Pain Management

The fifth vital sign American Pain

Society 2003

Identifying pain as the fifth vital sign

suggests that the assessment of pain
should be as automatic as taking a clients
BP and pulse
 whatever the person says it is, existing
whenever the experiencing person says it
does McCaffery & Pasero, 1999

Emphasizes the highly subjective nature of

pain
 Pain is the most COMMON reason clients
seek medical advice

Pain is a protective mechanism or a

warning to prevent further injury
 THE
PATHOPHYSIOLOGY
OF PAIN
 Pain Transmission
Nociceptors also called as pain
receptors are free nerve endings in the
skin that respond only to intense,
potentially damaging stimuli (mechanical,
thermal, or chemical)

The joints, skeletal muscle, fascia,

tendons and cornea also have nociceptors
 Large internal organs do not contain nerve
endings

Polymodal nociceptors respond to all

three types of stimulus

Histamine, bradykinin, acetylcholine,

serotonin, and substance P are
chemicals that increase transmission of
pain
 Prostaglandins are chemical substances
that are believed to increase the sensitivity
of pain receptors by enhancing the pain
provoking effect of bradykinin

There are 2 main types of fibers involved

in the transmission of nociception:
Myelinated, A delta fibers fast pain
Type C fibers second pain
 Chemicals that reduce or inhibit the
transmission or perception of pain include
endorphins and enkephalins
 The Gate Control Theory
Proposed by Melzack and Wall in 1965

Stimulation of the skin evokes nervous

impulses

Stimulation of the large diameter fibers

inhibits the transmission of pain, thus
closing the gate
 Types of Pain
Acute Pain usually of recent onset and
commonly associated with specific injury;
lasting from seconds to 6 months

Chronic Pain constant or intermittent

pain that persists beyond the expected
healing time and seldom attributed to a
specific cause or injury; lasts for 6 months
or longer
 Cancer Related Pain may be acute or
chronic; can be directly associated with the cancer,
a result of cancer treatment, or not associated with
the cancer

Pain classified by location - aids in

communication about and treatment of the pain

Pain classified by etiology to predict course of

pain and plan effective treatment using this
categorization
FACTORS INFLUENCING PAIN
RESPONSE
 Past experience

Anxiety and Depression

Culture

Gender

Genetics

Placebo effect
PAIN ASSESSMENT
 Obtain a Pain History

Allow the client to describe the pain to establish a

trust relationship between you and the client

Discover the effects of pain on the client's quality

of life

Assess for emotional and spiritual distress and

coping abilities
 Ask about previous pain experience and
what measures have been effective as
well as those who have not

Use WHATS UP format or PQRST or

OLDCART in assessing pain
 W where is the pain? Be specific. Use drawing
of body if necessary

H how does the pain feel? Is it shooting,

burning, dull, sharp?

A aggravating and alleviating factors. What

makes the pain better? Worse?

T timing. When did the pain start? Is it

intermittent? Continuous?
 S severity. How bad is the pain on a 0 to
10 (0 to 5; faces) scale

U useful other data. Are you

experiencing any other symptoms
associated with the pain or pain
treatment? Itching, nausea, sedation,
constipation?

P perception. What is the clients

 P provoked

Q- quality

R region/radiation

S severity

T - timing
 O onset
L location
D duration
C characteristic
A aggravating factors
R radiation
T treatment
 Sample (PQRST)
With continuous, drilling, bilateral knee
pain that occurs upon ambulation; rated as
8/10 in the numeric pain rating scale, with
0 as no pain and 10 as excruciating pain.
 Sample (OLDCART)
With continuous, penetrating, right flank pain
that occurred 1 hour prior to admission while
client was consuming fried dried fish; rated as
9/10 in the numeric pain rating scale with 0 as
no pain and 10 as excruciating pain in the pain
rating scale; radiating on the left shoulder;
aggravated with ambulation and consumption of
salty foods such as dried fish and corned beef
and alleviated with rest, deep breathing
exercises, and guided imagery.
 Daily Pain Diary
For clients who experience chronic pain
May help the client and nurse identify pain
patterns and factors that exacerbate or mediate
pain
The record can include: time or onset of pain,
activity before pain, pain-related positions or
behaviors, pain intensity level, use of
analgesics or other relief measures, duration
of pain, time spent in relief activities.
 Visual Analogue Scales
Useful in assessing the intensity of pain
Includes a horizontal 10cm line, with
anchors indicating the extremes of pain
The client is asked to place a mark
indicating where the current pain lies on
the line
Left: none or no pain
Right: severe or worst possible pain
 Faces Pain Scale
This instrument has six faces depicting
expressions that range from contented to
obvious distress

