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PRN Analgesia Leads to Expectations of Peak-and-Trough Pain

PRN Analgesia Leads to Expectations of Peak-and-Trough Pain

MADISON, Wis--An anomaly of pain management is that patients generally
report satisfaction with their pain management, even though they
are still experiencing pain. The downside of this finding is that
if patients are truly satisfied, institutions may see no need
to improve pain management programs.

With that in mind, two researchers from the University of Wisconsin,
Madison--Sandra E. Ward, PhD, RN, of the School of Nursing, and
Debra B. Gordon, MS, RN, of the Hospital and Clinic--looked for
the reasons behind these high patient satisfaction ratings.

It may be that pain severity is generally less than patients expect,
and so they are not dissatisfied. However, Dr. Ward offers a different
hypothesis. Since most patients receive analgesics "as needed,"
she says, patients come to expect, and be satisfied with, a cyclical
pattern of pain relief. Thus, expectation of a pattern of pain
relief rather than expectation of severity may be the most important
factor in patient satisfaction.

Dr. Ward notes that most analgesics are still prescribed "as
needed," even though "around-the clock" scheduling
is recommended by all pain management guidelines.

With "as needed" administration, patients experience
pain, ask for an analgesic, receive some level of pain relief,
and then wait for the pain to return. In other words, they expect,
and receive, a peak-and-trough pain cycle.

The issue was examined in a longitudinal study of patient satisfaction,
measured at baseline and 2 years after implementation of a program
to improve pain management (see table below). The protocol called
for chart reviews and outpatient assessments via questionnaires
and telephone interviews in an attempt to overcome the limitations
of the inpatient evaluations used for the baseline study.

For example, in the baseline study, nurses determined eligibility.
If a nurse did not think a patient had pain, that patient was
not asked to complete a survey. "The very patients most likely
to be dissatisfied with care may have been excluded from study,"
Dr. Ward says. In addition, despite efforts to assure confidentiality,
patients might have been hesitant to express dissatisfaction with
the people currently providing their care.

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