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Chapter 5

Pain: The Fifth Vital Sign

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Definitions of Pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Pain is whatever the experiencing person says it is and exists whenever he or she says it does (McCaffery, 1999).

Self-report is always the most reliable indication of pain.

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Types of Pain Types of pain:

Acute pain Chronic pain:

• Chronic cancer pain• Chronic non-cancer pain

Sources of pain: Nociceptive pain types:

• Somatic pain• Visceral pain

Neuropathic pain

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Pain Transmission

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Attitudes and Practices Related to Pain

Attitudes of health care providers and nurses affect interaction with patients experiencing pain.

Many patients are reluctant to report pain: Desire to be a “good” patient Fear of addiction

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Addiction, Pseudoaddiction, Tolerance, and Physical Dependence

Addiction—primary, chronic neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations

Pseudoaddiction—iatrogenic syndrome created by the undertreatment of pain

Tolerance—state of adaptation in which exposure to a drug results in a decrease in one or more the drug’s effects over time

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Addiction, Pseudoaddiction, Tolerance, and Physical Dependence (Cont’d)

Physical dependence—adaptation manifested by a drug-class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist

Withdrawal or abstinence syndrome—N&V, abdominal cramping, muscle twitching, profuse perspiration, delirium, and convulsions

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Collaborative Management

History Physical assessment/clinical

manifestations: Location of pain:

• Localized pain• Projected pain• Radiating pain• Referred pain

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Pain Pharmacologic Therapy—Non-Opioid Analgesics

Acetylsalicylic acid (aspirin) and acetaminophen (Tylenol) are most common

Most are NSAIDs, including aspirin: Can cause GI disturbances COX-2 inhibitors for long-term use

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Non-Opioid Analgesics (Cont’d) Acetaminophen (Tylenol):

Available in liquid form; can be taken on empty stomach

Preferable for patients for whom GI bleeding is likely

Can cause renal or liver toxicity if used long-term

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Pain Pharmacologic Therapy—Opioid Analgesics

Block the release of neurotransmitters in the spinal cord

Drugs include codeine, oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol, meperidine, oxymorphone

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Side Effects of Opioids

Nausea and vomiting Constipation Sedation Respiratory depression

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WHO Analgesic Ladder World Health Organization’s

recommended guidelines for prescribing, based on level of pain (1-10, 10 is most severe pain)

Level 1 pain (1-3 rating)—Use non-opioids Level 2 pain (4-6 rating)—Use weak

opioids alone or in combination with an adjuvant drug

Level 3 pain (7-10 rating)—Use strong opioids

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Pain Management in End of Life

Opioid regimen should stay consistent with dose in weeks before last weeks of life

Generally believed that patient still feels pain when unconscious

Does not hasten death unless the dose was not properly and gradually titrated

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Routes of Opioid Administration

Can be administered by every route used PRN range orders Patient-controlled analgesia (PCA)

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PCA Infusion Pump

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Spinal Analgesia

Epidural analgesia Intrathecal (subarachnoid) analgesia

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Implantable Devices

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Adjuvant Analgesics Antiepileptic drugs Tricyclic antidepressants Antianxiety agents Local anesthetics Dextromethorphan, ketamine Local anesthesia infusion pumps Topical medications

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Nonpharmacologic Interventions Used alone or in combination with drug

therapy Physical measures Physical and occupational therapy Cognitive/behavioral measures

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Physical Interventions

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Cognitive/Behavioral Measures

Strategies that can be used to relieve pain as adjuncts to drug therapy: Distraction Imagery Relaxation techniques Hypnosis Acupuncture Glucosamine

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Invasive Techniques for Chronic Pain

Nerve blocks Spinal cord stimulation Surgical techniques:

Rhizotomy Cordotomy

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Surgical Procedures for the Alleviation of Pain

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Community-Based Care

Home care management Health teaching Health care resources