The client is asked to point to the face that

most closely resembles the intensity of his
or her pain
 Guidelines for Using Pain
Assessment Scale
Written pain scale may not be possible if a
person is seriously ill, is in severe pain, or
has just returned from surgery

The scale should be used consistently

The nurse teaches the client how to use

the pain scale before the pain occurs
 Numerical rating should be documented
and used to assess the effectiveness of
pain relief interventions

Pain scale may help assess the

effectiveness of the interventions if the
scale is used before and after the
interventions are implemented
Non pharmacologic
interventions
 Non-pharmacologic nursing activities can
assist in pain relief

Not a substitute for medication

Combining nonpharmacologic
interventions with medications may be the
most effective way to relieve pain
 Cutaneous stimulation and
massage
The gate control theory of pain proposes
that stimulation of fibers that transmit
nonpainful sensations can block or
decrease the transmission of pain
impulses

Rubbing the skin and using heat & cold

are based on this theory
 Massage is a generalized cutaneous stimulation
of the body that often concentrates on the back
and shoulders

Massage have an impact in the descending

control system and does not merely stimulate
nonpain receptors

Promotes comfort through muscle relaxation

 Thermal therapies
Proponents believe that ice and heat
stimulate the nonpain receptors in the same
receptor field as the injury

Ice should be placed on the injury site

immediately after injury or surgery

Ice therapy after joint surgery can

significantly reduce the amount of analgesic
medication required
 Assess skin first before applying ice

Ice should be applied on an area for no longer

than 15 to 20 minutes at a time and should be
avoided in clients with compromised circulation

Application of heat increases circulation to an

area and contributes to pain reduction by
speeding healing
 Both ice and heat therapy must be applied
carefully and monitored closely to avoid
injuring the skin

Neither therapy should be applied to areas

with impaired circulation or used in clients
with impaired sensation
Transcutaneous electrical nerve
stimulation (TENS)
Uses a battery-operated unit with
electrodes applied to the skin to produce a
tingling, vibrating, or buzzing sensation in
the area of pain

Decreases pain by stimulating the nonpain

receptors in the same area as the fibers
that transmit pain
 Distraction
Involves focusing the clients attention on
something other than the pain

Thought to reduce the perception of pain

by stimulating the descending control
system

Effectiveness depends on the clients

ability to receive and create sensory input
other than pain
 Examples are watching TV, listening to
music, complex physical and mental
exercises

Stimulation of sight, sound, and touch is

likely to be more effective than the
stimulation of a single sense
 Relaxation techniques
Believed to reduce pain by relaxing tense
muscles that contribute to the pain

Consists of abdominal breathing at a slow,

rhythmic rate

The client may close both eyes and

breathe slowly and comfortably
 Guided imagery
Using ones imagination in a special way
to achieve a specific positive effect

May consist of combining slow, rhythmic

breathing with a mental image of
relaxation and comfort

The client is asked to practice guided

imagery for about 5 minutes, three times a
day
 Hypnosis
Has been effective in relieving or
decreasing the amount of analgesic
agents required in clients with acute and
chronic pain

Mechanism is unclear

Induced by specially skilled people

 Music therapy
An inexpensive and effective therapy for
the reduction of pain and anxiety
Pharmacologic interventions
 Premedication assessment
The nurse should ask the client about
allergies to medications and the nature of
any previous allergic responses

