Acute and Chronic Pain:

Assessment and
Management

Presented by:

12400 High Bluff Drive

San Diego, CA 92130

This course has been awarded four (4.0) contact hours.

This course expires on September 22, 2010.

Copyright © 2004 by RN.com.

All Rights Reserved. Reproduction and distribution
of these materials are prohibited without the
express written authorization of RN.com.

First Published: October 27, 2004 Revised Date: September 22, 2007
Acknowledgements ____________________________________________________________ 4
Purpose & Objectives __________________________________________________________ 5
Defining Pain__________________________________________________________________ 6
Categorizing Pain Types ________________________________________________________ 6
Nocioceptive Pain______________________________________________________________ 6
Neuropathic Pain ______________________________________________________________ 7
Acute Pain versus Chronic Pain __________________________________________________ 7
Summary of Pain Types_________________________________________________________ 7
Barriers to Effective Pain Assessments and Management ____________________________ 8
Patient Barriers________________________________________________________________ 8
Healthcare Professional Barriers _________________________________________________ 8
Health System Barriers _________________________________________________________ 8
Addressing Barriers to Pain Relief ________________________________________________ 9
Minimizing Barriers ____________________________________________________________ 9
Fears about Addiction __________________________________________________________ 9
Fears about Opioid Tolerance and Physical Dependence ____________________________ 10
Exaggerating Fears Related to Respiratory Depression _____________________________ 10
Principle of Double Effect ______________________________________________________ 10
Misconception that the Doctor or Nurse Knows Best _______________________________ 11
Impact of the Nursing Shortage on Pain Management_______________________________ 11
JCAHO Standards ____________________________________________________________ 11
Pain Assessment _____________________________________________________________ 12
Provocation or Palliative Symptoms _____________________________________________ 12
Quality ______________________________________________________________________ 12
Radiation ____________________________________________________________________ 13
Severity _____________________________________________________________________ 13
Timing ______________________________________________________________________ 13
Physical Examination: Inspection _______________________________________________ 13
Physical Examination: Auscultation _____________________________________________ 14
Physical Examination: Palpation and percussion __________________________________ 14
Summary of Assessment Findings ______________________________________________ 14
Communicating Assessment Findings ___________________________________________ 14
Case Discussion______________________________________________________________ 16
Pain Management _____________________________________________________________ 18
Understanding Opioids ________________________________________________________ 18

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Non-Opioid Analgesia: Acetaminophen and NSAIDs ________________________________ 24
COX-2 Inhibitors ______________________________________________________________ 26
Adjuvant Analgesia ___________________________________________________________ 26
Non-pharmacological Therapies_________________________________________________ 27
The WHO Ladder to Manage Chronic Malignant Pain _______________________________ 28
Special Populations ___________________________________________________________ 29
Infants & Children_____________________________________________________________ 29
The Elderly __________________________________________________________________ 31
The Cognitively Impaired_______________________________________________________ 31
The Critically Ill _______________________________________________________________ 32
Culture Issues________________________________________________________________ 32
Patients with Prior History of Substance Abuse____________________________________ 32
Conclusion __________________________________________________________________ 33
Appendix A __________________________________________________________________ 34
Appendix B __________________________________________________________________ 35
References __________________________________________________________________ 37
Post Test Viewing Instructions __________________________________________________ 39

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 Acknowledgements
RN.com acknowledges the valuable contributions of…

...Lori Constantine, MSN, RN-BC, author of this continuing nursing education course. Lori is a
nurse with 12 years medical surgical experience. She has worked as a staff nurse, charge nurse
and nurse preceptor on many different medical-surgical units including, vascular, neurology,
neurosurgery, urology, gynecology, ENT, general medicine, geriatrics, oncology and blood and
marrow transplantation. She received her Bachelors in Nursing in 1994 and a Masters degree in
Nursing in 1998, both from West Virginia University. In 1998, Lori was certified as a Family Nurse
Practitioner, and in 2005 became board certified in medical surgical nursing through the American
Nurses Credentialing Center. She has held positions at West Virginia University School of
Nursing, and is currently an adjunct faculty member for Waynesburg School of Nursing in
Pennsylvania and a staff nurse on a surgical-trauma unit at West Virginia University Hospitals.

…Robin Varela, RN, BSN, for updating and editing the revised version of this continuing nursing
education course. Robin has over 20 years experience in critical care and emergency department
nursing. During her years as a staff nurse and nurse preceptor she has been certified as CCRN,
TNCC, BLS, ACLS, ACLS Instructor, PALS and MICN. As an emergency department Clinical
Nurse Manager, Varela took an active role in numerous multi-disciplinary committees and
partnered with local EMS to co-ordinate emergency preparedness within the community. She has
worked for American Mobile Healthcare as a Clinical Services Clinical Liaison RN and works per
diem as a critical care transport nurse. Varela completed her BSN in 2003 and plans to begin
graduate school the summer of 2007.

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 Purpose & Objectives
The purpose of this continuing nursing education course is to provide healthcare professionals with
information about pain assessment and pain management. Post-surgical pain and chronic cancer
pain will be the focus. Since managing acute and chronic pain requires astute assessment skills
and knowledge of pharmacological and non-pharmacological therapies, healthcare professionals
should be aware that the patient’s self-report is the most essential way to assess pain. The course
includes principles of pharmacological pain management, a discussion of patient controlled
analgesia (PCAs) enquianalgesic dose conversions, the WHO 3-step ladder, as well as information
about the needs of special populations that includes the elderly, children, patients with different
cultural backgrounds and patients with a history of substance abuse.

After successful completion of this course, the participant will be able to:

1. Define pain and describe various pain types.

2. Describe patient, provider, and health system barriers associated with poor pain control.
3. Identify patient and provider misconceptions regarding pain management.
4. Describe how pain is assessed based upon the patient’s self-report.
5. Identify pharmacological and non-pharmacological strategies associated with achieving pain
control particularly in the acute post-surgical patient and chronic pain suffers.
6. Identify special groups that are at risk for under-treatment of pain.

Disclaimer
RN.com strives to keep its content fair and unbiased.
The author(s), planning committee, and reviewers have no conflicts of interest in relation to
this course. There is no commercial support being used for this course.
There is no "off label" usage of drugs or products discussed in this course.

You may find that both generic and trade names are used in courses produced by RN.com.
The use of trade names does not indicate any preference of one trade named agent or
company over another. Trade names are provided to enhance recognition of agents
described in the course.

Note: All dosages given are for adults unless otherwise stated. The information on
medications contained in this course is not meant to be prescriptive or all-encompassing.
You are encouraged to consult with physicians and pharmacists about all medication
issues for your patients.

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 Defining Pain
Pain is a universal affliction that can affect all of us at some point in our lives. Practically all
hospitalized patients experience pain at some point in their stay. The presence of pain negatively
affects the patient and family and has significant clinical effect on recovery, morality and quality of
life (Jacox et al., 1992). Despite the fact that satisfactory pain relief can occur in approximately
90% of pain suffers, it is still not regularly occurring (Stjernsward & Teoch, 1992). The
International Association for the study of pain (IASP) and the American Pain Society adopted the
following definition of pain:

“Pain is an unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms such as damage” (APS, 1992; Mersky & Bogduk
1994).

When it comes down to assessing for pain, healthcare professionals cannot always determine the
source of the patient’s pain or identify any source or damage that could be responsible for a report
of pain. Yet, the person is experiencing pain. This does not infer that the pain is not real.
McCaffery addresses this perceived incongruence by explaining that, “Pain is whatever the
experiencing person says it is, existing whenever he (or she) says it does” (1979). In other words,
pain is personal. Only the individual experiencing the pain can fully describe it. Pain may also be
induced by the psychic perception of real, threatened, or fantasized injury (Engel, 1970).
Therefore, the patient’s meaning of pain may play a significant role in how that person experiences
it.

Categorizing Pain Types

Healthcare professionals often document pain using a variety of Critical Thinking Tip:
terms. Some of the terms used to describe pain are somatic, The patient’s self-
visceral, referred, chronic, acute, malignant or non-malignant. It report is the gold is
useful to review the true meanings of these words and categorize standard of the
them so that a full understanding of pain types is achieved. The healthcare provider’s
physiologic basis of pain is categorized into two major types: pain assessment.
nocioceptive and neuropathic.

