2. Outline
◦ 1) Definition of pain and approach to pain
◦ 2)Pain assessment
◦ 3) Classification of pain
◦ 4) Acute pain management
◦ 5) Morphine pain protocol
◦ 6) Management of opioid side effect
3. DEFINITION OF PAIN
“ An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage
International association for the Study of Pain
(IASP – Merskey)
4. WHAT DOES THAT MEAN?
◦ What we (health care provider) understand ….
◦ •Unpleasant
◦ •Emotions are important
◦ •The cause is not always visible
◦ For the patient…..
◦ PAIN is what the patient says……HURTS
7. WHY ASSESS / MEASURE PAIN?
•Produce a baseline to assess therapeutic interventions e.g.
administration of analgesic drugs
•Facilitate communications between staff looking after the
patient
•For documentation
8. HOW TO ASSESS PAIN
P: Place or site of pain
◦ “where does it hurt?”
◦ Record on a body chart
A: Aggravating factors
◦ “what makes your pain worse?”
I: Intensity
◦ “How bad is the pain?”
N: Nature and neutralising factors
◦ “what does it feel like’
◦ “What makes the pain better?”
9. MOH PAIN SCALE
On a scale of ‘0’ to ’10’(show the pain scale).
If ‘0’ = no pain, and 10 = worst pain you can imagine, what is your pain score now?
Patient is asked to slide the indicator along the scale to
show the severity of pain, which is recorded as a number (
0 to 10)
10. PAIN MEASUREMENT
◦ •Scale used in children/infants and in cognitively impaired patients
◦ •Faces scale (self report scale)
◦ •FLACC scale (behavioural pain scale)
11. WONG BAKER FACES PAIN RATING SCALE
Category
0 1 2
Face No particular expression
or smile
Occasional grimace,
frown, disinterested,
Frequent to constant
Clenched jaw
Legs Normal position or
relaxed
Uneasy, restless, tense Kicking, legs drawn up
Activity Lying quietly, moves
easily
Squirming, shifting back
and forth, tense
Arched, jerking, rigid
Cry No cry (awake or sleep) Moan or whimpers Crying steadily,
screaming or sobs
Consolability Content, relaxed Reassured by occasional
touch, hug
Difficult to console
12. WHEN SHOULD PAIN BE ASSESSED
◦ 1.At regular interval
◦ •as the 5thvital signs during routine observation of BP, HR, RR, and temperature
◦ •This can be done 4hourly, 6houry, or 8 hourly
◦ 2.On admission of patient
◦ 3.On transfer in of patient
13. ◦ 4. At other times apart from scheduled observations:
◦ •½ to 1 hour after administration of analgesics and nursing intervention
for pain relief
◦ •During and after any painful procedures in the ward e.g. wound
dressing
◦ •Whenever the patient complains of pain
14. WHO SHOULD BE ASSESSED?
◦ ALL patients
◦ •Patient in labourroom
◦ •Operating theatre (recovery room)
◦ •ICU/ HDU/CCU
◦ •Ambulatory day care units
◦ •Clinics
15. SELECTION OF ASSESSMENT TOOL
◦ •Recommendations by Ministry of Health, Malaysia
Age Scale
Adult MOH pain scale
Pediatrics
1month- 3 years FLACC scale
3 years- 7 years Wong baker scale
> 7 years MOH pain scale
•Sedated patients
•Unconscious patient
•Record ‘unable to assess/score’
16. CLASSIFICATION OF PAIN
BASIS TYPE OF PAIN
Duration Acute
Chronic
Acute on chronic
Cause Cancer
Non cancer
Mechanism Nociceptive
Neuropathic
Acute pain – pain associated with tissue injury e.g. pain after
surgery, fracture,
burns, inflammation, etc.
o Nociceptive somatic pain is usually well localized, described as
sharp,
aching or throbbing, often worse on movement.
o Visceral pain is usually poorly localized; described as deep,
cramping,
gnawing or colicky.
17. DIFFERENCES BETWEEN ACUTE AND CHRONIC PAIN
Acute pain Chronic pain
Onset& timing Sudden,short duration
Resolves /disappears when tissue
heals
Insidious onset
Pain persists despite tissue healing
Sign Warning sign of actual or potential
tissue damage
Not a warning signal of damage
False alarm
Severity Correlates with amount of damage Severity not correlated with
damage
CNS involvement CNS intact-acute pain is a
symptoms
CNS may be dysfunctional-chronic
pain is a disease
Psychological effect Less, but unrelieved pain anxiety
and sleeplessness (improves when
pain is relieved)
Often associate with depression,
anger, fear, social withdrawal etc.
18. NOCICEPTIVE vs NEUROPATHIC PAIN
Nociceptive pain Neuropathic pain
Well localized Not well localized
Sharp
Worse with movement
Burning
Shooting
Numbness
Pins and needles
Obvious tissue injury or illness Tissue injury may not be obvious
Inflammation Nerve injury
Changes in wiring
Abnormal firing
Loss modulation
25. MORPHINE PAIN PROTOCOL
•Use for rapid control of severe acute pain
•Route: IV
•Morphine dilution: 10 mg/10 ml (1mg/ml)
•Monitoring (every 5 minutes)
•Pain score
•Sedation score
•Respiratory rate
26.
27. MANAGEMENT OF OPIOID SIDE EFFECTS
1) Nausea and vomiting
•A common side effect of opioids
•Treat nausea and vomiting and continue giving opioids
28. RESPIRATORY DEPRESSION
◦ •Very uncommon
◦ •May occur with overdose of opioids, always associated with sedation
◦ •Risk of respiratory depression is minimal
◦ •If strong opioids are titrated to effect
◦ •Only used to relieve pain ( ie not to help patients to sleep or to calm down agitated patients)
◦ •Risk of respiratory depression also minimal in patients on chronic opioids use (e.g. patients on
morphine for cancer pain)
29. ◦ •Confirm diagnosis
◦ •Respiratory rate < 8/minute & sedation score=2 (difficult to arouse)
◦ •Or Sedation score = 3 (unarousable)
◦ •Pin Point pupils
◦ •Sedation score
◦ •0 = none (patient is alert)
◦ •1 = mild (patient is sometimes drowsy)
◦ •2 = moderate (patient is often drowsy but easily arousable)
◦ •3 = unarousable
◦ •S = patient is sleeping, easily arousable
30. MANAGEMENT OF RESPIRATORY DEPRESSION
◦ 1.Stop the drug and call for help
◦ 2.Administer oxygen –face mask or nasal prongs
◦ 3.Stimulate the patient-tell him/her to breathe
◦ 4.Dilute naloxone 0.4mg/mg in 4 mls
◦ •Give 0.1 mg (1ml) every 1-2 minutes until the patient wakes up or respiratory rate >10/min
◦ 5.Monitor RR, sedation score hourly for 4 hours
◦ 6.Give another dose of naloxone if respiratory depression recurs
◦ 7.Refer to ICH/HDU for close monitoring (patient may require naloxone infusion)
