This document discusses pain management and common misconceptions about pain. It defines pain and describes pain assessment and different types of pain. Non-pharmacological and pharmacological pain management methods are outlined, including the WHO analgesic ladder and use of opioid and non-opioid medications. Side effects of pain medications are also summarized. Assessment tools for pain are listed along with why standardized scales are important for evaluating pain.

1. Pain Management
Prepared & Presented by
Ahmad Thanin

2. Pain—the definition….
 An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.
 Most common reason for seeking health care.
 Pain is considered the 5th vital sign.
 Pain Management – is a process of assessing,
treating and re-assessing pain utilizing non-
pharmacologic and pharmacological method.

3. Common Misconceptions
among Elderly and Nurses
 Pain is unavoidable.
 Pain is a punishment.
 Asking for pain medication is too
demanding and means I’m not a
good patient.
 Pain medication are addictive.
 Taking pain medications means
I’ll lose my independence and
mental clarity.
 Pain is not harmful.
 Nurses don’t have the time to
give extra medication.
 Elderly patients have
decreased sensations of pain.
 Elderly patients who are
cognitively impaired don’t feel
pain.
 A sleeping patient is not in
pain.
 Elderly patients complain more
about pain as they age.
 Narcotics will hasten death.
 Potent analgesics are
addictive.
 Potent pain meds will cause
respiratory depression.

4. Descriptions of pain:
 Duration
 Location
 Etiology
 Intensity
 Quality
 Temporal pattern
 Associated characteristics

5. Pain assessment:
 Should be as automatic as taking
pulse and BP.
 Pain is the 5th vital sign

9. Pain threshold: amount of pain
stimulation a person requires
before feeling pain.
Pain tolerance: the highest
intensity of pain that the
person is willing to tolerate.

10. The categories of pain:
Acute Chronic
Cancer – Related
Pain
Breakthrough Pain
Pain
Categories

11. Effects of acute pain:
 Neuroendocrine response to stress
 Increased metabolic rate
 Increased cardiac output
 Impaired insulin response
 Increased retention of fluids
 Increased risk for physiologic disorders
 Decreased deep breathing and mobility

12. Effects Chronic Pain:
 Suppressed immune function
 Resultant increased tumour growth
 Depression and lack of motivation
 Anger
 Fatigue

14. What alternative therapies can
close the gate?
 Music
 Distraction of any sort
 Ice and heat therapies
 Deep breathing
 Massage
 Art therapy

15. Alternative therapies which may
close the gate:
 Cutaneous stimulation and massage
 Transcutaneous electrical nerve
stimulation
 Relaxation techniques
 Guided imagery
 Hypnosis

16. Let’s try an experiment….
Have each attendant take pen
and place over nail bed and push.
Describe sensation to neighbor.
All the same?
Now try counting backwards
from 10 while holding pressure on
nail bed. Is the pain as bad?

17. Pharmacological management:
 Selection of appropriate drug, dose, route
and interval
 Aggressive titration of drug dose
 Prevention of pain and relief of
breakthrough pain
 Use of coanalgesic medications
 Prevention and management of side
effects

18. WHO Analgesic ladder

20. WHO 3-step Analgesic ladder
COX-2, Aspirin, Acetaminophen, Diclofenac, Ibuprofen, Tenoxicam,
Panadeine, Nurofen. Pain rating 1-2-3
Non-opioid (mild pain) +/- adjuvant
Opioid (mild to moderate pain) +/- non-opioid adjuvant +/- adjuvant
Codeine, Propoxyphene, Tramadol, Sevredol, DHC Continus,
Dihydrocodeine tartate. Pain rating: 4-5-6
Opioid (moderate to severe pain)
+/-non-opioid, +/-adjuvant
Step 1
Step 2
Step 3
Oxycodone, Morphine, Fentanyl, Pethidine
Ketamine Pain rating 7-10

21. Analgesic ladder in action:
 Step 1: non-opioid analgesics (Paracetamol
and Aspirins, NSAIDS)
 Step 2: mild opioid is added (not
substituted) to step 1
 Step 3: Opioid for moderate to severe pain
is used and titrated to effect

22. Breakthrough pain
 Use extra (rescue) doses of opioids.
 Use the immediate-release form of same
opioid they are on.
 Rescue dose 5-15% of the 24-hour dose.
 If 3 or more rescue doses needed/24 hrs—
need to titrate routine drug to effect (25-
100% current dose).

23. Pain management through
medication and/or neurosurgery
 Oral analgesia
 PCA (Patient-controlled analgesia)
 Cordotomy: division of certain tracts of the cord.
 Rhizotomy: A lesion is made in the dorsal root to
destroy neuronal dysfunction and reduce nociceptive input.

24. Universal Side Effect
 Constipation.
 Nausea and Vomiting.
 Itching.
 Respiratory Depression.

25. Examples of Narcotic Analgesics
 Narcotic analgesics
 Morphine
 Pethidine
 Controlled Analgesic
drugs
 Tramal

26. Placebo – HMG Policy
 Placebo (e.g. normal saline) should not be
given to treat pain even with written medical
order.
 Using placebo to diagnose or treat pain is
considered unethical and violating patient
right to have optimal pain relief

27. Assessment tools used at Dr. Sulaiman Al Habib Hospital
Qaseem Hospital
 Numeric Pain Rating Scale.
 Wong-Baker Face Pain Rating Scale.
 FLACC Scale.
 NIPS Pain Scale.
 CRIES Pain Scale.
 Critical Care Pain Observation Tool or
CPOT.
 Comfort Pain Scale

28. Why have a pain scale?
 Sometimes hard to put words to pain
 Pain is multi-faceted (How long? Where?
How intense? What kind feeling?
 Visual scales help us understand where
pain located.
 Faces help us understand how pain
makes patient feel.
 Numeric scales help quantify pain using
numbers.

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