Nocioceptive Pain
Nocioceptive pain results from real or impending tissue damage, either to the viscera or the soma.
Nocioceptive, somatic pain usually occurs due to real or impending damage to bone, muscle, skin,
or connective tissue. Somatic pain is most commonly described as localized, aching, or throbbing.
Nocioceptive visceral pain usually occurs due to real or impending damage to the thoracic,
abdominal, or pelvic organs such as the heart, liver, or bowel. Visceral pain is often described as
deep, cramping, referred, aching, or gnawing (Griffie, McKinnon, & Heidrich, 2002).

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Neuropathic Pain
Neurophathic pain occurs from damage to peripheral or central nervous tissue or from distorted
processing of pain. Examples of neuropathic pain include: peripheral neuropathies, neuralgias,
phantom limb pain, and spinal cord injuries. It is often described as burning, piercing, lacerating,
and pricking (Griffie, McKinnon, Berry, & Hedrich, 2002).

Nocioceptive Pain Neuropathic Pain

Somatic Central
Localized, aching, throbbing Burning, piercing, lacerating, pricking

Visceral Peripheral
Deep, cramping, aching, referred, gnawing Burning, piercing, lacerating, pricking

Acute Pain versus Chronic Pain

Acute pain is usually brief and diminishes as healing occurs. Chronic pain is long standing and
can be further classified as either malignant or non-malignant pain (McCaffery & Pasero, 1999).
Chronic non-malignant and chronic malignant pain may be either nocioceptive or neuropathic
depending upon its origin and dissemination. For example, a patient may experience visceral,
nocioceptive pain from liver metastasis but, may also be experiencing neuropathic pain from
chemotherapy induced neuropathy. Additionally, a person with chronic pain may have
exacerbations of acute pain, known as breakthrough pain.

Referred Pain
Referred pain is often nocioceptive in origin and involves Critical Thinking Tip:
visceral organs. It is not well organized. For example, the • Acute pain diminishes as
pain of the gall bladder disease is often referred to the right healing occurs.
shoulder and cardiac pain may be felt in the neck, back, • Chronic pain may be
jaw or arms. Diaphragmatic and pulmonary pain may also exacerbated by acute pain.
be felt in the neck. Kidney pain is often felt in the
• Referred pain is not well
associated flank as well as the lateral thigh. Pancreatic
localized and usually visceral in
pain may be experienced in the back. The exact
origin.
mechanism of referred pain is not fully understood. It is
known, however, that the site of referred pain is linked to
the involved nerve root.

Summary of Pain Types Types of Pain Include:

In summary, all pain can be categorized as either nocioceptive • Somatic
or neuropathic. Pain descriptors are useful in identifying the • Visceral
origin of pain. Patients may experience only one pain type or • Referred
all pain types during the course of their illness. It is important • Acute
to be knowledgeable about these pain types so that effective • Neuropathic
pain management strategies can be employed. • Chronic
• Break-through

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 Barriers to Effective Pain Assessments and Management

Patient Barriers
Fear is often the most prevalent reason that a patient will not report or under-reports pain. Some
of the fears patients experience related to pain control include the fear of addiction (U.S.
Department of Health and Human Services, 1994; Cleeland, 1984;
McCaffery &Ferrell, 1997), the fear unwanted side effects (U.S. Patients may fear
Department of Health and Human Services, 1994; McCaffery & addiction tolerance or
Beebe, 1989), and the fear of the stigma attached to taking narcotics unwanted side effects
(Twycross, 1982). Patients will often choose not to take pain related to pain
medications because they fear that when they really need them the medications.
medication will be ineffective. Subsequently, many patients wait to
ask for pain medication until the pain is so severe that it is much
more difficult to control.

Healthcare Professional Barriers

Unfortunately, healthcare professionals do not always assess or manage their patient’s complaints
of pain effectively. This is sometimes due to misconceptions about pain medications and in
particular, misconceptions about the use of opioids. In some instances healthcare professionals
may have had little training regarding the pharmacology of opioids,
associated side effects (such as respiratory depression), or concepts Healthcare professions
such as addiction (Health and Policy Committee, 1983), tolerance or may have unfounded
physical dependence (Bonica, 1987; Stjernsward & Teoh, 1990). fears due to lack of
Healthcare professionals also express concern about the regulation knowledge about
of controlled substances and state this to be a factor that influences pharmacology.
their pain management decisions (U.S. Department of Health and
Human Services 1994).

Health System Barriers

Barriers to effective pain assessment and management related to
Barriers that impact
healthcare systems are also prevalent. Inadequate
control of pain include:
reimbursement often makes the best treatment modality too
costly for patients to afford. Problems with the availability or • Fear
access to treatment also significantly hinder patients’ abilities to • Regulatory
achieve pain control. Finally, restrictive regulations of controlled • Lack of knowledge
substances may impact the healthcare professional’s ability or • Reports of pain
willingness to prescribe such medications (U.S. Department of
Health and Human Services, 1994).

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 Addressing Barriers to Pain Relief

Minimizing Barriers
Efforts have been made to minimize barriers to pain relief from a national and international
perspective for many years. The World Health Organization (WHO) established the problem of
inadequate cancer pain relief as an international public policy issue in 1986 (Benoliel, 1995). The
WHO responded to this need and subsequently published a set of guidelines for healthcare
professionals on the management of cancer pain (WHO, 1986). The Agency for Health Care
Policy and Research (AHCPR), part of the United States Public Health Service (Benoliel, 1995),
published a set of guidelines in 1994 that are vital to the delivery of pain management services
(U.S. Department of Health and Human Services, 1994). Other organizations that have worked
toward alleviating pain include the Ad Hoc Committee on Cancer Pain of the American Society of
Clinical Oncology, the American Pain Society, the American College of Physicians, the National
Cancer Institute, and the Robert Wood Johnson Foundation.

Addressing trends associated with patient and provider barriers regarding pain management is
paramount in controlling all types of pain. Healthcare professionals, including nurses, must be
aware of the barriers to effective pain management and involve the patient in making a decision
about analgesia whenever possible. Healthcare professionals must also be proactive in eliciting
pain reports or the signs and symptoms of pain in patients that are unable to report that they have
pain. As a healthcare professional, assessing and managing a patient’s unique needs to alleviate
pain should be an important part of your everyday practice. By being knowledgeable about
barriers to pain management, individual assessment techniques, and the pharmacology of pain
medications, healthcare professionals can help to reduce their patients discomfort related to pain.
Before a healthcare professional can accurately assess pain, a few of the most common fears
regarding pain management should be addressed. These fears include misconceptions about
addiction, tolerance, physical dependence, respiratory depression, and reservations associated
with giving the “last dose.”

Fears about Addiction

Many individuals do not understand the concept of addiction. In general, addiction can be
described as the overwhelming need to obtain and use a drug for its psychic effects. It is NOT the
need to use a drug for its medical benefit. Research indicates that less than 1% of all patients that
take an opioid for pain relief ever become addicted (Griffie, McKinnon, Berry, & Heidrich, 2002). It
is imperative that nurses learn about and understand this concept. It should also be
communicated to the patient if you are concerned about the patients’ fear of addiction. Patients
are sometimes stoic and might not share their fears with healthcare professionals or even their
families. Be proactive in discussing this common misconception with your patients and be secure
in the knowledge that the appropriate medical use of pain medications very rarely, if ever, causes
addiction.

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Fears about Opioid Tolerance and Physical Dependence
Opioid tolerance can occur after repeated administration of any opioid substance (Griffe,
McKinnon, Berry, & Heidrich, 2002). Tolerance to a drug occurs when an individual reports that
the initial dosage of medication is no longer effective in managing the pain. Tolerance is not
unusual and can often be expected with prolonged use of many types of pain medication. If
tolerance does develop, the healthcare provider may wish to increase the dose, prescribe the
same dose of the drug to be taken more frequently, or change the drug or route of administration.

Physical dependence occurs when, after repeated administration of the drug, withdrawal
symptoms appear when it is not taken. These symptoms include: anxiety, irritability, lacrimation
(tearing), rhinnorhea (runny nose), cramps, nausea, vomiting, and insomnia (Griffe, McKinnon,
Berry, & Heidrich, 2002). Opioid pseudoaddiction may occur when opioid physical dependence
occurs due to improper pain management (Weissman & Haddox, 1989).

