1. PAIN

2.  “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

3.  “whatever the person
says it is, existing
whenever the
experiencing person
says it does” –
McCaffery &
Pasero, 1999
 Emphasizes the highly
subjective nature of pain

4.  Pain is the most
COMMON reason
clients seek medical
advice
 Pain is a protective
mechanism or a
warning to prevent
further injury

5. THE PATHOPHYSIOLOGY OF PAIN

6. 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

7.  Large internal organs do not contain nerve
endings
 Polymodal nociceptors respond to all three
types of stimulus
 Histamine, bradykinin, acetylcholine, seroto
nin, and substance P are chemicals that
increase transmission of pain

8.  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”

9.  Chemicals that reduce or inhibit the
transmission or perception of pain include
endorphins and enkephalins

10. 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

11. 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

12.  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

13. FACTORS INFLUENCING PAIN
RESPONSE

14.  Past experience
 Anxiety and Depression
 Culture
 Gender
 Genetics
 Placebo effect

15. PAIN ASSESSMENT

16.  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

17.  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

18.  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?

19.  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?

20.  P – provoked
 Q- quality
 R – region/radiation
 S – severity
 T - timing

21.  O – onset
 L – location
 D – duration
 C – characteristic
 A – aggravating factors
 R – radiation
 T – treatment

22. 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.

23. 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.

24. 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.

25. 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

26. 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

27. 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

28.  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

29. NON PHARMACOLOGIC
INTERVENTIONS

30.  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

31. 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

32.  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

33. 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

34.  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

35.  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

36. 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

37. 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

38.  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

39. 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

40. 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

41. 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

42. Music therapy
 An inexpensive and effective therapy for the
reduction of pain and anxiety

43. PHARMACOLOGIC INTERVENTIONS

44. 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

45. APPROACHES FOR USING
ANALGESIC AGENTS

46. 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

47. Pro re nata
 The nurse waits for the client to complain of
pain and then administer analgesia

48. 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

49.  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

50. 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

51.  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

52.  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

53. 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

54.  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

55.  NSAIDs block synthesis of prostaglandin
 Examples are salicylates (aspirin); NSAIDS
(ibuprofen, ketorolac, naproxen); COX-2
inhibitors (celecoxib); acetaminophen

56. 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

57.  Monitor CBC, liver/renal function tests, and
for signs and symptoms of GI bleeding
 Remember: NSAIDS!!!

58. 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

59.  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

60.  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

61. 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)

62. 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

63. 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

64.  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

65. Fentanyl (Sublimaze,
Duragesic)
 Can be administered parenterally,
intraspinally, or by transdermal patch

66. 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

67. 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

68.  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

69. 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

70. Steroids
 May reduce pain by decreasing inflammation
and the resultant compression of healthy
tissues

71. 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

72. 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

73.  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

74. 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

75. ROUTES FOR ANALGESIC
ADMINISTRATION

76. Oral
 Preferred route in most cases
 Convenient, inexpensive
 Slower onset than IV
 Can provide consistent blood levels

77. 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

78. 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

79.  May be less effective in smokers owing to
circulatory alterations
 Absorption may be increased with fever
 Use caution not to touch medication when
applying

80. 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

81. Intramuscular
 For acute pain
 Rapid pain relief
 Painful
 Use only if other routes cannot be used

82. 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

83. 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

84. SURGICAL INTERVENTIONS

85. 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

86.  Care must be taken to destroy only the
sensation of pain, leaving motor functions
intact

87. 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

88.  The spinal roots are divided and banded with
a clip to form a lesion and produce
subsequent loss of sensation

89. 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