Pain management
Pain Assessment and Management
Learning Outcomes
Demonstrate a comprehensive understanding of the main concepts related to pain
Apply the biopsychosocial model of pain to nursing practice
Identify the importance of providing person-centred care by adopting a biopsychosocial approach when caring for patients with pain
Perform a comprehensive patient assessment and advocate for appropriate care by accepting and acting on the patient’s report of pain
Explain the pharmacology of the three analgesic groups in pain management and the concept of multimodal analgesia
Develop nurse-initiated and collaborative interventions for pain management
Describe the role of the nurse in providing safe and effective pain management for patients receiving patient-controlled analgesia, epidural or intrathecal analgesia, or peripheral nerve blocks
Describe non-pharmacological interventions for pain
What is pain?
"An unpleasant sensory and emotional experience associated with actual or potential tissue damage"
"Pain is whatever the experiencing person says it is, existing whenever he or she says it does"
Types of pain
Acute pain
Directs immediate attention
Short duration and resolves with healing
Responds with analgesics
Rapid rehabilitation
Mostly nociceptive etiology
Simple management with multimodal approach
Poorly controlled pain can lead to adverse outcomes
Rehabilitation can be delayed
Prolonged hospitalization
Chronic pain (Non-cancer)
Persists for months beyond healing time
Poor response to conventional analgesics
Disability, diminished social roles, poor quality of life
Anxiety and depression are common features
Can occur after injury or surgery, with chronic disease and disability
Associated with features of neuropathic pain
Radiates from origin of injury
Other forms of pain
Cancer
Nociceptive
Neuropathic
Nociplastic pain
Mixed
Pain theories
Pain theory
Renē Descartes, 17th-century philosopher
Direct relationship between tissue damage and perceived pain
Biomedical model of pain
Devised 19th and early 20th century
Assessment and treatment focused on underlying tissue damage or injury
Psychological and social factors seen as secondary role and response to pain
Gate control theory of pain
Devised by Melzack and Wall
'Open' and 'Close' gates in the spinal cord to inhibit transmission of noxious signals to the brain
Psychological factors play a role in pain perception
Three brain systems and response to pain
Sensory-discriminative refers to sensory location, intensity, and quality of pain
Motivational-affective refers to the emotional response to pain
Cognitive-evaluative involves the appraisal of pain in terms of attention, meaning, and past experience
Biopsychosocial model of pain
Environment
Pain behavior (disability)
Psychological distress (suffering)
Attitudes and beliefs
Pain perception
Nociception
Physiology of pain
Acute pain is mediated by the nociceptive system
Four physiological processes involved:
Transduction
Transmission
Perception
Modulation
Misconceptions: barriers to the assessment and treatment of pain
The best judges of the existence and severity of patients' pain are the medical staff and nurses caring for the patients
Clinicians should use their personal opinions and beliefs about the truthfulness of patients to determine patients' true pain status
It is essential to establish the patients' self-reports of pain as the standard for pain assessment
Comparable noxious stimuli produce comparable pain in different people
Patients should not receive analgesics until the cause of pain is diagnosed
Visible signs, either physiological or behavioral, accompany pain
Lack of pain expression does not necessarily mean lack of pain
Cognitively impaired older patients are unable to use pain-rating scales
Cognitively impaired patients, especially those who are unable to self-report, do not experience as much pain as those who are cognitively intact
Critically ill patients, especially those who appear to be unconscious or have received a neuromuscular blocking agent, do not feel pain and do not recall painful episodes in intensive care units (ICUs)
Persons with intellectual disabilities (IDs) or mental retardation are either insensitive to pain or have greater tolerance for it
Gathering information
Foundation of pain assessment: accepting the patient’s report of pain
Performing a pain assessment
Starship Child Health Pain assessment and management algorithm
Choose appropriate pain scale for age and development level
Consider location, duration, onset, behavioral signs, physiological signs, contextual factors, cause of the pain
Document intervention (pharmacological & non-pharmacological)
Re-assess
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Pain assessment tools:
FLACC scale
Behavioral Observation Pain Rating Scale
Categories and scoring of pain assessment tools:
Face: No particular expression or occasional grimace (0), frequent to constant frown, withdrawn clenched jaw, quivering chin (1), disinterested expression or smile; or frown (2)
Legs: No position or uneasy, restless, tense (0), kicking, or legs drawn up or relaxed (1)
Activity: Lying quietly, normal position, back and forth, tense moves easily (0), squirming, shifting, arched, rigid, or jerking (1)
Cry: No crying or moans or whimpers (0), crying steadily, screams or sobs, frequent complaints (1)
Consolability: Content, relaxed (0), reassured by occasional touching, hugging, or comfort or talking to (1), difficult to console (2)
Each category is scored from 0-2, resulting in a total score between 0 and 10.