Exaggerating Fears Related to Respiratory Depression

Respiratory depression related to opioid administration is a common fear among healthcare
professionals. Morphine is the medication most commonly associated with this fear. Although one
of the side effects of opioids is that they act as a depressant on the respiratory center of the brain,
this is usually a gradual process and does not occur suddenly. It is more common in those who
are opiod naïve, in other words, haven’t received opioids previously. Therefore, careful
assessment is indicated during the initial doses of opioid administration. Respiratory depression is
rare in patients that are on long-term opioid therapy because the respiratory system becomes
tolerant to this effect. Auditory and physical stimulation are often effective in mild opioid-induced
respiratory depression. Naloxone (Narcan) is an opioid antagonist that is usually administered to
counteract the effects of an opioid overdose. It may be given intravenously and acts within
moments (McPhee & Schroeder, 1997). Careful administration of naloxone is warranted in
patients with comfort care or chronic pain in order to prevent rebound or uncontrollable pain after
the naloxone is administered.

Principle of Double Effect

Occasionally healthcare providers, professionals, and even family members that care for their
loved one at home are afraid that just one more dose of medication may cause death of the
patient. This fear is best addressed by examining the principle of double effect. This principle is
based upon the intent of the person administering the medication. In managing pain, the intent is
not to hasten death, but rather to provide effective pain relief. While healthcare professionals must
be knowledgeable about the side effects of opioids, the fear of giving the last dose should not
impair the provider in providing effective pain relief. The American Medical Association (AMA),
American Nurses Association (ANA), and numerous other medical experts have addressed this
issue by acknowledging that it is ethically acceptable to provide pain relief even if it hastens death.
Again, it is not the intent to cause death or respiratory depression in these situations. It is the
intent for pain to be controlled in end-of-life situations.

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Misconception that the Doctor or Nurse Knows Best
The patient is the only one that can fully describe his or her pain. The patient’s self-report of pain
is the standard by which healthcare professionals should base their pain assessments. Often the
healthcare provider, families, and patients themselves believe that the provider knows or best
understands the patient’s pain. This is not the case. The patient’s reports of pain must be
believed first and foremost. In situations when patients are not able to report their pain because of
cognitive or motor abilities, pain must be assessed judiciously. Assessments should focus on
changes in non-verbal behavior, vocalizations, changes in daily routines, and objective findings.
The regular caregiver may also be a valuable resource in assessing pain in these individuals
(American Geriatrics Society Panel on Chronic Pain in Older Persons, 1998).

Impact of the Nursing Shortage on Pain Management

Nursing shortages have been reported across the nation since 1988 (Buerhaus, Staiger, &
Auerbach, 2000). Officials with the Health Resources and Services Administration (HRSA)
released projections in April 2006 that the nation's nursing shortage would grow to be more than
one million nurses by the year 2020. Analysts state that all 50 states will experience a shortage of
nurses to varying degrees by the year 2015 (AACN, 2006). Pain assessment and management
has, and will be impacted. Compounding the problem is that hospitalized patients tend to be sicker
than ever and people with chronic diseases are living longer. This often results in the need for
complex medical care, including pain management. The nursing shortage impacts a healthcare
professionals’ ability to provide quality care to all of their patients, especially those that are actively
experiencing pain.

How does the healthcare professional deal with these challenges? First and foremost make it a
priority to be knowledgeable about your patients’ conditions and understand pain mechanisms,
barriers, assessments, and management strategies. Secondly, be proactive in assessing pain and
effectively communicating pain to the interdisciplinary team. Being knowledgeable of and
confident about using pain management strategies is the first step toward providing quality care to
your patients.

JCAHO Standards
The Joint Commission (JCAHO) standards clearly outline how healthcare institutions should
manage pain. These standards focus on making pain management more of a priority, the critical
5th vital sign. Click on this link to review JCAHO pain standards: www.JointCommission.org

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 Pain Assessment

P Provocative or Palliative: What makes the pain better or worse?

Q Quality: Describe the pain. Is it burning, shooting, aching, stabbing, crushing, etc.?

Radiation: Does the pain radiate to another body part?

R
Severity: On a scale of 0 -10, (10 being the worst) how bas is your pain? (may use
S other scales also).

T Timing: Does it occur in association with something else? (e.g. eating, exertion,
movement)

Provocation or Palliative Symptoms

Assessment of provocative or palliative symptoms gives you clues to the origin of pain. Ask the
patient what makes the pain better or worse. For example, exertion may intensify anginal pain and
rest may alleviate it. Movement of an injured body part may intensify pain while applying heat or
cold to the injured part may ease the pain. Gastrointestinal pain may either improve or worsen with
food intake. Additionally, post-surgical pain is often intensified prior to getting out of bed, or while
ambulating or coughing and deep breathing. While assessing for provocative or palliative
symptoms that accompany the patient’s pain, ask about other associated symptoms as well.
Accompanying symptoms provide additional clues to the origin or nature of the patient’s pain. For
example, diaphoresis and nausea often accompany cardiac pain. Also, burning and tingling in an
ipsolateral limb may accompany sciatic pain.

Quality
Pain descriptors such as; aching, throbbing, burning, piercing, shooting, tearing, or crushing can
also give clues to the origins of pain. Remember, somatic pain is most commonly described as
localized, aching, and throbbing. Visceral pain is often described as deep, cramping, referred,
aching, or gnawing. Neuropathic pain is often described as burning, piercing, lacerating, and
pricking. Qualifying the patient’s pain allows you and your team to determine the appropriate
analgesic or adjuvant treatment.

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Radiation
Ask the patient where the pain on their body is. They can point, describe, or use an outline of a
person to shade in areas that are painful. Pain is localized if the patient can point to exactly where
it is hurting. If the patient can pinpoint where the pain is, it is often somatic in origin (bone, muscle,
or connective tissue). Referred pain or pain that radiates is not well localized and can complicate
understanding a person’s pain if a thorough history is not explored. Some common pathologic
processes that cause pain to radiate or be referred include acute coronary syndrome, gall bladder
disease, appendicitis, and pancreatitis. Depression and anxiety also play key roles in pain
processing and may exacerbate pain. When a patient describes their pain as being all over their
body, chronic pain syndromes and psychological components of the pain should be explored.

Severity
Most patients are able to use a numerical pain rating scale to quantify their pain. When using a
numerical scale, ask the patient to rate their pain on a scale from 0 to 10. Zero means no pain.
Ten means the worst pain imaginable or that they have ever experienced.

Timing
When assessing the timing of pain, ask the patient how long the pain has lasted and how often it
occurs. Chronic pain usually lasts for longer than six months. Acute pain is commonly related to a
new disease process, bodily injury, post-surgery or post-procedure, or may be an exacerbation of
chronic pain. Pain that is always present may be termed baseline pain. Baseline pain may be
aggravated by acute increases in intensity throughout the day. This is known as breakthrough
pain. Often patients with chronic disease and post-operative patients experience both baseline
and breakthrough pain.

Physical Examination: Inspection

A physical examination to elicit pain information should be performed only after a thorough history
of the pain is obtained. There are observable signs and symptoms of pain including grimacing,
withdrawal, clenching of the teeth or hands, assuming a fetal posture, or sleeping due to
exhaustion from pain.

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Physical Examination: Auscultation
Auscultate for associated physical exam findings prior to palpation or percussion. Auscultation
may provide clues to help localize a patient’s pain. For example, hyperactive bowel sounds with a
subjective report of cramping abdominal pain may indicate early bowel obstruction. Diffuse
abdominal pain with absent bowel sounds may indicate a late bowel obstruction. Wheezing or
crackles with a history of cough or localized lateral chest pain may indicate pneumonia or
atelectasis.

Physical Examination: Palpation and percussion

After inspection and auscultation, palpation and
percussion may be useful in determining the cause of Critical Thinking Tip:
the patient’s pain. If one particular area is identified as • Patients history and self-report will
painful, palpate around the area working towards it. provide the healthcare provider
Start gently and increase depth of palpitation. Avoid with 80% of the necessary
inducing more pain. Percussion is also useful to information to treat the patient
assess for pneumonia, ascites, gas, or changes in effectively.
underlying organs. Dullness is heard over areas of • Listen and ask questions!
consolidation or over solid surfaces. If dullness is
percussed over an area, further examination and
diagnostic testing is warranted. Additionally, tympany
(a hollow-filled sound) may be heard over a gas-filled abdomen.

Summary of Assessment Findings

Information obtained from the physical exam should be used to confirm suspicions as to the cause
of pain. Often, in the hospital setting, healthcare professionals are faced with managing pain from
an already diagnosed origin or an obvious cause such as surgery or invasive procedures. If this is
the case, the patient self-report and history is the key factor in monitoring the progression or relief
of the pain. Whether the pain is post-surgical, procedural, or chronic in nature, using the
pneumonic PQRST will allow the healthcare professional to effectively manage the pain as
interventions are delivered. If new pain or symptoms occur, a thorough history and exam are
warranted to assess for complications.

