PAIN MANAGEMENT

What is the IASP (2021) definition of pain?

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

What is McCaffery's (1968) classic definition of pain?

"Whatever the experiencing person says it is, existing whenever he says it does."

What is considered the most reliable indicator of pain?

The patient's self-report of pain.

Why is pain sometimes called the "fifth vital sign"?

Because pain assessment is considered so important to quality, safe patient care that it's assessed alongside the four traditional vital signs.

Can pain be measured objectively?

No — pain is personal and subjective; it cannot be measured objectively.

What causes acute pain, and how long does it last?

Tissue damage from surgery, trauma, burns, or venipuncture; it is short in duration.

What causes chronic pain, and how long can it last?

Can be from cancer or noncancer origin (e.g., peripheral neuropathy, back pain); can persist for a lifetime.

What is breakthrough pain?

Chronic pain with an acute exacerbation (e.g., baseline arthritic knee pain that suddenly becomes unbearable with weight-bearing).

What is nociceptive pain?

Pain arising from damage to non-neural tissue with normal pain transmission (physiologic pain) — e.g., surgical incisions, trauma, burns.

What is neuropathic pain?

Pain caused by a lesion or disease of the somatosensory nervous system (pathophysiologic pain) — e.g., diabetic neuropathy, shingles (postherpetic neuralgia); may occur without tissue damage or inflammation.

What are the four processes of nociception?

Transduction, transmission, perception, and modulation.

What is transduction?

The process by which noxious stimuli (e.g., a surgical incision or burn) activate primary afferent neurons called nociceptors.

Where are nociceptors located in the body?

Throughout the body in the skin, subcutaneous tissue, visceral (organ) tissue, and somatic (musculoskeletal) tissue.

What is transmission in nociception?

The action potential traveling along A-delta fibers (rapid, thermal/mechanical injury, responsible for rapid reflex withdrawal) and C fibers (slower, respond to thermal/mechanical/chemical stimuli).

What is perception in nociception?

The awareness of pain, which requires activation of higher brain structures.

What is modulation in nociception?

The body's ability to regulate pain perception; occurs at every level from the periphery to the cortex and involves many neurochemicals.

What excitatory compounds are released during transduction?

Serotonin, bradykinin, histamine, substance P, and prostaglandins.

How do NSAIDs relieve pain at the transduction level?

Prostaglandins initiate inflammatory responses; NSAIDs inhibit COX (cyclooxygenase) enzymes, producing anti-inflammatory and pain-relieving effects.

What are the key components of a comprehensive pain assessment?

Patient's verbalization/description, onset and duration, etiology/mechanism of injury if known, location, quality/character/intensity, aggravating factors, alleviating factors, effect on function, and the patient's pain management goal.

What does the PQRST pain assessment acronym stand for?

P = Provokes (what causes it), Q = Quality (what it feels like), R = Region & Radiates (where/does it spread), S = Severity (0-10 scale), T = Time (onset, duration, what treatment helps).

Which pain assessment tool is used for verbally communicative patients?

The 0-10 Numeric Rating Scale.

Which pain assessment tool uses facial expressions to help describe pain?

The Wong-Baker FACES Pain Rating Scale.

Which pain assessment tool is used for critically ill patients who cannot self-report (e.g., intubated ICU patients)?

The Behavioral Pain Scale (BPS).

Which pain assessment tool is used for patients with advanced dementia or cognitive impairment?

The PAINAD Pain Scale.

What objective physiologic indicators can suggest a patient is in pain?

Increased heart rate (tachycardia), elevated blood pressure, increased respiratory rate (tachypnea), and nausea/vomiting.

What does the FLACC scale assess, and in whom?

Face, Legs, Activity, Cry, and Consolability — used for young children who cannot self-report.

Should the same pain assessment tool be used consistently throughout a hospital stay?

Yes, when possible, to allow for accurate comparison over time.

If a patient rates pain a 7/10 but requests oral pain pills instead of the ordered IV push medication, what should the nurse do?

Honor the patient's request and document it (e.g. 'per patient request, wanted hydrocodone, pain scale 7/10') — the nurse must chart the reason behind giving a medication that doesn't strictly match the pain scale protocol.

What are the three first-line IV push opioid analgesics discussed?

Fentanyl, morphine, and hydromorphone (Dilaudid).

How would you describe fentanyl's onset and duration?

Fast onset, short duration.

How would you describe morphine's onset and duration?

Slower onset, longer duration; it can build up in fat cells.

How does hydromorphone (Dilaudid) compare in strength to morphine?

It is 2 to 8 times stronger than morphine, with onset/duration intermediate between morphine and fentanyl.

What is hydrocodone used for, and how is it typically given?

PO (oral), for mild to moderate pain, usually combined with a nonopioid like acetaminophen.