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O L D C A R S T pain assessment:
Onset: When did the pain begin?
Location: Where is the pain? Can the patient point to the location?
Duration: How long does the pain last? Is it persistent or intermittent?
Characteristics: Describe the pain (e.g., crushing, stabbing, indigestion-like, dull, or ache)
Associating factors: What other symptoms are associated with the pain (e.g., nausea, vomiting, weakness, fatigue, breathlessness, syncope, feeling cold and clammy)?
Radiating/relieving factors: Does the pain radiate? Does it stop and start? What relieves the pain?
Treatment: Has the patient taken medication for the pain? Used a heat pack?
Severity: How bad is the pain on a scale of 1-10?
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Potential problems with managing pain:
Example clinical situations and decision-making relating to pain:
Post-anaesthesia: Patient reports severe pain but appears sedated and comfortable based on observations. PACU nurse carries out a thorough physical assessment and discovers a wound haemorrhage, surgical team is engaged to return to the operating suite.
Post-delivery: Woman who delivered her baby by caesarean requests ibuprofen for pain. Nurse discovers she has preeclampsia and collaborates to cease the drug as it may affect kidney function.
Medical ward: Patient admitted for respiratory distress complains of nausea, insomnia, abdominal cramping, and sweating. Nurse undertakes a health history and discovers the patient is withdrawing from opioids because the usual oral oxycodone dose for cancer pain has not been prescribed since admission 4 days ago.
Surgical ward: Patient's pain score is 7/10 at rest after a total abdominal hysterectomy. Decision is made that the pain management plan is inadequate. RN calls the acute pain service and the nurse practitioner orders patient-controlled analgesia.
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Pain management - multimodal approach:
Various approaches to pain management:
Paracetamol
NSAIDs
Opioids
Tramadol
Alpha2 agonists
Ketamine
Local anesthetics
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World Health Organization's Pain Multi-modal Relief Ladder:
Analgesic options based on pain severity:
Free from cancer pain
Opioid for moderate to severe pain
Nonopioid +/- Adjuvant
Pain persisting or increasing
Analgesic Drug Concentration
Opioid for mild to moderate pain +/- Nonopioid
Pain persisting or increasing
Nonopioid +/- Adjuvant
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Pharmacology of analgesics:
Principles for administering analgesics:
Know the patient's previous responses
Administer medications based on clinical reasoning
Know the accurate dosage
Assess the right time and interval for administration
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Risks for administering various analgesics:
Definitions and application of key pharmacological terms:
Pharmacodynamics: What the drug does to the body and events caused by the interaction of a drug with a receptor (e.g., opioids may cause respiratory depression, sedation, nausea, pruritus, and constipation)
Pharmacokinetics: What the body does to the drug and concerns relating to drug absorption, metabolism, distribution, and elimination (e.g., intravenous injection of morphine peaks in 15-20 minutes in plasma)
Half-life: The time it takes for plasma concentration of a drug to decrease by 50% (e.g., half-life of morphine is 2-3 hours)
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Different approaches to pain management:
Non-opioid analgesics
Opioids
Patient-controlled analgesia (PCA)
Continuous subcut infusion devices
Prevention and management of opioid-induced effects
Adjuvants
Local anesthesia and peripheral nerve blocks
Epidural and intrathecal analgesia
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Analgesics:
Opioids:
Act on the central nervous system to reduce pain
Produce analgesia, sedation, respiratory depression, nausea, and constipation
Not recommended for renal impairment
Patient-controlled analgesia (PCA):
Intravenous administration
Patient controls administration
Regular monitoring of patient