Communicating Assessment Findings

Communication of assessment findings is crucial in managing pain effectively. If you believe that
another intervention may be effective, it is your responsibility to report assessment findings to the
healthcare provider and ask about potential alternatives. Communication about pain should be
described in terms of the pneumonic, PQRST. Important physical exam findings, whether positive
or negative, should also be communicated to the healthcare provider. Another important piece of
information to obtain is what interventions have worked well for the patient’s pain and what
seemed to work best to relieve it. By using this approach, the healthcare provider can develop a
more thorough understanding of the patient’s pain.

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Critical Thinking Activity
Review the following three cases and consider what type of pain each patient is experiencing.
This exercise will help to promote critical thinking about pain assessment. When finished
answering each question, compare and contrast your answers with the answers provided in the
case discussion section.

Diane
Diane is a 27-year-old admitted to your unit for observation with blunt chest and abdominal trauma
following a motor vehicle collision earlier today. Her husband and child are at her bedside. Diane
appears to be in no distress and is currently taking Tylenol for pain control. Diagnostic tests are
pending.

Elizabeth
Elizabeth is a 77-year-old that has been on your unit for approximately 24-hours after being
transferred from a nursing home with a fever of unknown origin. She has a history of Alzheimer’s
disease, coronary artery disease, hypertension and a left-sided CVA that occurred in 1999. Blood
cultures are pending. Urinalysis is within normal limits. She was eventually diagnosed with right
lobar pneumonia following a chest X-ray and physical exam. She has been started on broad-
spectrum IV antibiotics and is pleasantly confused.

Benjamin
Benjamin is a 5-year-old admitted to your unit with a diagnosis of appendicitis. He is currently in
the emergency department and is expected to go to surgery within the hour. After his surgery he
will be admitted to the pediatric floor. In the meantime, you are responsible for his care until the
operating room is available. His parents are at his side but speak very little English. Benjamin
speaks English fluently.

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Case Discussion
Describe the focus of your pain assessment with each patient and discuss how you would
assess the pain.

Diane: The focus of Diane’s pain assessment should center on looking for complications from her
blunt chest and abdominal trauma. Using the pneumonic, PQRST, you discover Diane’s pain
worsens with coughing or palpation of her upper abdomen. Her pain is a dull ache that is diffuse
across her abdomen and chest. It does not radiate. It is a 7 on a numeric scale of 0-10. It has
been present for the past few hours and is not worsening. She is alert and oriented x 3. Lungs are
clear to auscultation bilaterally. Heart rate is regular S1 and S2 are heard. Abdomen is soft and
slightly tender with hypoactive bowel sounds. Extremities are warm and pink. BP = 106/74, HR =
88, Respirations = 22 Temp = 37.5 °C orally.

Elizabeth: Elizabeth’s pain assessment is complicated due to her cognitive impairment. There is
no family available to discuss her pain with you. Elizabeth can only nod her head “yes” when
asked if she hurts. The responses to all other assessment questions are a blank stare. You notice
that when Elizabeth coughs, she grimaces and pulls her right arm to midline. The focus of
Elizabeth’s pain assessment should center on her non-verbal cues and physical exam findings.
She continues to be febrile with a current temperature of 38.0 °C orally. BP=148/90, HR = 92,
Respirations = 24. Her lungs have crackles in the right lower and middle lobes and are diminished
bilaterally. She has a frequent productive cough of yellow sputum. Heart rate is regular. S1 and
S2 are normal. Abdomen is soft, non-tender with normal bowel sounds. Extremities are warm but,
pale with a capillary refill of 5 seconds.

Benjamin: Benjamin’s pain assessment should be appropriate for his age. The patient, if
possible, is the best person to report the pain. In this case, Benjamin’s self report is especially
important to elicit since his parents speak little English. His pain assessment should be focused on
his abdominal region. When asked about provocative or palliative factors, Benjamin does not
respond. He clings tightly to his mother. When asked about how his pain feels, he replies, “like
something poking me really hard.” Benjamin points to the face that corresponds with the number 8
on the faces pain rating scale. There is no radiation of the pain. He is alert and oriented x 3. His
breath sounds are clear to auscultation bilaterally. Heart rate is regular. S1 and S2 are normal.
His abdomen is soft with hypoactive bowel sounds. BP= 90/64, HR = 90, Temperature = 38.2 °C
orally, Respirations = 24.

16
How will a baseline pain assessment and physical exam will determine your care for each
patient.

Diane: A baseline pain assessment in Diane’s case is imperative to monitor for signs and
symptoms of complications of blunt chest and abdominal trauma. Complications that may manifest
in pain or other symptoms related to blunt chest or abdominal trauma include pneumothorax, rib
fractures, pericardial tamponade, aortic tear, and intra-abdominal bleeding. The pain
characteristics assessed in combination with other physical exam findings, such as quality of
breath and heart sounds and a detailed abdominal exam will help to identify the cause of your
patient’s pain and the potential for the development of other complications.

Elizabeth: Given Elizabeth’s pain assessment, you can most likely surmise that Elizabeth is
having some degree of pain upon coughing, probably due to pneumonia. A thorough history and
physical exam provides you with the clues needed to create a tentative judgment about the
patient’s pain source and will aid the physician in correctly diagnosing this patient.

Benjamin: Increased pain, radiation, or changes in his abdominal exam are especially important
for Benjamin and should be reported to his physician immediately. His initial complaints of
periumbilical pain are still present, but you notice that he is now guarding his right lateral abdomen.
When asked to cough or jump (which would elicit peritoneal irritation), Benjamin continues to cling
to his mother and whimpers slightly. Correlating new physical exam findings will help to confirm
the diagnosis of appendicitis or point the healthcare provider in another direction.

Example of Effective Nurse to Physician Communication:

This communication pertains to Diane’s case. Read the following excerpt from a phone
conversation between the healthcare provider and Diane’s nurse.

Nurse: Dr. Jones?

Physician: Yes?

Nurse: This is Betty on 8-East, Diane Richmond’s nurse. Diane is status post a MVC 6 hours
ago, with blunt chest and abdominal trauma. During my initial assessment of Diane, I
discovered she is experiencing a significant amount of pain in her upper abdomen. She rates
it as a 7 on a numeric scale of 1-10. Coughing significantly increases her pain. Her
abdomen is soft and tender with hypoactive bowel sounds. Other assessment findings are
negative. Her BP = 106/74, HR = 88, Respirations = 22 Temp = 37.5 orally. I am worried
about her abdominal pain and vital signs. Can you come and assess her please?
Physician: Thank you for calling. Why don’t you give her 4 milligrams of IV morphine & see
if that helps.
Nurse: It may help her pain. However, I am reluctant to do that since her BP is already
borderline low. I am really worried she may be bleeding internally. Can you come see her
now?
Physician: I will be right up. Thanks.

17
 Pain Management
Pharmacological treatment is largely determined based upon the type of pain the patient is
experiencing. Determining whether the pain is nocioceptive or neuropathic in origin will allow the
healthcare professional to accurately prescribe the right drug and administer it via the right route.
In addition, the healthcare professional should assess whether the pain is somatic, visceral, acute,
chronic, or any combination thereof. As mentioned previously, a large amount of pain experienced
by hospitalized patients is either post-surgical or procedural. Also important to note is that
hospitalized patients might already have a history of chronic pain; pain that they had before a
procedure or surgery. Therefore, it is useful to discuss pain management in this context.

Understanding Opioids
Opioids are commonly administered through enteral and parenteral routes. Some may even be
administered transdermally, subcutaneously, intrathecally, and epidurally. Around the clock oral
dosing is the preferred mechanism for managing chronic pain. Alternatively, parenteral
administration is usually a good choice for acute, surgical pain and breakthrough pain. Opioids
can be divided into two main groups, mu-agonists and agonist-antagonists, based upon their
mechanism of action.

Mu-Opioid Agonist

Mu-agonist opioids (also referred to as narcotics) are the most commonly used and include
morphine, codeine, hydromorphone (Dilaudid), fentanyl, methadone, oxycodone, levorphanol, and
meperidine (Demerol) (McCaffery & Pasero, 1999). These drugs are used most effectively in
malignant, breakthrough, and acute pain, including surgical pain. Adverse effects of these opioids
include constipation, nausea, vomiting, sedation, respiratory depression, and pruritus. These
effects are usually visible in the opioid-naive patient and diminish as tolerance develops.
Tolerance to constipation does not diminish; therefore an appropriate stool softener or bowel
regimen should be prescribed concurrently with any opioids. The following table gives common
dosages of common mu-opioid agonists.

