PAIN

 “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
client’s 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 WHAT’S 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 client’s perception

of what caused the pain?
 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 client’s attention on
something other than the pain

 Thought to reduce the perception of pain by

stimulating the descending control system

 Effectiveness depends on the client’s 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 one’s 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 client’s 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 client’s 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 block others
 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 itching
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