Nurses Assessing and Managing Sickle Cell Disease Pain

Introduction

Sickle cell disease (SCD) entails a group of genetic diseases that result in hemolysis as a result of polymerization of hemoglobin when it is deoxygenated. This disease has a low life expectancy due to associated complications, chronic and episodic pain and reduced quality of life. However, pain is the main health issue that prevails in the emergency department. Despite the fact that there has been improvements in the management of this disease as indicated by results from the US as noted by Haywood Jr. et al. (2009), there is still evidence showing varied morbidity and mortality rates in the country. Hence, it is imperative to evaluate how nurses assess and manage pain as the main occurring comorbid in the emergency department for patients with sickle cell disease.

Literature Review

Research studies indicate that nurses, apparently, use their subjective judgment in the management of pain in SCD. According to Haywood Jr. et al. (2009), therapies for managing SCD are underutilized due to barriers such as negative attitudes by the health provider staff and lack of provider knowledge. Nurses will not address pain issues in SCD seriously because they presume that the patient is not genuine and he or she may be overly reliant on drugs. This results in underutilization of pain management therapies; hence the high morbidity and mortality rates in some areas of the US. Nurses, therefore, should be educated and trained on objective assessment and management strategies to help the patients.

Provider-targeted interventions have been shown to yield positive results compared to patient-targeted interventions. In the review by Haywood Jr. et al. (2009), an improvement in the clinical protocol and structure and organization of care, and use of audit-feedback strategy were found to have a positive association with pain assessment and management of SCD patients with vaso-occlusive crisis. Auditing and provision of feedback to providers enabled the providers to learn of areas that needed improvement. It is important that tools specific to pain management in the case of vaso-occlusive crisis (VOC) are developed. Health workers are not aware of the pain that SCD patients experience; hence, the health workers tend to assume that these patients are not serious or that they are drug addicts. According to Frei-Jones, Baxter, Rogers & Buchanan (2008), the use of self-report pain instruments after an initial administration of IV morphine dose was shown to be effective in managing pain compared to use of morphine alone. Van Beers et al. (2007) study gives a rationale for this by indicating that morphine use is inversely related to pain scores.

In a study by Hafner, Martinovich & Artz (2012), patients who had few and frequent visits to the emergency department experienced decreased pain scores during discharge. The study by Mitchell et al. (2007) can explain this since it indicates that negative thinking is associated with frequent hospital visits; hence, the more reason why nurses should have a friendly attitude towards the patients. Standard nurse-initiated analgesic protocols for emergency departments were associated with reduced arrival to pain, increased use of hydromorphone and reduced use of morphine sulfate. Assessment tools to allow timely detection and management of SCD pain are thus an essential requirement (Mousa, et al. 2010, p. 373). Much as it is being said that the healthcare provider staff lack knowledge, Solomon (2008) notes that the medical textbooks themselves are not adequately insightful. Despite the existence of available guidelines on the use of opioid in the management of VOC in SCD, only four out of 19 reviewed medical textbooks contain information about treatment that is commensurate with these available guidelines (Solomon, 2008, p. 997).

Controversies

Adherence to treatment has always been believed to be an imperative factor in the successful treatment of any disease. However, the study by Haywood Jr. et al. (2009) seems to counter indicate this by showing no relationship between patients’ adherence to treatment and utilization of treatment. A patient with SCD is thought to be severely ill and in a lot of pain, however, nurses think otherwise as indicated by Haywood Jr. et al. (2009) and Pack-Mabien, Herbert & Haynes Jr. (2001). These studies indicate that nurses do not perceive the pain expressed by SCD patients seriously. Contrary to the high held belief by health workers, including nurses, that SCD patients are addicted to opioid in the management of pain, Pack-Mabien, Herbert & Haynes Jr. (2001, p. 191) indicate that data shows the converse of this. The use of pain scores has been shown to be effective in reducing pain during discharge unlike when the nurses merely ask the patient to report their pain. On a different note, however, self-reported instruments have been indicated to be effective in early detection of pain, according to Frei-Jones, Baxter, Rogers & Buchanan (2008, p. 285). Studies indicate that patients fail to report their pain due to the attitudes and demeanor portrayed by the nurses. Information on pain management in SCD should be available and easily accessible, yet this is not the case. Hence, it is illogical to expect nurses to be adequately informed because they lack the resources for learning (Solomon, 2008, p. 1000).

