Pain Management

1. PAIN
MANAGEMENT
Prepare by
Halimatu Usman RN, BSN

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Introduction
 Definition : An unpleasant sensory and
emotional experience associated with
actual or potential tissue damage.
 Pain may not be directly proportional to
amount of tissue injury.
 Highly subjective, leading to
undertreatment

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 In cancer, the prevalence of pain in
advanced disease is 70-90%.
 " In HIV disease, pain prevalence is
about 50%.
 " Other illnesses may have significant
pain but no clear data.

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Classification
I. Acute
II. Chronic :
i. Non malignant
ii. Malignant

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 Injury, trauma, spasm or disease to skin, muscle, somatic
structures or viscera;
 Perceived and communicated via peripheral mechanisms
(pathways)
 Usually associated with autonomic response as well
(tachycardia, blood pressure, diaphoresis, pallor,
mydriasis (pupil dilation).
I. Acute Pain

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i. Non-malignant
 Pain persists beyond the precipitating injury
 Rarely accompanied by autonomic symptoms
 Sufferers often fail to demonstrate objective
evidence of underlying pathology.
 Characterized by location-visceral, myofacial, or
neurologic causes.
II. Chronic Pain

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ii. Malignant
 Has characteristics of chronic pain as well as
symptoms of acute pain (breakthrough pain).
 Has a definable cause, e.g. tumor recurrence
 In treatment, narcotic habituation is generally
not a concern.
II. Chronic Pain

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 Types of Pain
 Somatic
 Visceral
 Bone
 Neuropathic
 Emotional/Spiritual

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I- Somatic Pain
 Aching, often constant
 May be dull or sharp
 Often worse with movement
 Well localized
 Skin, Muscle, Joints, superficial or deep.
 Eg:
o Bone & soft tissue
o chest wall

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II- Visceral Pain
 Constant or crampy
 Aching, burning
 Poorly localized
 Referred
 Organs of Thorax & Abdominal Cavity.
 Usually as a result of stretching, infiltration and
compression
 Eg:
o Liver capsule distension
o Bowel obstruction

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III- Bone Pain
 Poorly localized, aching, deep, burning.
 Common with malignancy of Breast, Lung,
Prostate, Bladder, Cervical, Renal, Colon,
Stomach and Esophagus
 Can lead to pathological fractures.
 Vertebral Metastases can lead to cord
compression.

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IV- Neuropathic Pain
 Caused by disturbance of function or pathological
changes in a nerve.
 May arise from a lesion or trauma, infection,
compression or tumour invasion.
 Described as burning, shooting, tingling.
 Does not respond well to standard analgesics.

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 Categories of Pain
 Classified by inferred pathophysiology:
I. Nociceptive pain (stimuli from somatic and
visceral structures)
II. Neuropathic pain (stimuli abnormally
processed by the nervous system)

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I. Nociceptive:
 Caused by invasion &/or destruction &/or pressure on
superficial somatic structures like skin, deeper skeletal
structures such as bone & muscle and visceral structures
and organs.
 Types: superficial somatic, deep somatic, & visceral.

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II. Neuropathic:
 Caused by pressure on &/or destruction of peripheral,
autonomic or central nervous system structures.
 Radiation of pain along dermatomal or peripheral nerve
distributions.
 Often described as burning and/or deep aching &
associated with dysesthesia or lancinating pain.

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Effects of pain
 Sympathetic responses
o Pallor
o Increased blood pressure
o Increased pulse
o Increased respiration
o Skeletal muscle tension
o Diaphoresis

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Effects of pain
 Parasympathetic responses
o Decreased blood pressure
o Decreased pulse
o Nausea & vomiting
o Weakness
o Pallor
o Loss of consciousness

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Pain History
 The site of pain
 Type of pain
 Exacerbating & Relieving factors
 How frequently
 Impact on daily life

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Pain History
 Other important additional questions to be asked.
o What is the response to past and current analgesic
therapy?
o Any kind of diary or record about the pain?
o Fears they have about analgesics?

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PAIN ASSESSMENT Tools
Verbal Analogue Scales.
Visual Analogue Scales.
The Faces Scale

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Factors to consider in choosing a
pain scale
1. Age of patient
2. Physical condition
3. Level of consciousness
4. Mental status
5. Ability to communicate

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Numeric Pain Rating Scale
 Ask the patient to rate their pain intensity on a scale of 0 (no pain) to 10
(the worst pain imaginable).
 Some patients are unable to do this with only verbal instructions, but may
be able to look at a number scale and point to the number that describes
the intensity of pain.

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Wong-Baker FACES Pain Rating Scale
 Can be used with young children (sometimes as young as 3 years of age)
 Works well for many older children and adults as well as for those who speak a
different language
 Explain that each face represents a person who may have no pain, some pain, or as
much pain as imaginable. Point to the appropriate face and say the appropriate
description. e.g. “This face hurts just a little bit”
 Ask the patient to choose the face that best matches how she or he feels or how much
they hurt.

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Severity Assessment
 McGill Pain Questionnaire
 Scale from 0 to 5
 From None to Severe Pain
 for children or adults who understand numerical
relationships.

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Goals of Pain Management Therapy
1) Decreased pain
2) Decreased healthcare utilization
o Decreased “shopping” for care
o Decreased emergency room visits
3) Improved functional status
o Increased ability to perform activities of daily living
o Return to employment

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Management
 Non-Pharamcological treatment
 Pharmacological treatment:
 Analgesics
 Adjuvants
 Others

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Non-pharmacological interventions
 Exercise
 Weight reduction
 Counseling
 Smoking cessation
 Massage ,Relaxation therapy
 Heat & cold applications

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WHO Pain Management Ladder
 Step I:
 NSAIDS ± adjuvants
 Step II:
 NSAID + Mild opioids ± adjuvant
 Step III:
 Strong opioids + NSAIDS ± adjuvants

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Opioid Dosing
 Opioid analgesia is most effective when titrated to effect.
 Effective doses are highly variable between patients.
 “Standard” doses may be insufficient.
 When used properly for analgesia addiction occurs in less
than 1% of patients.

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Opioid Side Effects
 Constipation :
o need proactive laxative use
 Nausea/vomiting:
o consider treating with dopamine antagonists and/or prokinetics (metoclopramide, domperidone,
prochlorperazine, haloperidol)
 Urinary retention
 Itch/rash
o worse in children; may need low-dose naloxone infusion. May try antihistamines, however not great
success
 Dry mouth
 Respiratory depression
o uncommon when titrated in response to symptom

31. ThanKs You
for Listining