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Chapter 5

Pain: The Fifth Vital Sign

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Definitions of Pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999).

Self-report is always the most reliable indication of pain.

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Types of Pain Types of pain:

Acute pain – usually from injury, disease, or surgery Chronic pain:

• Chronic cancer pain - cancer, HIV• Chronic non-cancer pain– usually associated with tissue injury

that has healed, chronic back pain, arthritis

Sources of pain: Nociceptive

• Somatic pain – cutaneous, superficial, sharp, burning (acute-incisional, chronic-bone mets)

• Visceral pain – organs and linings of cavities, dull, aching, cramping (acute-chest tubes, chronic-pancreatitis)

• Neuropathic pain – nerve fibers, spinal cord, shooting, burning, fiery, painful numbness (acute-phantom limb pain, chronic-diabetic neuropathy)

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Characteristics of Acute/Chronic

Acute Short duration Well-defined cause Decreases with healing Is reversible Ranges from mild to severe May be accompanied by

restlessness and anxiety

Chronic Lasts longer than 3 months May not have defined cause Begins gradually and

persists Exhausting and useless Ranges from mild to severe May be accompanied by

depression, fatigue, decreased functionality

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Attitudes and Practices Related to Pain

Attitudes of health care providers and nurses affect interaction with patients experiencing pain

Many patients are reluctant to report pain:

Desire to be a “good” patient Fear of addiction Fear of falling

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Addiction, Pseudoaddiction, Tolerance, and Physical Dependence

Addiction—primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations

Pseudoaddiction—iatrogenic syndrome created by the undertreatment of pain

Tolerance—state of adaptation in which exposure to a drug results in a decrease in one or more the drug’s effects over time

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Physical dependence—adaptation manifested by a drug-class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist

Withdrawal or abstinence syndrome—N&V, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions

Addiction, Pseudoaddiction, Tolerance, and Physical Dependence

(Cont’d)

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Collaborative Management

History Any precipitating factors, aggravating factors,

character and quality of pain, location, duration

Physical assessment/clinical manifestations:

Location of pain:• Localized pain – confined to the site of origin• Projected pain – along a specific nerve root• Radiating pain – diffuse pain around site of origin not well

localized• Referred pain – perceived in an area distant from the site

of painful stimuli

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Assessing Nonverbal Patients

Six common indicators Facial expressions – grimacing, crying Vocalizations – moaning, screaming Body movements – restlessness Changes in interpersonal interactions Changes in activity patterns or routines Mental status changes – confusion, increased

confusion

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Pain Pharmacologic Therapy—Non-Opioid Analgesics

Acetylsalicylic acid (aspirin) and acetaminophen (Tylenol) are most common

Most are NSAIDs, including aspirin: Can cause GI disturbances COX-2 inhibitors for long-term use

Acetaminophen (Tylenol): Available in liquid form; can be taken on empty stomach Preferable for patients for whom GI bleeding is likely Can cause renal or liver toxicity if used long-term

Ketorolac – toradol Popular NSAID for short term use

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Pain Pharmacologic Therapy—Opioid Analgesics

Block the release of neurotransmitters in the spinal cord

Drugs include codeine, oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol, meperidine, oxymorphone – morphine is the gold standard

There is no ceiling in the dose of a pure opioid agonist

Can be administered via all available routes

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Side Effects of Opioids

Nausea and vomiting – early side effects, often antiemetic give concurrently

Constipation – inhibits peristalsis, initiate measures such as stool softeners and laxatives

Sedation – depress CNS, monitor sedation levels

Respiratory depression – more apt to occur in an opioid naïve patient, reversal agent (Narcan)

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WHO Analgesic Ladder

World Health Organization’s recommended guidelines for prescribing, based on level of pain (1-10, 10 is most severe pain)

Level 1 pain (1-3 rating)—Use non-opioids

Level 2 pain (4-6 rating)—Use weak opioids alone or in combination with an adjuvant drug

Level 3 pain (7-10 rating)—Use strong opioids

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Nursing Interventions to Prevent SE of Opioids

Constipation Assess bowel habits, push fluids, encourage activity, bulk,

roughage, track BMs, administer stool softeners, laxatives, suppositories

Nausea and Vomiting Assess actual cause, temporary SE, antiemetic

prophylactically, oral compazine, reglan before meals and at bedtime

Sedation and Confusion Assess actual cause, may occur after 2-3 days, caffeine

may counteract effect, consider opioid rotation

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Nursing Interventions to Prevent SE of Opioids