Conclusion

It is inarguably true that VOC is the main cormobid for patients with SCD. Coupled with improved medical interventions, there are available guidelines to help in the management of this pain. Unfortunately, there is a void in the implementation of the available medical therapies and improvement is required on the part of the healthcare providers. These providers require training and revised clinical protocols to aid in effective assessment and management of VOC.

Literature Review Template.

Citation Study Design Type
Framework/Theory
Setting Key Concepts/Variables Findings Hierarchy of Evidence Level
Frei-Jones, M., Baxter, A., Rogers, Z., & Buchanan, G. (2008). Vaso-occlusive episodes in older children with sickle cell disease: Emergency department management and pain assessment. J Pediatr, 152, 281-285. Type of study: Retrospective cross-sectional review
Design type: Mixed method
Children’s Medical Center Dallas ED Review of clinical records to describe management of VOC in children between 8 and19 years and identify factors associated with disposition and return to the Emergency department.
Independent variable: IV morphine initial administration
Dependent variable: Admission
Controlled variables: factors other than VOC that could be associated with admission
Self-report scores after administration of IV morphine are effective in determining a subsequent admission due to VOC, help in early and timely control of analgesia by patients and prevent premature discharge. Level V
Van Beers, E., Van Tujin, C., Nieuwkerk, P., Friederich, P., Vranken, J., & Biemond, B. (2007). Patient-controlled analgesia versus continuous infusion of morphine during vaso-occlusive crisis in sickle cell disease, a randomized controlled trial. American Journal of Hematology, 82, 955-960. Type of study: randomized controlled trial
Design: Prospective
Academical Medical Center, Amsterdam. A randomized clinical trial that seeks to establish the efficacy of patient-controlled analgesia in the management o VOC
Independent variable: Patient-controlled analgesia
Dependent variable: VOC
Controlled variable: intravenous morphine
The study indicated that morphine consumption was lower when patients had control over their pain compared to continuous infusion of intravenous morphine, yet PCA morphine had greater benefits. Level II
Mousa, S., Al Momen, A., Sayegh, F., Jaouni, S., Nasrullah, Z., Al Saeed, H., …Qari, M. (2010). Review: Management of painful vaso-occlusive crisis of sickle-cell anemia: Consensus opinion. Clin Appl Thromb Hemost, 16, 363-376. Type of study: Integrative review
Design: Cross-sectional
International Suggested guidelines, clinical experience and reviews to aid in the management of VOC. Standardized pain assessment tools are useful in the effective management of VOC. Oral fluids, oral analgesics and comfort measures are effective measures in the management of mild vaso-occlusive episodes at home. Opioids should not be restricted due to fear of addiction. Level VII
Mitchell, M., Lemanek, K., Palermo, T., Crosby, L., Nichols, A., & Powers, S. (2007). Parent perspectives on pain management, coping, and family functioning in pediatric sickle cell disease. Clin Pediatr, 46, 311-319. Type of Study: Survey

Design: Cross-sectional including both qualitative and quantitative data
Framework/Theory: McMaster Model

Three Children’s hospital in Ohio The relationship between patients’ coping strategies, family functioning and utilization of health care and outcome in VOC management.
Independent variables: Family functioning, Coping strategies and utilization of health
Dependent variable: VOC outcome
The study revealed that coupled with family involvement in managing SCD is the importance of including children in the management of SCD and associated comorbidities. This interaction in the management of SCD and related comorbidities was associated with fewer admissions. Level VI
Pack-Mabien, A., Herbert, L., & Haynes Jr., J. (2001). Nurses’ attitudes and practices in sickle cell pain management. Applied Nursing Research, 14(4), 187-192. Type of Study: Survey
Design: Cross-sectional
Southern University Teaching Hospital Alabama This survey aimed to investigate the influence of nurses’ attitudes on their practice in the management of SCD pain episodes.