The nurse obtains the clients medication

history, along with a history of health
disorders
Approaches for using analgesic
agents
 Balanced analgesia
Refers to the use of more than one form of
analgesia concurrently to obtain more pain
relief with fewer side effects

Using two or three types of agents

simultaneously can maximize pain relief
while minimizing the potentially toxic
effects of any one agent
 Pro re nata
The nurse waits for the client to complain
of pain and then administer analgesia
 Preventive approach
Currently considered as the most effective
strategy because a therapeutic serum
level of medication is maintained

Smaller doses of medication are needed

Better pain control can be achieved

 In using this approach, the nurse should
assess the client for sedation before
administering the next dose

The goal is to administer analgesia before

the pain becomes severe
 Patient controlled analgesia
Used to manage postoperative pain as
well as persistent pain

Allows clients to control the administration

of their own medication within
predetermined safety limits

Is electronically controlled by a timing

device
 The timer can be programmed to prevent
additional doses from being administered
until a specified time period has elapsed
(lock-out time) and until the first dose has had
time to exert its maximal effect

Continue monitor respiratory status

Instruct client not to wait until the pain gets

severe before pushing the button
 Remind client not to be so distracted with
a visitor or activity so that he/she will not
forget to administer the drug

If PCA is to be used in the clients home,

he/she and family are taught about the
operation of the pump as well as the side
effects of the medication and strategies to
manage them
 Nonopioids
Generally the first class of drugs used for
treatment of pain

Useful for acute and chronic pain from a

variety of causes such as: surgery,
trauma, arthritis, and cancer

Have a ceiling effect to analgesia

 A ceiling effect indicates that there is a dose
beyond which there is no improvement in the
analgesic effect and there may be an increase in
side effects

Does not produce tolerance or physical

dependence

Most nonopioids have antipyretic effects

Works primarily at the site of injury, or peripherally

 NSAIDs block synthesis of prostaglandin

Examples are salicylates (aspirin);

NSAIDS (ibuprofen, ketorolac, naproxen);
COX-2 inhibitors (celecoxib);
acetaminophen
 Celecoxib (Celebrex)
Inhibition of prostaglandin synthesis,
primarily through inhibition of
cyclooxygenase-2 (COX2). This results in
anti-inflammatory, analgesic, and
antipyretic activities

For osteoarthritis, rheumatoid arthritis, and

acute pain in adults
 Monitor CBC, liver/renal function tests,
and for signs and symptoms of GI
bleeding

Remember: NSAIDS!!!
 Opioids
The goal of administering this medication
is to relieve pain and improve quality of life

Opioids are classified as full agonists,

partial agonists, or mixed agonists and
antagonists

Full agonists have complete response at

the opioid receptor site
 Partial agonists has lesser response

The mixed agonists and antagonists activates one

type of opioid receptor while blocking another

Opioids alone have no ceiling effect to analgesia

Controlled-release opioids such as oxycodone

(Oxycontin) and morphine (MS Contin) are
effective for prolonged, continuous pain
 Controlled or time-release medication should
never be crushed, but always taken whole

Common adverse effects of opioids are: CRINCS!

C- constipation
R- respiratory depression
I- itching
N- nausea, vomiting
C- constricted pupils
S- sedation
 Morphine
Is the drug of choice for the treatment of
moderate to severe pain

Used as a standard against which all other

analgesics are compared

Long acting (4-5 hours)

 Hydromorphone (Dilaudid)
Commonly used for moderate to severe
pain

Shorter acting than morphine but has a

faster onset

Good option for pain management in most

clients
 Meperidine (Demerol)
Should be reserved for healthy clients
requiring opioids for a short period or for
those who have unusual raections or
allergic responses to other opioids

Produces a toxic metabolite called

normeperidine
 Normeperidine is a cerebral irritant that
can cause adverse effects ranging from
dysphoria and irritable mood to seizures

Should be avoided in clients over the age

of 65, in those with impaired renal
function, and in those receiving MAOI
antidepressants
 Fentanyl (Sublimaze,
Duragesic)
Can be administered parenterally,
intraspinally, or by transdermal patch
 Methadone (Dolophine)
Is a potent analgesic that has a longer duration of
action than morphine