Drug Morphine Fentanyl Hydromorphine Meperidine

Normal PO 10-30 mg q 4 5/mcg/kg 1-6 mg q 4-6 50-150 mg q 3-4

Dose hours hours hours
1.0-2.0 mg/kg; 0.5-2.0 mg 2-4 mg q 4-6 50-100 mg q 3-4
Normal IV Dose Up to 0.1 mg/kg hours hours

Other forms or Ext. release SC IM Transdermal Rectal IM SC

routes IM Oral
Rectal Transmucosal

(Skidmore-Roth, 2002)

18
Agonist-Antagonist Opioids

Agonist-antagonist opioids are most appropriately used for acute, non-malignant pain and may be
particularly helpful in nocioceptive (visceral or somatic) pain. Some examples of agonist-
antagonists are butorphanol (Stadol), Nalbuphine (Nubain), and Pentazocine (Talwin) (McCaffery
& Pasero, 1999). Their side effects are limited. They also produce less analgesia and have a
lower dependency potential than opioids. This group is not useful in the management of chronic
pain. Agonist-antagonists displace opioids from their mu-receptor sites and often produce
withdrawal reactions and further prevent adequate pain control in chronic pain sufferers (McKenry
& Salermo, 2003). Therefore, they are contraindicated in patients taking long-term opioids or are
physically dependant on opioids because they will displace the opioid at its binding site — possibly
leading to physical withdrawal symptoms (Skidmore-Roth, 2002).

Drug Nalbuphine Butorphanol Pentazocine

50-100 mg q 3-4
Normal PO Dose Not applicable Not applicable Not to exceed 600
mg/day

10-20 mg q 3-6 hours IV 30 mg q 3 hours

0.5-2.0 mg IV
Normal IV Dose Not to exceed 160 Not to exceed 600
Every 3-4 hours
mg/day mg/day

IM = 1-4 mg q 3-4
IM & SQ = 0-20 IM & SC = 30 mg q 3
hours
Mg q 3-6 hours hours
Other Intranasal = 1 spray
Not to exceed 160 Not to exceed 360
In 1 nostril q 3-4
mg/day Mg/day
hours
Respiratory
Major Respiratory Depression Respiratory
Considerations Depression Geriatrics – give ½ Depression
dose
(Skidmore-Roth, 2002)

19
Opioid Antagonists
Opioid antagonists reverse the effects of opioid mu-agonists such as morphine, fentanyl, and
meperidine. Naloxone (Narcan) is the primary opioid antagonist. Its main purpose is to rapidly
reverse opioid induced-respiratory depression. The standard dose for naloxone is .4 mg diluted in
9 ml’s of IV fluid. It can be given as .4 mg every 2 minutes up to 4.0 mg. It onset is 1-2 minutes
with a peak effect of 5-15 minutes.

FYI…
Care must be taken in administering the right opioid for the right patient. For instance,
meperidine is not used for chronic pain due to its ceiling effect and potential for accumulation of
metabolites, which may lead to seizures. Propoxyphene (Darvon) is appropriate for short-term,
non-malignant pain due to renal toxicity with long-term use. Transdermal fentanyl is not a good
choice for acute, surgical pain as its peak effect is delayed (McCaffery & Pasero, 1999). It is
however an excellent choice for chronic pain in individuals that cannot tolerate oral dosing, but
must be applied over dry, non-edematous skin.

Elimination half-life is 90 minutes and duration of action is approximately 45 minutes. If this drug is
given to opioid-dependant patients, it may result in severe physical withdrawal (American Pain
Society, 1999; Skidmore & Roth, 2002).

Patient-Controlled Analgesia (PCA)

Most post-surgical, post-procedural, and acute or breakthrough pain is managed initially via the
parenteral route. Parenteral administration of opioids is usually via IV injection, or often by a PCA
(patient controlled analgesia) pump. The greatest advantage of PCAs is that, within parameters,
they give patients the chance to be involved in their own care by allowing them to control the
dosing of their pain medication. PCA pumps deliver a set amount of an opioid at given intervals,
by continuous dosing or by a combination of both. Patients do not have to wait for a caregiver if
they need additional medication and can administer a pre-determined dose of medication at any
time they desire. Because the patient is the only one who administers the dose, respiratory
depression rarely occurs.

Since sedation is a precursor to respiratory depression, the patient will usually fall asleep prior to
administering too much opioid. Thorough patient teaching, as well as teaching for the family is
imperative. The family should be warned against administering doses while the patient is sleeping
to prevent accidental overdose.

Eventually, the post-surgical patient will be transitioned to an oral route of pain medication. This
transition to oral prn dosing usually begins within the first 48 hours post-surgery depending on the
patient’s condition and surgical procedure. Chronic pain sufferers may also receive opioids
parenterally to control breakthrough pain. They too, will eventually be transitioned to the oral
route. Oral around-the-clock dosing is the best way to effectively manage chronic, malignant, and
non-malignant pain. This transition between opioid delivery routes is often what causes healthcare
providers and patients the most distress in the pain management process, partially because
providers do not fully understand equianalgesic dose conversions and patient barriers are
prevalent.

20
Equianalgesic Dose Conversions
Equianalgesic dosing means using different medications or routes of delivery that provide similar
effectiveness of pain control. Often nurses are responsible for managing a patient’s pain when
converting from one opioid to another or converting from different routes of delivery. Equianalgesic
dose charts should be used to help you determine if the patient is receiving the appropriate dose of
medication via the appropriate route when therapy changes are made.

Equianalgesic charts such as the one in the following table, adapted from McCaffery & Pasero
(1999), provide an equialgesic conversion tool that converts common dosages of opioids quickly
and efficiently. Remember, this chart is a tool. Clinical judgment and patient response should
always guide your practice first and foremost. These doses are adult approximations. Doses
should be reduced for children or the elderly as clinically indicated.
Equianalgesic Dose Chart
Dose (mg) Dose (mg)
Drug Duration (Hour)
Parental Oral
Morphine 1.0 30 3-4
Hydromorphone
1.5 7.5 3-4
(Dilaudid)
Oxycodone
NA 30 3-4
(Oxycotin)
Levorphanal
2 4 6-8
(Levo-Dromoran)
Methadone NA 2-5 6-12
Codeine NA 200 3-4

Hydrocodone
NA 30-75 3-4
(Vicodin)
Meperidine
100 300 3-4
(Dermerol)
Microgram per hour dose of
transdermal
Fentanyl 0.1-0.25 mg fentanly
72
(Duragesic) (100-250 mcg) approximates ½ of the milligram per
day dose of oral morphine up to 200
mg per day
Doses of drugs in this chart are listed as compatible doses. For example 30 mg of oral morphine =
7.5 mg of oral hydromorphone = 1.5 mg of IV hydromorphone (McCaffery and Pasero, 1999).

21
Dose Conversion Practice
A Few Rules…
• Tape your equianalgesic table to your clipboard or other easily accessible place.
• Know where to find your equianalgesic dose chart.
• Use a calculator
• Don’t be afraid. It is easier than you think!

Converting from the “OLD” drug to the “NEW” drug

1. Calculate the total dose of the “old” opioid in a 24-hour period.
2. Set up the following ratio:

mg “old” opioid = mg “new” opioid

Current mg of (old) in 24 hr. X

Where X = mg of “new” opiod you are trying to calculate in a 24 hours period.

3. Divide the 24-hour dose of the “new” opioid to obtain the desired interval dose
(e.g., q4th, q12h, etc.)
4. When converting from PO to IV, you may want to consider reducing the dose by one third to
one half to accommodate for the first pass effect of oral agents through the liver. Since IV
agents enter the bloodstream directly, a smaller initial dose is indicated.

For Example…

Elizabeth who been taking 30 mg of oxycontin q 4 hours PO can no longer swallow. You want to
start a continuous IV morphine infusion at an equianalgesic dose.
1. 30 mg oxycontin q4h = 30 mg x 6 doses in a 24-hours period = 180 mg oxycontin in a 24-hour
period.
2. Your equianalgesic dose table says that 30 mg PO oxycontin = 30 mg of oral morphine = 10
mg of IV morphine
30 mg PO Oxycontin = 10mg IV morphine
180 mg PO oxycodone/24 hrs X mg IV morphine/24 hrs

X= 60 mg IV morphine in 24 hrs

3. The hourly infusion rate = 60 mg in 24 hrs = approximately 2.5 mg IV morphine per hour.

4. Since we are converting from PO to IV – we should reduce the dose by 1/3 to ½ to

accommodate for the first pass effect of oral agents through the liver.

