CRITICALCARENURSE Vol 23, No. 2, APRIL 2003 99 Julie Stanik-Hutt is an acute care nurse practitioner in the pulmonary and critical care division, department of medicine, at the Johns Hopkins University School of Medicine, Baltimore, Md. agement just as your unit has stan- dards for frequency of vital signs, intake and output, changing intra- venous tubing, positioning, and checking the crash cart. As a unit, choose a method for measuring and documenting pain and include pain assessment as a fifth vital sign to be recorded on flowsheets. Continue to monitor outcomes related to pain management. Emphasize pain prevention. It is easier to control pain when you pre- vent it from gaining a foothold in the first place. Ask physicians and nurse practitioners who admit patients to your unit to write orders for regularly scheduled analgesic doses or patient-controlled analge- sia, rather than as-needed doses, for any patient expected to have pain. This around-the-clock dosing will allow you to prevent the onset of pain. If pain is not expected but occurs anyway, begin analgesic ther- apy as soon as possible after the pain begins. Ensure that all patients have at least as-needed analgesic orders so you can immediately begin to treat pain if it occurs. Once initial pain is controlled, remember to use non- pharmacological pain-relief meth- ods such as positioning, relaxation, applications of heat and cold, and guided imagery. Many of these methods fall within nursing’s scope of practice (Table 1). Don’t give up. Many clinical nurse specialists, physical thera- pists, clinical pharmacists, and anesthesiologists have special train- ing in the management of pain. medical conditions including ischemia, infections, inflammation, edema, and distention. Immobil- ization, incisions, wounds, and the use of invasive and noninvasive medical devices can also cause pain. In addition, many commonly per- formed nursing procedures such as suctioning, turning, dressing changes, and insertion and removal of catheters may be a source of pain. Some patients are particularly at high risk for poor pain manage- ment, specifically those who are unable to vocally communicate because of intubation, those who are chemically paralyzed, and those who are unable to clearly communi- cate their needs because of sedation or an altered mental status. The very young and the very old frequently fall into these high-risk groups. Q: Quality improvement data show that patients are not very satisfied with their pain management. How can we do better? Make pain management a priority. Establish unit standards related to pain assessment and man- ProtocolsforPractice Author To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. P ain has been found to be a major stressor 1,2 and patients’ worst memory of critical care. 3 Many patients erroneously believe that pain is to be expected and endured, or are fearful that use of opioid anal- gesics will lead to addiction. Individual healthcare providers may be unaware of patients’ discomfort or of the harmful physiological effects of unrelieved pain. It is important to recognize that despite our many advances in healthcare, unrelieved pain remains a problem. The first step to solving this problem is to recognize pain. Assume that all critically ill patients are in pain or are at high risk for pain. Pain can be triggered by many Pain Management in the Critically Ill Julie A. Stanik-Hutt, RN, PhD, CCRN, ACNP