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Prevention and management of opioid-induced effects:
Common side effects of opioids:
Constipation
Nausea and vomiting
Sedation
Itching (pruritus)
Ensure lowest effective dose of opioid is administered
Regular monitoring of vital signs, sedation score, and asking the patient
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Adjuvants:
Medications prescribed with analgesics:
Ketamine: Blocks sensory receptors
Clonidine: Agonist with morphine to produce analgesia
Anti-depressants: Enhances serotonin levels, used for chronic pain (e.g., neuropathic pain)
Anti-convulsants: Decrease firing of neurons, used if anti-depressants are ineffective or contraindicated
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Non-pharmacological strategies:
Should be used in conjunction with analgesia, especially if anxiety or fear is present
Strategies include:
Asking the patient about fears and worries
Positional changes
Heat packs
Massage
Distraction and relaxation techniques (e.g., music, videos)
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Treating acute pain:
Assessment of pain:
Pain scores
Functional pain score (3 or more = action)
Review within a short period at the expected peak effect of the drug
Pharmacological or non-pharmacological intervention
Check for side effects
Treatment cycle: Assess, intervene, review
Use pharmacological or non-pharmacological interventions based on pain level
Regular monitoring of patient
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Key concepts
Pain is subjective and exists when the experiencing person says it does.
The patient's assessment of pain and its effectiveness is crucial.
Communication with the patient is essential for determining the outcomes of care.
Taking a biopsychosocial, patient-centered perspective is important.
Four key processes in normal pain processing: transduction, transmission, perception, and modulation.
Psychosocial factors influencing acute pain experience include fear, anxiety, depression, perceived control, pain catastrophizing, and social support.
Healthcare professionals have a responsibility to accept and act on what the patient says about their pain.
Routine pain assessment should include various aspects such as intensity, quality, onset, duration, location, aggravating and relieving factors, associated symptoms, and impact on functioning.
Acute postoperative pain intensity should be assessed at rest and on movement to determine adequacy of pain control.
Analgesia is the cornerstone of acute pain management, and nurses should have knowledge of different types of analgesics.
Multimodal analgesia combining different drugs is recommended for effective pain relief with fewer side effects.
The nursing role is critical for patient safety, including pain assessment, treatment advice, administration, monitoring, and support.
Non-drug therapies can be used in conjunction with analgesia to enhance effectiveness and patient coping.
Accurate and thorough documentation is important for effective communication and reporting.
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Nurses' knowledge and attitudes about pain can impact patient satisfaction.
Financial toxicity and symptom burden in cancer survivors are related.
Opioid-induced respiratory depression can be prevented and reversed.
Chronic pain management requires a biopsychosocial approach.
Pain intensity on the first day after surgery varies across different procedures.
Various resources and studies provide information on pain management.
Pain assessment scales and procedures are available for adults.
Adjuvant and miscellaneous drugs are used in pain management.
Psychopharmacologic and psychotherapeutic approaches are used for pain management.
Acute pain management requires a psychosocial perspective.
Various books and publications provide information on pain management.
Nurse practitioners can lead pain management after caesarean section.
The Pain Catastrophizing Scale is a validated tool for assessing pain.
Therapeutic Guidelines provide information on analgesics.
The biopsychosocial model of pain is important in understanding pain.
Various studies and resources provide