How do opioid analgesics work physiologically?

They act on the CNS to inhibit the activity of ascending nociceptive pathways.

How do NSAIDs relieve pain?

By inhibiting cyclooxygenase (COX), an enzyme that causes inflammation.

How do local anesthetics relieve pain?

By blocking nerve conduction when applied to nerve fibers.

What are examples of nonopioid analgesics?

Acetaminophen and NSAIDs (ibuprofen, naproxen, celecoxib).

What is multimodal pain management?

Combining medications that act on different receptors/pathways (e.g., an opioid plus a nonopioid and/or an adjunct) to control pain more effectively than a single agent alone.

Give an example of a multimodal postoperative pain regimen for moderate-to-severe pain.

Morphine 2-4 mg IVP q4-6h PRN (opioid) + Ketorolac 30 mg IVP q6h (NSAID, usually only for 5 days postop) + Gabapentin 300 mg PO BID (adjunct).

What adjunctive medications are used for neuropathic/nerve pain?

Anticonvulsants like gabapentin and pregabalin (Lyrica); antidepressants such as TCAs (amitriptyline, desipramine, nortriptyline) and SNRIs (duloxetine, venlafaxine).

What is pregabalin's brand name, and what conditions is it associated with?

Lyrica; used for nerve pain and restless leg syndrome.

What is a typical starting dose of gabapentin for burning neuropathic pain?

300 mg, usually twice a day.

What local anesthetic adjunct can be applied directly over a painful area?

Lidocaine patch 5%.

What is ketamine used for in pain management, and what is a key risk?

A dissociative anesthetic used in the OR and in pain clinics (smaller doses); high doses can cause hallucinations.

What is a TENS unit, and how does it work?

Transcutaneous Electrical Nerve Stimulation — delivers low-voltage electrical current near the nerves at the pain site, blocking or changing the patient's perception of pain.

What is the normal adult respiratory rate range?

12 to 20 breaths per minute.

What is bradypnea, and what is its main cause in a patient on opioids?

A respiratory rate below 12; the main cause is drug overdose.

What should the nurse always check before administering an opioid?

Respiratory rate and sedation level.

What is the most common antagonist used to reverse opioid effects?

Naloxone.

What adverse opioid effects does naloxone reverse?

Respiratory depression, sedation, and hypotension.

By what routes can naloxone be administered?

IV (undiluted), IM, and intranasally.

What is the adult IV naloxone dose, and can it be repeated?

0.4-2 mg IV, may repeat every 2-3 minutes up to 10 mg if necessary.

Before administering opioids to a patient, what must be present on the chart?

A naloxone PRN order — if it is not there, the nurse should not give the opioid and should contact the provider.

After administering naloxone, should the nurse give the patient more opioids for their pain?

No — naloxone completely reverses the opioid effect (including pain relief), so the patient should be monitored rather than immediately re-dosed with an opioid.

What is opioid physical dependence?

A normal physiologic response after 2+ weeks of opioid use, manifested by withdrawal symptoms if stopped abruptly.

What is opioid tolerance?

A normal response to regular opioid use in which increased doses are needed to achieve the same pain relief.

What is substance use disorder, in the context of opioids?

Using opioids for non-therapeutic reasons.

On the Pasero Opioid-Induced Sedation Scale, what does a score of 3 mean, and what should the nurse do?

Frequently drowsy, arousable, drifts off to sleep during conversation — unacceptable; monitor respiratory status and sedation level closely until stable and RR is greater than 12.

On the Pasero scale, what does a score of 4 mean, and what should the nurse do?

Lethargic, minimal/no response to stimulation, RR less than 12 — unacceptable; stop the opioid, consider naloxone, call the Rapid Response Team, stay with the patient, and support respirations; notify the provider.

What are common adverse effects of analgesic agents?

Respiratory depression, sedation, nausea/vomiting, constipation, and pruritus.

Why do opioids commonly cause constipation?

They cause delayed gastric emptying, slowed bowel motility, and decreased peristalsis; risk increases with age.

What medication is commonly given for opioid-induced pruritus?

An antihistamine, such as diphenhydramine.

What medication is commonly given for opioid-induced nausea/vomiting, and how?

Ondansetron (Zofran), 4 mg IV push.

When should pain be reassessed after a parenteral (IV) pain medication?

Within 15-30 minutes.

When should pain be reassessed after an oral pain medication?

Within 1-2 hours.

What nursing documentation principle applies to pain reassessment?

"If it is not charted, it was not done."

Why are older adults more sensitive to opioid analgesics?

They metabolize pain medication more slowly than younger adults, and are more sensitive to sedation and CNS effects.

How should opioid dosing be approached in older adults?

Initiate with a low dose and titrate slowly, reassessing response before increasing.

