Pain management

PAIN MANAGEMENT
Jamilah Saad Alqahtani
Nurse Lecturer, MSN,TOT, OR Nurse Specialist, RGN, BSN

At the end of this lecture, the student will be
able to:
■ Compare the characteristics of acute pain, chronic pain, and cancer
pain.
■ Describe factors that can alter the perception of pain.
■ Describe the pathophysiology of pain.
■ Describe the use of pain measurement instruments.
■ Identify appropriate pharmacologic and non-pharmacologicpain
management.
2jamilah s alqahtani1/18/2020

Definition
■ Is an unpleasant sensory and emotional experience
resulting from actual or potential tissue damage.
■ Is the most common reason for seeking health care.
■ May result from many disorders, diagnostic tests, and
treatments.
■ Pain is what a patient says it is.
■ Pain is totally subjective.
■ Everyone experiences pain differently.

Definition
■ considered the 5th vital sign
■ Joint Commission (JCI) standards state that “pain
is assessed in all patients” and that “patients
have the right to appropriate assessment and
management of pain.”

Classic Types
1. Acute Pain
■ Usually of recent onset and commonly associated with a
specific injury.
■ Can last from seconds to 6 months.
2. Chronic Pain
• Is constant or intermittent pain that persist beyond the
expected healing time .
• Is defined as pain lasting for 6 months or longer.
• Is often difficult to treat because the cause or origin may be
unclear

Classic Types
3. Cancer Pain
•Can be directly related with cancer
due to nerve compression or as a
result of treatment (surgery)
•NOTE! Most cancer pain is a direct
result of tumor involvement.

Pathophysiology
1. Nociception
■ Refers to neurologic transmission of pain.
■ Nociceptors are receptors involved in the transmission of pain perceptions to and
from the brain.
■ Nociceptors are free nerve endings in the skin that
respond ONLY to possibly damaging stimuli.
■ Such stimuli can be mechanical, thermal or
chemical in nature.

Pathophysiology
2. Peripheral Nervous System
■ In response to an injury, pain-causing substances are released into the body tissue
and increase the transmission of pain.
– Examples: histamine, bradykinin, serotonin and
prostaglandin.
■ Chemicals that reduce or inhibit the transmission or perception of pain include
endorphins and enkephalins.

Pain Assessment: Characteristics
■ INTENSITY
– ranges from none to mild discomfort to excruciating
– Is influenced by pain threshold (the point at which a stimulus is
perceived as painful) and pain tolerance (the maximum amount of
pain a person can tolerate).
■ TIMING
– refers to the onset of pain whether it began suddenly or gradually
and if what time the pain gets worst.
– Example: ischemic pain (gradual) & arthritis pain (at night)

■ LOCATION
– Point to the area of the body where the pain originates.
– May use drawings of human figures and patient is asked to shade in the
area involved.
– Identifies radiating or referred pain.
■ QUALITY
– Description of pain in own words by asking how the pain feels like.
– Can be burning, aching, throbbing, or stabbing.

■ PERSONAL MEANING
– How the pain affects the patient’s daily life.
– Patient experience pain differently.
■ AGGRAVATING ANDALLEVIATING FACTORS
– What makes the pain worse and what makes it better.
■ PAIN BEHAVIORS
– Example: facial grimace, crying, rubbing the affected area,
guarding movements, immobilizing the affected area

■ Visual Analogue Scale
– is a horizontal 10-cm line with anchors (ends) indicating the extremes of pain
with left anchor (no pain) and right anchor (severe/worst pain)
– To score the results, a ruler is placed along the line, and the distance the
patient marked from the left is measured in millimeters or centimeters.

■ 0-10 Numeric Pain Intensity Scale
■ Simple Descriptive Pain Intensity Scale

■ Face Pain Scale
– Has 6 faces showing expressions appropriate for
helping children describe pain.
– Patient is asked to point to the face that most
closely be like the intensity of his or her pain.

A. Opioid Analgesic Agents
• Oral route is preferred while other routes include intravenous, subcutaneous,
intranasal, rectal and transdermal.
• Are metabolized by the liver and excreted by
the kidneys.
• Drug tolerance develops in patients
– Tolerance: the need to increase dose to achieve
the same therapeutic level.

• Adverse effects:
1. Respiratory depression and sedation – most serious if given intravenous, subcutaneous
and epidural.
2. Nausea and vomiting – can be managed by fluids, antiemetics, and moving patient
slowly.
3. Constipation – common side effect; give laxatives or stool softeners, fluids, and fibers.
4. Pruritus (itching) – give antihistamine.
• Examples:
– Morphine
– Codeine - also an antitussive (anti-cough)
– Meperidine
– Tramadol

B. Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
• More effective when given with opioids.
• Administer smaller doses to patients with impaired kidney function.
• Long-term use causes gastro-intestinal tract irritation and bleeding.
• Has some anticoagulant effects.
• Examples:
– Celecoxib
– Ibuprofen
– Aspirin - Oldest NSAID

World Health Organization
(WHO)
"Pain ladder" describes its guidelines for the use
of drugs in pain management
■ Bottom step of ladder (mild pain):
Non opioid
■ Middle step of ladder (moderate pain): Weak
opioid +/- non opioid
■ Highest step of ladder (severe pain): Strong
opioid +/- non opioid

C. Local Anesthetic Agents
• Blocks nerve transmission.
• Administered topical or by injection.
• Are rapidly absorbed in the bloodstream which
increases the risk for toxicity.
• Example: Lidocaine

Approaches for Using Analgesic Agents
■ BALANCEDANALGESIA
– Use of more than one type of analgesic for more pain relief with fewer side effects.
– NOTE:Use of one agent alone require higher dose to be effective.
■ PRO RE NATA (PRN) or “As Needed”
– Means analgesic is administered only after the client complains of pain.

• PREVENTIVE APPROACH
– Administering analgesic agents at a set of intervals.
– Aims to allow the medication to act before the pain gets worst.
– Example: every 4 hours, around-the-clock
• PATIENT-CONTROLLED ANALGESIA (PCA)
– Allows patient to control the administration of their own medication within
a pre-set amount.
– Is controlled by a timing device to prevent getting additional doses.

23
Patient-Controlled Analgesia
jamilah s alqahtani1/18/2020

1. Massage
– A cutaneous stimulation of the body.
– Promotes comfort through muscle relaxation.
2. RelaxationTechnique
– Relaxes stressed muscles that add to the pain.
– Consists of abdominal breathing at a slow, rhythmic rate.
– Close both eyes and breathe slowly and comfortably.

3. ThermalTherapies
• Stimulate nonpain receptors in the
injury site.
A. Ice therapy
– Apply immediately after injury
– Should no longer be more than 15-20 minutes to
avoid problems such as frostbite or nerve injury.
B. HeatTherapy
– Increases blood flow to the area.
– Reduces pain and speeds up healing.

4. Transcutaneous Electrical Nerve Stimulation (TENS)
– uses a battery-operated unit with electrodes applied to the skin to produce a vibrating
sensation in the pain site.

5. Distraction
– involves focusing the patient’s attention on something other than the pain.
– Decreases pain stimuli transmitted to the brain.
– Examples: watchingTV, listening to music, mental games

6. Guided Imagery
■ Combines slow breathing with a mental image of relaxation and
comfort.
7. MusicTherapy
• Inexpensive and effective pain relief therapy.

7. Hypnosis
• Must be conducted by skilled people like
psychologist or a nurse with special
training.
• Effectiveness depends on the hypnotic
susceptibility of the patient.

ThankYou!
Any Questions?

Pain management

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