Has a very long half life and accumulates in the

body with continued dosing

Well absorbed from the GI tract and is very

effective when given orally

also used in drug treatment programs during

detoxification from heroin and other opioids
 Opioid Antagonists
Naloxone (Narcan) is a pure opioid
antagonist that counteractsthe effects of
opioids

Often used in the emergency department

setting for treatment of opioid overdose

Some analgesics are classified as

combined agonist and antagonist. These
drugs bind with some opioid receptors and
 The most commonly used agonist-
antagonist drugs are butorphanol (Stadol)
and nalbuphine (Nubain)

Nalbuphine can be used to treat itching

and nausea that may accompany the
administration of opioids
 Analgesic Adjuvants
Are classes of medications that may
potentiate the effects of opioids or
nonopioids

Are especially important when treating

pain that does not respond well to
traditional analgesics alone
 Steroids
May reduce pain by decreasing
inflammation and the resultant
compression of healthy tissues
 Benzodiazipines
Midazolam (Versed) or diazepam (Valium)
are effective for the treatment of anxiety or
muscle spasms associated with pain

These drugs do not provide pain relief

except in the treatment of muscle spasms

May cause sedation

 Tricyclic antidepressants
Amitriptyline, imipramine, desipramine,
and doxepin have been shown to relieve
pain related to neuropathy and other
painful nerve related conditions

Must be taken for days to weeks before

they are fully effective
 Instruct clients to continue taking the
medications even if they seem ineffective
at first

Additional benefits of this class of

medications may include mood elevation
and improved ability to sleep
 Anticonvulsants
Carbamazepine (Tegretol) and gabapentin
(Neurontin) are often used to relieve the
sharp or cutting pain caused by peripheral
nerve syndromes

These medications must be taken

regularly before full benefit is realized
Routes for analgesic
administration
 Oral
Preferred route in most cases

Convenient, inexpensive

Slower onset than IV

Can provide consistent blood levels

 Rectal
May be used to provide local or systemic
pain relief

Can be used when client is unable to take

oral medication

May be difficult to administer

 Transdermal patch
For chronic pain

Easy to apply; delivers pain relief for 3

days without patch change

12-hour delay before effective drug level

reached, and delay in excreting once
removed
 May be less effective in smokers owing to
circulatory alterations

Absorption may be increased with fever

Use caution not to touch medication when

applying
 Intravenous
Preferred route for post operative and chronic
cancer pain for clients who cannot tolerate
oral route

Provides rapid relief; continuous infusion

provides steady drug level

Difficult to use in home care setting

Follow instructions for administration

 Intramuscular
For acute pain

Rapid pain relief

Painful

Use only if other routes cannot be used

 Subcutaneous
May be used if IV route is problematic

Can deliver effective pain relief

Injection may be painful

May be effective for treatment of chronic

cancer pain
 Intraspinal (epidural or
subarachnoid)
May be used for traumatic injuries or
chronic pain unrelieved by other methods

May be able to control pain with lower

doses of opioid because relief is delivered
closer to site of pain; fewer systemic side
effects

Requires single or continuous injection in

back; may be associated with intense
Surgical interventions
 Cordotomy
Is the division of certain tracts of the spinal
cord

May be performed percutaneously, by the

open method after laminectomy, or by
other techniques

Is performed to interrupt pain transmission

 Care must be taken to destroy only the
sensation of pain, leaving motor functions
intact
 Rhizotomy
Sensory nerve roots are destroyed where
they enter the spinal cord

A lesion is made in the dorsal root to

destroy neuronal dysfunction and reduce
nociceptive input

Is usually performed to relieve severe

chest pain
 The spinal roots are divided and banded
with a clip to form a lesion and produce
subsequent loss of sensation
 assignment
Write at least 3 nursing interventions for
each of the following side effects of opioid
analgesic agents:
1. Respiratory depression
2. Nausea and vomiting
3. Constipation
4. Itching