2.5 mg/hour /2 = 1.25 mg per hour

2.5 mg/hour /3 = 0.8333 = 2.5 – 0.833 = 1.67mg/hour

New dose of IV Morphine should be between 1.25-1.67 mg/hour based upon your patient’s
specific needs.

22
Another Example…

Diane, a status post MVA patient, has had satisfactory relief of pain with an IV
hydromorphone infusion of 1 mg per hour. You want to send her home on an equianalgesic
dose of sustained release oral morphine (MS Contin or OraMorph SR given q12h, or Kadian
q day).

1. mg hydromorphone per hour = 24 mg IV hydromorphone in 24 hrs

2. Your equiananalgesic dose table says that 1.5 mg IV hydromorphone = 7.5 of oral
hydromorphone = 30 mg of oral morphine.

Make the dosage ratio:

1.5 mg IV hydromorphone = 30 mg PO morphine

24 mg IV hydromorphone/24 hrs X mg PO Morphine/24 hrs

X = 480 mg PO morphine/24 hrs

3. q12h dose = 240 mg sustained-release morphine PO q12h

4. Since we are not converting from PO to IV reduction in the dose is not needed. Careful
assessment of this patient is needed to ensure this dose is enough however, given liver and
renal function.

Now it is your turn…

Jerry is a 54-year-old male returning to the hospital 2 weeks after port placement for initial doses of
chemotherapy. While receiving chemotherapy in the outpatient setting, he became significantly
nauseated, with uncontrolled episodes of emesis. He is admitted to your facility for re-hydration,
nausea and pain control. Calculate a satisfactory dose of IV morphine for Jerry to control his pain.
At home, he had been taking 100 mg of MS Contin every 12 hours.

Step 1:
Calculate the total dose of the “old” opioid in a 24-hour period

Step 2:
Set up the following ratio

Mg “old” opioid = mg “new” opioid

Current mg of “old” in 24 hr X

Where X = mg of “new” opioid you are trying to calculate in a 24 hour period.

Step 3:
Divide the 24-hour dose of the “new” opioid to obtain the desired interval dose
(e.g., q4h, q12h, etc.)

23
Answer:

1. Jerry has been taking 200mg of MS Contin in a 24-hour period.

2. 30 mg of PO morphine = 10 mg IV morphine

Ratio: 10mg IV morphine = 30 mg PO morphine

X mg IV morphine/24 hrs 200 mg PO morphine/24hrs

X = 66.6 mg IV morphine/24hrs

3. The q1hr dose of the IV morphine is 67 mg / 24 hours = 2.79 mg/hr

4. When converting from PO to IV, you may want to consider reducing the dose by 1/3 to ½ to
accommodate for the first pass effect of oral agents through the liver. Since IV agents enter the
bloodstream directly, a smaller initial dose is indicated

So, 2.8 mg / 2 = 1.4 mg/hour; 2.8 mg / 3 = .933; 2.8 .933 = 1.867 mg

New IV dose should be between 1.4mg and 1.8 mg per hour IV.
The information above is for informational purposes only, and should be used solely as a reference. It should not be
used as a substitute, or in lieu, of professional judgment. RN.com disclaims all warranties, express or implied, related
to the contents of this tool. Always refer to specific facility medication guidelines/standards on medication
administration.

Non-Opioid Analgesia: Acetaminophen and NSAIDs

Another class of analgesics used for controlling
pain is the non-opioids. Non-opioids consist of
acetaminophen (Tylenol), NSAIDs, and Cox-2 •
Inhibitors. Recent information about risks of
Cox-2 Inhibitors has severely limited their use. •
Acetaminophen has antipyretic and analgesic
effects. Often acetaminophen has fewer adverse
affects and may be used safely in patients with •
decreased platelets or gastrointestinal disorders.
However, acetaminophen has very little effect
against inflammation, may cause liver toxicity
and has a maximum dose of 4000 mg/day in most
McCaffery & Pasero, 1999).
Critical Thinking Tip:
Avoid acetaminophen in patients with
liver disease
Avoid NSAIDs in patients with platelet
disorders, bleeding tendencies, history of
gastric ulcers or renal disease.
Some Cox-2 Inhibitors have been taken
off the market, the use of others is now
limited in patients with heart disease.
adult patients (McKenry & Salermo, 2003;

NSAIDs have analgesic, antipyretic and anti-inflammatory effects. The adverse effects of NSAIDs
include gastrointestinal dysfunction (nausea, vomiting, diarrhea, cramps, and gas), gastric ulcers,
gastric bleeding, and interference with platelet aggregation. NSAIDS should be used with extreme
caution in patients with a history of gastrointestinal bleeding or ulcers, those with low platelet
counts, or those with renal insufficiency. Examples of commonly used NSAIDs include: aspirin,
choline magnesium trisalicylate (Trilisate), ibuprofen (Motrin, Advil), ketoralac (Toradol), ketoprofen
(Orudis), and naproxen (Naprosyn) (McKenry & Salermo, 2003; McCaffery & Pasero, 1999).

24
The following table represents commonly used non-opioid analgesics (AHCPR, 1992; Roth, 2002).
Please note that all doses are approximate and the patient’s clinical condition must be taken into
consideration prior to administration of these drugs.

Commonly Used Non-Opioids

Non-Opioid Adult Dose Pediatric Dose Issues
Acetaminophen 650-975 mg q 4hr 10-15 mg/kg q 4 hr Acetaminophen does not
(Tylenol) have anti-inflammatory
properties
Contraindicated in liver
failure or disease
Aspirin 650-975 mg q 4 hr 10-15 mg/dg q 4 Inhibits platelet
hr aggregation
Choline magnesium 1000-1500 mg bid 25 mg/kg bid May have minimal anti-
trisalicylate platelet activity
(Trilisate) Available as an oral liquid
Ibuprofen (Motrin, 400 mg q 4-6 hr 10 mg/kg q 6-8 hr Available as several
others brand name and generic
Available in oral
suspension
Ketoprofen(Orudis) 25-75 mg q 6-8 hr

Magnesium salicylate 650 mg q 4 hr Many brands and generic

forms available
Naproxen 500 mg initial dose 5 mg/kg q 12hr Available as oral liquid
(Naprosyn) followed by 250 mg q
6-8 hr
Naproxen sodium 550 mg initial does
(Anaprox) followed by 275 mg q
6-8 hr
Ketorolac 30 or 60 mg IM/IV Intramuscular/Intravenous
tromethamie initial dose followed by dose not to exceed 5
(Toradol) 15 or 30 mg q 6 hr days
Oral dose following
IM/IV dosage: 10 mg
q 6-8 hr

25
COX-2 Inhibitors
COX-2 inhibitors were developed to reduce inflammation by selectively blocking the COX-2
enzyme. Blocking this enzyme halts the production of prostaglandins that cause the pain and
swelling. The COX-2 inhibitors represent a new class of drugs that do not affect COX-1, but
selectively block only COX-2. This selective action provides the benefits of reducing inflammation
without irritating the stomach. The only COX-2 inhibitor that is now on the market is celecoxib
(Celebrex). The analgesic efficacy of COX-2 selective inhibitors is comparable to non-selective
NSAIDs such as naproxen, ibuprofen, and sulindac and seem to be of great value to people with
arthritis.

Vioxx, known generically as rofecoxib, was recalled in on October 1, 2004, in the largest
prescription drug withdrawal in history. The withdrawal was prompted after a new study examining
Vioxx's impact on bowel cancer found the drug caused an almost twofold increase in heart attacks
and strokes. However, the controversy does not end there. The FDA asked Pfizer to withdraw
Bextra (valdecoxib) from the market because the overall risk of heart disease and life-threatening
skin reactions outweighed its therapeutic benefits. Celebrex is now the only Cox-2 drug on the
market and it carries a very strong warning against cardiovascular and skin complications. One
other Cox-2 inhibitor, lumiracoxib, has been made available outside of the U.S. and is being
marketed under the name Prexige. As of 2007, the drug is still not approved for use in the U.S.