Independent variable: Attitude
Dependent variable: nursing practice

The survey showed that age, education and experience influenced the attitude of nurses in the management of VOC. Sensitization of nurses is deemed imperative to enable them deal with both external and internal barriers to successful delivery of care to SCD patients. Level VI
Haywood Jr., C., Beach, M., Lanzkron, S., Strouse, J., Wilson, R., Park, H., …Segal, J. (2009). A systematic review of barriers and interventions to improve appropriate use of therapies for sickle cell disease. J Natl Med Assoc., 101, 1022-1033. Type of Study: Systematic Review
Design: Mixed
Limited utilization of therapies for the management of SCD pain prompted the investigation of challenges to health-care providers, use of approved treatments for SCD and effective interventions to increase proper use of therapies to manage SCD and related pain. The review identified health-care providers’ negative attitudes and failure to comprehend patients’ needs as the salient barriers. Adherence to interventions did not deem to improve utilization of treatment, but training of health workers, self-assessment exercises and use of standardized clinical protocols have been identified to be effective means to help address internal and external barriers to utilization of health care among the health-care providers. Level I
Level V
Hafner, J., Martinovich, Z., & Artz, N. (2012). Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management. Acad Emerg Med, 19(4), pp. 430-438. Type of Study: Cohort-prospective

Design: Longitudinal

Variation in pain management process and outcomes as reported by the patients, as well as pre- and post utilization of analgesic protocols in managing SCD. Also, the study will determine if the site and frequency of visit to the hospital has an influence on pain scores and time to analgesic. Pain reduced between pre- and post-implementation of analgesic protocols. Less morphine was used while the use of hydromorphone increased. Increasing frequency of visits to the ED was associated with no improvement in relation to pain scores. Level IV
Solomon, L. R. (2008). Treatment and prevention of pain due to vaso-occlusive crises in adults with sickle cell disease: an education void. The American Society of Hematology, 111, 997-1003. Type of Study: Integrative Review Education void in the treatment and prevention of pain in SCD patients. Despite available guidelines, few textbooks and publications contain details of management of SCD and related comorbidities in accord with these guidelines. Level VII

References

Frei-Jones, M., Baxter, A., Rogers, Z., & Buchanan, G. (2008). Vaso-occlusive episodes in older children with sickle cell disease: Emergency department management and pain assessment. J Pediatr, 152, 281-285.

Hafner, J., Martinovich, Z., & Artz, N. (2012). Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management. Acad Emerg Med, 19(4), pp. 430-438.

Haywood Jr., C., Beach, M., Lanzkron, S., Strouse, J., Wilson, R., Park, H., …Segal, J. (2009). A systematic review of barriers and interventions to improve appropriate use of therapies for sickle cell disease. J Natl Med Assoc., 101, 1022-1033.

Mitchell, M., Lemanek, K., Palermo, T., Crosby, L., Nichols, A., & Powers, S. (2007). Parent perspectives on pain management, coping, and family functioning in pediatric sickle cell disease. Clin Pediatr, 46, 311-319.

Mousa, S., Al Momen, A., Sayegh, F., Jaouni, S., Nasrullah, Z., Al Saeed, H., …Qari, M. (2010). Review: Management of painful vaso-occlusive crisis of sickle-cell anemia: Consensus opinion. Clin Appl Thromb Hemost, 16, 363-376.

Pack-Mabien, A., Herbert, L., & Haynes Jr., J. (2001). Nurses’ attitudes and practices in sickle cell pain management. Applied Nursing Research, 14(4), 187-192.

Solomon, L. R. (2008). Treatment and prevention of pain due to vaso-occlusive crises in adults with sickle cell disease: an education void. The American Society of Hematology, 111, 997-1003.

Van Beers, E., Van Tujin, C., Nieuwkerk, P., Friederich, P., Vranken, J., & Biemond, B. (2007). Patient-controlled analgesia versus continuous infusion of morphine during vaso-occlusive crisis in sickle cell disease, a randomized controlled trial. American Journal of Hematology, 82, 955-960.