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
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
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
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
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
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
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
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
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