Adjuvant Analgesia
Adjuvants are drugs that are used to treat other disorders but also have analgesic properties.
Adjuvants are most effective against neuropathic pain. They are generally grouped into
antidepressants (amitriptyline [Elavil], desipramine [Norpramin], nortriptyline [Pamelor]),
corticosteroids (dexamethasone [Decadron]), anticonvulsants (gabapentin [Neurontin],
carbamazepine [Tegretol]), and psychostimulants (dextroamphetamine [Dexedrine] and
methylphenidate [Ritalin]) (McKenry & Salermo, 2003). Almost all adjuvants can be given orally,
however some may be given parenterally, transdermally, intrathecally, or epidurally. Most
adjuvants have ceiling effects and must be titrated upward. A delayed response is common until
the drug is at an effective dose and has reached its peak efficacy. Therefore, adjuvants are most
commonly used in chronic pain (McKenry & Salermo, 2003; McCaffery & Pasero, 1999).

Critical Thinking Tip:

• Anticonvulsants and antidepressants are best used to treat neuropathic, chronic pain.
• Titrate adjuvants upwards to achieve desired effect, keeping ceiling doses in mind.

26
 Commonly Prescribed Adjuvants for Pain

Drug Class Drug Name Normal Adult Dose Comments

Corticosteroids Dexamethasone 4-16mg per day May cause hyperglycemia

(Decadron) Do not abruptly stop use.
Antidepressants Amitriptyline 25-150 mg qhs Titration upwards should
(Elavil) occur every 3-5 days by
25 mg increments for
desired dose.

25-150 mg qhs Titration upwards should

occur every 3-5 days by
25 mg increments for
desired dose.
Imipramine is less
sedating
Anticonvulsants Gabapentin 300mg once daily Maximum dose =
(Neurontin) Then 300mg twice a day, 3600 mg/day
titrate to pain relief.

Valproic Acid Begin with 250mg TID and May be given rectally
(Depakote) titrate.

Other routes such as intranasal, rectal, and topical are also effective for pain relief in certain
conditions. Consider what is appropriate for your patient and the best drug for their needs when
advocating pain management strategies.

Non-pharmacological Therapies
In addition to pharmacological therapies, non-pharmacological therapies can augment pain relief in
all pain types. Heat, cold, massage, and repositioning in combination with acetaminophen or a
NSAID may control mild pain. Other useful non-pharmacological measures include talking with a
caregiver, relaxation, distraction, guided imagery, and changing the meaning of one’s pain.
Relaxation is an active process and requires concentration but has a direct physical and mental
effect on how the patient perceives pain. Distraction and guided imagery allow the mind to
concentrate on things other than the pain. Changing the meaning of pain counteracts the negative
thoughts patients have about pain (Davis, 2000). Talking with a caregiver allows the patient to
explore the meaning of their pain and may also provide distraction from the pain. Whichever non-
pharmacological intervention is used to manage the patient’s pain, assessment of the
effectiveness of these therapies must be based upon the patient self-report and re-assessment
must occur.

27
 The WHO Ladder to Manage Chronic Malignant Pain
The World Health Organization (WHO) has advocated using pharmacological and non-
pharmacological strategies in combination for chronic cancer pain with around-the-clock oral
dosing as the basis for effective pain control. The rationale behind around-the-clock oral dosing
stems from the fact that steady drug states are achieved more quickly with around-the-clock dosing
compared to dosing on a PRN only basis. WHO advocates for a three-step approach to managing
pain (WHO, 1996). A visual representation of this method for managing pain is illustrated below.
When pain is not effectively controlled or pain increases, move up the ladder using the treatments
recommended. Multiple studies have illustrated the effectiveness of this approach. Using the
WHO guidelines for cancer pain results in clinically significant pain reduction and reduces the need
for invasive pain control procedures. At a minimum, adequate analgesia was observed in two-
thirds to all patients using this approach (Zech, Grond, Lynch et al., 1995; Jadad & Browman,
1995).

WHO Ladder

Critical Thinking Tip:

• Around-the-clock oral dosing is the most effective pain relief strategy in controlling
chronic pain.
• Advocate for the patient using your knowledge of WHO ladder’s 3-Step Approach to
Freedom from Cancer pain

28
 Special Populations
Treating pain in special populations is based upon individual assessment and knowledge of unique
characteristics of these populations. Infants and children, the elderly, people from different
cultures, and those with a prior history of substance abuse are most likely to experience
inadequate pain control. Therefore, it is useful to discuss pain management in terms of the
specific beliefs and actions of the healthcare provider toward these populations.

Infants & Children

Pain in infants and children is particularly challenging. A popular misconception is that infants’
pain cannot be measured. In fact, infants can express pain through cries and experience an
increase in heart rate and drop in oxygenation as painful as stimuli is received. Additionally, some
healthcare professionals often believe that infants do not experience pain as fully as a child or an
adult. In reality, at birth the infant’s nerve ending are similar if not greater than adults. The infant’s
cortex has a complete set of neurons at 20-weeks gestation. Research shows that in adults,
myelination is not a factor in the infant’s ability to process pain either (McCaffey & Pasero, 1999).
Likewise, children often do not report their pain and may have difficulties describing or quantifying
their pain experience. Utilizing age specific assessments pain tools and knowing common
behaviors in infants and children is paramount to understanding and managing their pain.

Parent or guardian support and interpretation of their child’s pain can be critical however, in the
absence of a parent or guardian how do we safely treat pain in infants and children – without
under-treating? There are many pain scales that can be utilized in this population to qualify and
quantify their pain. Some of these scales are the FLACC, CRIES, NIPS, Faces, and CHEOPS.

FLACC
Evaluation of each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolably is
scored from 0-2, which in total score between zero and ten.

Scoring
Category
1 2 3
Occasional grimace or Frequent to constant
No particular expression
Face frown, withdrawn, quivering chin,
or smile
disinterested clenched jaw
Normal position or Kicking , or legs
Legs Uneasy, restless, tense
relaxed drawn
Lying quietly normal Squirming, shifting back Arched, rigid or
Activity
position, moves easily and forth, tense jerking
Crying steadily
Moans or whimpers;
Cry No cry (awake or asleep) screams or sobs,
occasional complaint
frequent complaints
Reassured by
occasional touching, Difficult to console or
Consolability Content, relaxed
hugging or being talked comfort
to, distractible
Adapted from The FLACC: A behavioral scale for scoring postoperative pain in young children, by S. Merkel and
others, 1997, Pediatric Nurse 23(3), p. 293-297.

29
CRIES
The CRIES tool has been well received by health professionals. The five parameters represented
are below. The maximum score of 10 points is calculated in a similar manner as the Apgar score –
a score of four or more represents pain requiring intervention to reduce pain and maintain comfort.
For example, a grimace, the facial expression most often associated with pain, gains a score of 1
but if associated with a grunt will be scored a 2. The scale is particularly useful for neonatal
postoperative pain. Researchers concluded that CRIES postoperative pain assessment scale was
a valid and reliable measure of postoperative pain in neonates 32 to 60 weeks gestation.

Crying
Requires oxygen to maintain saturation greater than 95%
Increased vital signs
Expression
Sleepless
(See Appendix A for the entire scale and scoring criteria)

NIPS
Neonatal/Infants Pain Scale has been used mostly in infants less than one year of age. Facial
expression, cry, breathing pattern, arms, legs, and state of arousal are observed for one minute
intervals before, during and after a procedure and a numeric score is assigned to each. A score
>3 indicates pain. (See Appendix B for entire scale.)

FACES
Children or persons with cognitive impairment may better quantify their pain using a faces pain
rating scale instead of a numeric scale. A faces pain scale allows the patient to express their pain
using graphical representations of their pain instead of numbers. The Wong and Bakers Faces of
Pain Scale is an alternative to the numerical scale (Wong, 1997).

30
CHEOPS

CHEOPS stands for Children's Hospital of Eastern Ontario Pain Scale. It is intended for children
ages 1-7 yrs old. It assesses cry, facial expression, verbalization, torso movement, if child touches
affected site, and position of legs. Very basically, a score >= 4 signifies pain. (See Appendix B for
entire scale.)

Critical Thinking Tip:

No matter what scale your institution uses, it is important to try to get a self-report from the child
first. Children older than 3 years old can often give an accurate self-report. If a self-report is not
possible, then one of the aforementioned scales can be used or another scale. Be sure you use
the scale appropriate to the age you are trying to assess and you understand how to score and
what the score means.

