/triple check system is an easy tool for both expert and novice nurses to utilize and

understand (2016). A nurse can compare the patient’s own rating with their own assessment as

well as the patient's chart. Using this system can often help a nurse determine if a patient pain

rating may be underrated or overrated.

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Therapeutic Nursing Interventions

An article published in the American Academy of Pain Medicine details a study

conducted using IV Ibuprofen for primary pain control in post op orthopedic patients. This

“randomized, double-blind placebo-controlled trial” included 185 orthopedic patients (Singla et

al., 2010). They were randomly selected to receive either a placebo or IV Ibuprofen both pre and

post operatively every 6 hours for pain management. Each patient had PRN morphine available

if needed. The results found that “patients receiving IV-ibuprofen used 30.9% less morphine

compared to those receiving placebo” (2010). Based on this primary research, the inclusion of IV

ibuprofen into the regular analgesic orders might help post op orthopedic patients in this setting

receive better pain management. At the least it would be another tool in the nurses’ belt - so to

speak - to relieve pain via an IV analgesic without having to resort to an opioid or narcotic. It

would also serve as an alternative if a patient were to have an allergy to certain analgesics. Often

when a post op ortho patient first starts complaining of pain it can be sudden and severe as the

nerve block wears off. In an article posted in the Canadian Journal of Pain, a study was

conducted via interviews of 10 orthopedic nurses. They were asked the question “What factors

do nurses consider when deciding whether to give the first dose of opioid to a patient who has

had a nerve block for a total knee arthroplasty?” (Denness et al., 2017). The study concluded that

3 main factors contribute to the nurses’ approach to managing pain: unit culture, nurses self-

concept, and perception of pain assessment (2017). The direct jump right into an opioid, while

sometimes necessary, can have the potential to become an issue of overmedication.

Nurses are taught and expected to provide culturally competent care to each individual

patient. For pain management, sometimes a patient’s culture has little to no effect on their

preferences or expression of pain. In other instances, it can have a great effect and ignoring

failing to determine these preferences can have an impact on their care. Patients of certain
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Therapeutic Nursing Interventions

cultures might be more stoic and can be more difficult to assess their pain level. Others might

prefer not to use strong analgesics but would prefer alternative therapies such as acupuncture,

aromatherapy, or cupping. Language can be a barrier to accurately assessing pain. There also

may be a religious aspect that would guide a patient’s expression or treatment choice for their

pain. One way to determine the best way to assess this is through a conversation or

questionnaire. An assessment questionnaire taken from an article in the American Journal of

Nursing is a great example of this (see Appendix for full questionnaire). It asks questions that

can help a nurse gain a better understanding of how that individual's pain can be best assessed

and what type of therapies would be appropriate (Narayan, 2010). A printout of a questionnaire

such as this would be a great tool to have on an orthopedic unit so that right from admission the

nursing staff and other providers can gain insight into the preferences of the patient and can

provide culturally appropriate care. Use of analgesics is often the main route for managing pain,

however complementary therapies are becoming more common and popular. An article

published in Experimental and Therapeutic Medicine attempted to gather data from previous

studies on the impact of complementary pain management therapies (Fan & Chen, 2020). They

were only able to find 5 previous studies that met their criteria. The article basically concluded

that more research is needed to study the effects of complementary therapies such as

acupuncture, massage, cupping, guided imagery, music/visual therapy, or aromatherapy

specifically for post op orthopedic patients (2020). As these might be the preference of some

patients based on their culture, practice or experiences. Use of these complementary therapies

would be a good intervention to add to the regular routine of the orthopedic unit setting.

Research would be needed to evaluate if the addition of any of these decreased the pain ratings in

postoperative patients.
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Summary

Adequate pain control is one of the first steps to recovery for postoperative orthopedic

patients. Nurses have the privilege to be on the front lines of assessment and treatment of pain.

There are many factors that surround adequate pain control for patients, just as there are many

factors that influence a nurses’ approach to treatment. Assessment, critical thinking and nursing

judgement are needed to help patients reach their goals. Complementary therapies would be a

good addition to current treatments, however more research is needed on this topic.
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References

Anekar AA, Cascella M. WHO Analgesic Ladder. [Updated 2020 May 17]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK554435/

Chatchumni, M., Namvongprom, A., Eriksson, H., & Mazaheri, M. (2016). Thai Nurses’
experiences of post-operative pain assessment and its’ influence on pain management
decisions. BMC Nursing, 15, 1–8. https://doi-org.proxy.lib.odu.edu/10.1186/s12912-016-
0136-8

Denness, K. J., Carr, E. C. J., Seneviratne, C., & Rae, J. M. (2017). Factors influencing
orthopedic nurses’ pain management: A focused ethnography. Canadian Journal of Pain,
1(1), 226–236. https://doi-org.proxy.lib.odu.edu/10.1080/24740527.2017.1403285

Fan, M., & Chen, Z. (2020). A systematic review of non-pharmacological interventions used for
pain relief after orthopedic surgical procedures. Experimental & Therapeutic Medicine,
20(5), N.PAG.

Ford, B. M. (2010). Hourly Rounding: A Strategy to Improve Patient Satisfaction Scores.

MEDSURG Nursing, 19(3), 188–191.

Narayan, M. C. (2010). Culture’s Effects on Pain Assessment and Management. AJN American
Journal of Nursing, 110(4), 38–47. https://doi-
org.proxy.lib.odu.edu/10.1097/01.NAJ.0000370157.33223.6d

Singla, N., Rock, A., & Pavliv, L. (2010). A Multi-Center, Randomized, Double-Blind Placebo-
Controlled Trial of Intravenous-Ibuprofen (IV-Ibuprofen) for Treatment of Pain in Post-
Operative Orthopedic Adult Patients. Pain Medicine, 11(8), 1284–1293. https://doi-
org.proxy.lib.odu.edu/10.1111/j.1526-4637.2010.00896.x
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Appendix
Explanatory Model Interview for Pain Assessment (Narayan, 2010)