By how much should the opioid starting dose be reduced in adults older than 70?

By 25% to 50%.

Why are NSAIDs used cautiously in older adults?

Increased risk for NSAID-induced GI toxicity (bleeding), and NSAIDs can damage the kidneys, which may already have reduced function in older adults.

What analgesic is preferred for mild pain in older adults?

Acetaminophen.

In the geriatric morphine case example, what happened when a young, fit patient vs. an elderly patient received similar opioid doses?

The young patient metabolized fentanyl quickly and was alert within 15 minutes; a 70-year-old given 1 mg of morphine was asleep for the whole hour — illustrating that patients must be dosed individually, not by a "one size fits all" approach.

What are examples of natural product-based nonpharmacologic pain therapies?

Herbs, botanicals, vitamins, and probiotics.

What are examples of mind/body nonpharmacologic pain therapies?

Acupuncture (acupressure), chiropractic manipulation, massage therapy, yoga, and tai chi.

What is an example of a physical modality nonpharmacologic pain therapy?

Cold therapy/cryotherapy.

What are examples of cognitive/behavioral nonpharmacologic pain therapies?

Hypnosis and meditation.

Can nonpharmacologic therapies replace pharmacologic therapy for severe pain?

No — they are usually effective alone only for mild-to-moderate pain; for severe pain they should complement, not replace, pharmacologic therapy as part of a multimodal approach.

Why is sucrose water sometimes given to infants for pain?

Sucking is soothing to infants, so the sucking motion helps comfort them.

What is a "walking epidural," and what does it contain?

An epidural block without lidocaine — just fentanyl or Dilaudid — allowing the patient to still walk/get out of bed.

If a patient's epidural block contains lidocaine, what precaution must the nurse take?

The patient cannot get out of bed, because lidocaine numbs the legs and the patient would be at risk of falling.

How long must a patient be NPO before general anesthesia during labor and birth?

At least 6 to 8 hours.

Is it true that infants and children don't feel pain the way adults do?

No — this is a myth; children and infants do experience pain and must be treated appropriately.

What behavioral indicators suggest an infant is in pain?

Lashing/kicking legs, throwing arms around, crying, and sweating.

What objective physiologic indicators suggest a pediatric patient is in pain?

Increased respiratory rate, increased blood pressure, increased heart rate, and increased intracranial pressure.

What factors affect a child's response to pain?

Type of pain, extent of pain, age/developmental level, and cultural/family norms surrounding expression of pain.

How should nurses adjust communication about pain based on a child's developmental level?

Ask younger children (toddlers) about their "boo-boo"; be aware teens may be reluctant to admit pain because they don't want to seem out of control.

What non-pharmacological technique is especially helpful for disoriented, crying children waking from anesthesia?

Distraction (e.g., holding/rocking the child, providing games or a phone) while waiting for the parents.

What is conscious sedation, as used in pediatric procedures?

The child is breathing on their own but sedated, often used for minor procedures (e.g., removing a swallowed object).

Are medications used for pediatric pain management different from those used for adults?

Largely the same medications (opioids and nonopioids) — just dosed differently for children.

In pediatric pain assessment, what two vital signs/parameters are especially important to monitor when giving pain medication?

Level of consciousness and respirations (and oxygen saturation).

Does addiction commonly occur when pain medication is taken for legitimate pain relief?

No — addiction rarely occurs when pain medication is taken for legitimate pain relief; this is supported by research.

How should a patient with a history of opioid use disorder be treated for acute pain (e.g., a fracture)?

They should still receive adequate pain relief using a multimodal approach, which may include opioids.

What is the nurse's ethical obligation when a patient reports pain?

To believe the patient and provide respectful, individualized care regardless of personal characteristics, values, or beliefs.

Are placebos an ethical approach to pain management?

No.

What is the nursing process framework for pain management?

Identify goals for pain management, establish a nurse-patient relationship with teaching, and perform a comprehensive, evidence-based pain assessment.

What is an example of a realistic postoperative pain management goal?

Reduce the pain score enough (e.g., to about a 3/10) that the patient can move from bed to chair or ambulate, without being overly sedated.

How does Maslow's Hierarchy of Needs apply to pain management at the Physiological level?

Adequate pain relief ensures physiological needs are met, allowing the body to function optimally.

How does Maslow's Hierarchy apply to pain management at the Safety level?

Patients need to feel safe and secure during pain management — a calm environment, explained procedures, and minimized anxiety.

How does Maslow's Hierarchy apply to pain management at the Love/Belonging level?

Emotional support from providers, family, and friends (compassion and empathy) contributes to overall pain control.

How does Maslow's Hierarchy apply to pain management at the Esteem level?

Recognizing patients' coping efforts and offering encouragement/positive reinforcement boosts self-esteem.