The Elderly
The elderly are also at risk for the under-treatment of pain. This is largely because of their inability
or reluctance to report pain and healthcare professionals fear of “overdosing” this type of patient.
The elderly may also have varying levels of cognitive impairment. Careful assessment of the
cognitively impaired elder through observable indicators and family information about their loved
one’s pain is very useful in recognizing pain in the elderly (see section on Cognitively Impaired).
When providing opioids for pain control, the key is to start at a low dose and titrate upward until a
desired effect is reached. Renal dysfunction in the elderly may also inhibit adequate pain
management. Therefore, monitoring of appropriate laboratory values is indicated.

The Cognitively Impaired

The cognitively impaired is another population at risk for the under-treatment of pain. Successful
and safe pain control in these patients can be particularly challenging. If your cognitively-impaired
patient can self-report pain, this is the most reliable indicator of pain, and should be believed. If a
person can not understand or use a numerical rating scale, sometimes a verbal descriptor scale
can be utilized effectively. These scales use vague words such as mild, moderate, and severe to
help the practitioner understand their patient’s pain. Other scales that may be useful include the
pain thermometer and the Faces pain scale (Herr & Garand, 2001). The pain thermometer is
diagram of a thermometer with word descriptors that shows increasing pain intensities.

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The Critically Ill
When caring for critically ill, mechanically ventilated patients, one of the most important priorities is
to relieve any pain that the patient might be experiencing. Mechanically ventilated patients can
often still self-report pain, either by blinking or raising a finger with some yes/no questions. Puntillo
(1990) found that 63% of 24 critically ill patients in the ICU experienced moderate to severe pain.
Another study by Stanick-Hutt et al. (2001) showed that of 30 traumatically injured patients in the
ICU, 96% reported pain from their injuries and 36% reported pain related to central lines, chest
tubes, nasogastric tubes, Foley catheters, wound drains, and orthopedic fixation devices.
Additionally, the Thunder Project II, sponsored by the American Association of Critical Care Nurses
(Puntillo et al., 2001) in a study of over 6,000 patients, ages 4 to 97, revealed that even simple
procedures in the ICU were associated with various levels of pain. These procedures include
turning, wound drain removal, femoral catheter removal, central line placement, and non-burn
wound dressing changes. Mechanically ventilated patients often try to communicate pain to their
nurses. Some techniques used to report pain in a mechanically ventilated patient include grabbing
the healthcare professionals arm, signaling with their eyes, and moving their legs up and down
(Puntillo, 1990). Some conscious, intubated patients can self-report and provide some information
regarding their pain. This self-report is the most accurate indicator of pain and should be taken
seriously. Pain relief measures should also be considered in the presence of pathologic conditions
or when procedures that might cause pain are performed. Healthcare professionals should be
aware of and consider behaviors (e.g. facial expressions, body movements, crying), reports from
family members, and physiologic measures such as blood pressure and respiratory rate when
assessing for pain (Pasero & McCaffery, 2000).

Culture Issues
People from different cultures experience pain largely based on their meaning of pain. Be aware
of your own cultural uniqueness and seek to accept the distinct perspectives of others. Be
cognizant of your approach to the patient, including the use of non-verbal communication styles.
The patient’s comfort with eye contact, various body postures, amount of physical space, and
appropriateness of touch are individual to various cultures. It is often difficult for you to be
knowledgeable about all of the possible cultural norms of patients; however, you can be alert to the
patient’s verbal and non-verbal cues. A careful approach to the patient in these instances will
often set the stage for successful pain management.

Patients with Prior History of Substance Abuse

Treating patients with a prior history of substance abuse can be challenging. You may be torn
between providing adequate pain control for the patient and your own reluctance to provide an
adequate dose of an opioid due to fear of future addiction or the thought that you are supporting
“drug-seeking” behavior. Regardless of the drug abused, the disease of addiction increases the
patient’s pain experience through changes in the endogenous opioid pathways, stimulation of the
sympathetic response, and by decreasing the patient’s pain threshold (Savage, 1994; Miller &
Gold, 1993; Mao, Price & Mayer, 1995). While this population may be difficult to treat for
numerous reasons, withholding an opioid for pain relief must not occur. This may even cause the
patient to seek their “old habits” to reduce pain. Instead, judicious assessment and monitoring of
the patient’s pain must be basis in which healthcare providers initiate and adjust pharmacologic
therapies.

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 Conclusion
In conclusion, pain is a multifaceted symptom that must be accurately assessed to be managed
successfully. Healthcare professionals must actively participate in continuing to learn about new
theories and techniques in pain management. Barriers must be addressed at the patient, provider
and system level. A thorough patient history and assessment should be conducted for all existing
and new pain; recognizing that the patient is the best equipped to describe the pain. Successful
pain control is often achieved by providing both pharmacological and non-pharmacological
therapies. Finally, healthcare professionals must be aware of those at risk for under-treatment of
pain and current strategies in managing pain. Pain is a universal affliction and all healthcare
providers must take initiative to appropriately manage pain and alleviate suffering.

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Appendix A

34
 Appendix B
Pain Assessment Tools
Neonatal/Infant Pain Scale (NIPS)
(Recommended for children less than 1 year old) - A score greater than 3 indicates pain.
Pain Assessment Score
Facial Expression
0 – Relaxed Muscles Restful face, neutral expression
1 – Grimace Tight facial muscles; furrowed brow, chin, jaw, (negative
facial expression—nose, mouth, and brow)
Cry
0 – No Cry Quiet, not crying
1 – Whimper Mild moaning, intermittent
2 – Vigorous Cry Loud scream; rising, shrill, continuous (Note: Silent cry
may be scored if baby is intubated as evidence by
obvious mouth and facial movement).
Breathing Patterns
0 – Relaxed Usual pattern for this infant
1 – Change in Breathing Indrawing, irregular, faster than usual; gagging; breath
holding
Arms
0 – Relaxed/Restrained No muscular rigidity; occasional random movements of
arms
1 – Flexed/Extended Tense, straight legs; rigid and/or rapid extension, flexion
Legs
0 – Relaxed/Restrained No muscular rigidity; occasional random leg movement
1 – Flexed/Extended Tense, straight legs; rigid and/or rapid extension, flexion
State of Arousal
0 – Sleeping/Awake Quiet, peaceful sleeping or alert random leg movement
1 – Fussy Alert, restless, and thrashing

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 Children's Hospital Eastern Ontario Pain Scale (CHEOPS)
(Recommended for children 1-7 years old) - A score greater than 4 indicates pain.
Item Behavioral Definition Score
No cry 1 Child is not crying
Moaning 2 Child is moaning or quietly vocalizing silent cry
Cry Crying 2 Child is crying, but the cry is gentle or whimpering
Screaming 3 Child is in a full-lunged cry; sobbing; may be scored with complaint
or without complaint
Composed 1 Neutral facial expression
Facial Grimace 2 Score only if definite negative facial expression
Smiling 0 Score only if definite positive facial expression
None 1 Child not talking
Other 1 Child complains, but not about pain, e.g., “I want to see mommy”
complaints or “I am thirsty.”
Child Pain complaints 2 Child complains about pain
Verbal
Child complains about pain and about other things, e.g., “It hurts; I
Both complaints 2 want my mommy.”
Positive Child makes any positive statement or talks about other things
0
without complaint.
Neutral 1 Body (not limbs) is at rest; torso is inactive
Shifting 2 Body is in motion in a shifting or serpentine fashion
Tense 2 Body is arched or rigid
Torso
Shivering 2 Body is shuddering or shaking involuntarily
Upright 2 Child is in a vertical or upright position
Restrained 2 Body is restrained
Not touching 1 Child is not touching or grabbing at wound
Reach 2 Child is reaching for but not touching wound
Touch Touch 2 Child is gently touching wound or wound area
Grab 2 Child is grabbing vigorously at wound
Restrained 2 Child’s arms are restrained
Neutral 1 Legs may be in any position but are relaxed; includes gentle
swimming or separate-like movements
Squirm/kicking 2 Definitive uneasy or restless movements in the legs and/or striking
out with foot or feet
Legs Drawn
up/tensed 2 Legs tensed and/or pulled up tightly to body and kept there
Standing 2 Standing, crouching, or kneeling
Restrained 2 Child’s legs are being held down
UCLA Pediatric Pain Assessment Tools. (2005). Retrieved September 10, 2005 from
http://www.anes.ucla.edu/pain/assessment_tools.html

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© Copyright 2004 AMN Healthcare, Inc.

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