A Decision Tree Model for Postoperative Pain Management

Cynthia W. Ward, DNP, RN-BC, CMSRN, ACNS-BC


Urol Nurs. 2015;35(5):251-256. 

In This Article

Individual Factors Affecting Analgesic Use


Dysfunction or failure of major organs, particularly the liver and kidneys, impacts the distribution, clearance, and excretion of opioids. Because the liver plays a major role in the metabolism of opioids, its failure can cause decreased metabolism, delayed elimination, and in creased bio availability of these medications. This results in in creased half-life and a higher than expected plasma concentration, which in turn may cause in creased adverse effects of respiratory depression or sedation (Hallingbye, Martin, & Viscomi, 2011). Renal insufficiency also interferes with the elimination of drugs and decreases clearance, resulting in increased half-life and an increased incidence of adverse effects such as central nervous system and respiratory depression (Parmar & Parmar, 2013). Individuals with renal insufficiency also may have increased accumulation of active metabolites of drugs, which may cause significant adverse effects. Lower opioid doses and in creased patient monitoring thus are recommended for patients with renal or liver dysfunction (Pasero et al., 2011).

Drug Tolerance

When choosing an opioid dose, the health care provider must determine if the patient is opioid naïve or opioid tolerant. An opioid-naïve individual has not been taking opioids regularly in the recent past. An opioid-tolerant individual has been taking opioids regularly and has developed tolerance to their effects. Without understanding these characteristics, the health care provider could overdose an opioid-naïve person or under-dose an opioid-tolerant individual. Generally, the opioid-naïve patient will need smaller doses of the opioid to achieve an analgesic effect while the opioid-tolerant person will need larger doses. Following surgery, pa tients who also are being treated with opioids for chronic pain will require higher doses of opioids than opioidnaïve persons (Huxtable, Roberts, Somogyi, & Macintyre, 2011). One study suggested the opioid requirement may be two to four times higher for the opioid-tolerant individual. The nurse should monitor this patient closely for sedation and respiratory depression (Pasero et al., 2011).