Respiratory Depression Rarely seen in patients with severe pain caused by cancer Recognize pain and stress counteract respiratory

depression Respiratory depression usually preceded by sedation Monitor sedation level and respiratory status frequently for

the first 24-48 hours Respiratory rate alone is NOT indicative of respiratory

status In an unresponsive patient administer Narcan and observe

the patient

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Pain Management in End of Life

Opioid regimen should stay consistent with dose in weeks before last weeks of life

Generally believed that patient still feels pain when unconscious

Does not hasten death unless the dose was not properly and gradually titrated

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Routes of Opioid Administration Can be administered by every route used

Oral Rectal Intramuscular Transdermal Topical Sublingual Subcutaneous Intravenous PCA Spinal (Epidural and Intrathecal)

PRN range orders Prescribing guidelines Monitoring guidelines

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Spinal Analgesia

Epidural Analgesia

Intrathecal Analgesia Intrathecal catheter and infusion pump placement is

surgery to insert a catheter into the spinal fluid of the lumbar region and connect it to a pump underneath the abdominal skin that delivers medicine to the catheter. This procedure is used to control pain or other conditions that cannot be adequately treated by oral medication or treatments.

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Oxford University Press On-LineAaron Filler, MD

, PhD FRCS (SN)

About the Book Illustrations Table of Contents

Glossary

Index

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Disks, Spurs, Stenosis: Slippage, and Osteoporosis Chapter 6

Dermatome Map of the Body

Each of the spinal nerves provides sensation to a predictable area of skin. Pain radiating down the leg to the small toe in the general pattern of the S1 dermatome suggests that a herniated disk may be pinching the S1 nerve root in the spine. Reproduced from Atlas of Human Anatomy by Frank Netter, MD, with permission of Icon Learning Systems/Elsevier.

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Ramsey Sedation Scale

Score Response

1 Anxious or Restless or Both

2 Cooperative, Oriented, and Tranquil

3 Responding to Commands

4 Brisk Response to Stimulus

5 Sluggish Response to Stimulus

6 No Response to Stimulus

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Implantable Devices

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Adjuvant Analgesics

Antiepileptic drugs Tricyclic antidepressants Antianxiety agents Local anesthetics Dextromethorphan, ketamine Local anesthesia infusion pumps Topical medications

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Nonpharmacologic Interventions Used alone or in combination with drug

therapy

Physical measures

Physical and occupational therapy

Cognitive/behavioral measures

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Physical Interventions

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Cognitive/Behavioral Measures

Strategies that can be used to relieve pain as adjuncts to drug therapy: Distraction Imagery Relaxation techniques Hypnosis Acupuncture Glucosamine

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Invasive Techniques for Chronic Pain

Nerve blocks

Spinal cord stimulation

Surgical techniques: Rhizotomy Cordotomy

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Community-Based Care

Home care management

Health teaching

Health care resources

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Pediatric Analog Sedation Score.

Elsharkawi N G Anesth Analg 1999;88:227-227

©1999 by Lippincott Williams & Wilkins

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Question

The nurse assesses the sedation level of a patient receiving epidural morphine analgesia after a knee replacement. When assessing the patient for side effects of the drug, the nurse notes that the patient is slightly drowsy but can be easily aroused. What is the nurse's best action at this time?

A. Stop the morphine infusion immediately.B. Document the assessment on the sedation scale.C. Notify the charge nurse on the unit.D. Ask another nurse to assess the patient.

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LEARNING OUTCOMES Safe and Effective Care Environment Act as an advocate for patients in acute and chronic pain. Develop a teaching/learning plan for managing pain as part of community-based care. Health Promotion and Maintenance Teach patients in pain about complementary and alternative therapies as additions to their established

plan of care. Perform a complete pain assessment, and document per agency policy. Psychosocial Integrity Discuss the attitudes and knowledge of nurses, physicians, and patients regarding pain assessment

and management. Physiological Integrity Differentiate between addiction, pseudoaddiction, tolerance, and physical dependence. Compare and contrast the characteristics of the major types of pain and examples of each. Explain the role of non-opioid analgesics in pain management. Compare common opioid analgesics, using an equianalgesic chart. Develop a plan of care to prevent common side effects of opioid analgesics. Compare the advantages and disadvantages of drug administration routes. Determine the patient’s need for pain medication, including PRN and adjuvant therapy. Prioritize care for the patient receiving patient-controlled analgesia. Provide care for a patient receiving epidural analgesia. Identify special considerations for older adults related to pain assessment and management. Incorporate complementary and alternative therapies into the patient’s plan of care as needed to

control pain