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First Published: October 27, 2004 Revised Date: September 22, 2007

Acute and Chronic Pain: Assessment and

Management

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Acknowledgements ____________________________________________________________ 4 Purpose & Objectives __________________________________________________________ 5 Defining Pain__________________________________________________________________ 6 Categorizing Pain Types ________________________________________________________ 6 Nocioceptive Pain______________________________________________________________ 6 Neuropathic Pain ______________________________________________________________ 7 Acute Pain versus Chronic Pain __________________________________________________ 7 Summary of Pain Types_________________________________________________________ 7 Barriers to Effective Pain Assessments and Management ____________________________ 8 Patient Barriers________________________________________________________________ 8 Healthcare Professional Barriers _________________________________________________ 8 Health System Barriers _________________________________________________________ 8 Addressing Barriers to Pain Relief ________________________________________________ 9 Minimizing Barriers ____________________________________________________________ 9 Fears about Addiction __________________________________________________________ 9 Fears about Opioid Tolerance and Physical Dependence ____________________________ 10 Exaggerating Fears Related to Respiratory Depression _____________________________ 10 Principle of Double Effect ______________________________________________________ 10 Misconception that the Doctor or Nurse Knows Best _______________________________ 11 Impact of the Nursing Shortage on Pain Management_______________________________ 11 JCAHO Standards ____________________________________________________________ 11 Pain Assessment _____________________________________________________________ 12 Provocation or Palliative Symptoms _____________________________________________ 12 Quality ______________________________________________________________________ 12 Radiation ____________________________________________________________________ 13 Severity _____________________________________________________________________ 13 Timing ______________________________________________________________________ 13 Physical Examination: Inspection _______________________________________________ 13 Physical Examination: Auscultation _____________________________________________ 14 Physical Examination: Palpation and percussion __________________________________ 14 Summary of Assessment Findings ______________________________________________ 14 Communicating Assessment Findings ___________________________________________ 14 Case Discussion______________________________________________________________ 16 Pain Management_____________________________________________________________ 18 Understanding Opioids ________________________________________________________ 18

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Non-Opioid Analgesia: Acetaminophen and NSAIDs ________________________________ 24 COX-2 Inhibitors ______________________________________________________________ 26 Adjuvant Analgesia ___________________________________________________________ 26 Non-pharmacological Therapies_________________________________________________ 27 The WHO Ladder to Manage Chronic Malignant Pain _______________________________ 28 Special Populations ___________________________________________________________ 29 Infants & Children_____________________________________________________________ 29 The Elderly __________________________________________________________________ 31 The Cognitively Impaired_______________________________________________________ 31 The Critically Ill_______________________________________________________________ 32 Culture Issues________________________________________________________________ 32 Patients with Prior History of Substance Abuse____________________________________ 32 Conclusion __________________________________________________________________ 33 Appendix A __________________________________________________________________ 34 Appendix B __________________________________________________________________ 35 References __________________________________________________________________ 37 Post Test Viewing Instructions __________________________________________________ 39

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Acknowledgements

RN.com acknowledges the valuable contributions of… ...Lori Constantine, MSN, RN-BC, author of this continuing nursing education course. Lori is a nurse with 12 years medical surgical experience. She has worked as a staff nurse, charge nurse and nurse preceptor on many different medical-surgical units including, vascular, neurology, neurosurgery, urology, gynecology, ENT, general medicine, geriatrics, oncology and blood and marrow transplantation. She received her Bachelors in Nursing in 1994 and a Masters degree in Nursing in 1998, both from West Virginia University. In 1998, Lori was certified as a Family Nurse Practitioner, and in 2005 became board certified in medical surgical nursing through the American Nurses Credentialing Center. She has held positions at West Virginia University School of Nursing, and is currently an adjunct faculty member for Waynesburg School of Nursing in Pennsylvania and a staff nurse on a surgical-trauma unit at West Virginia University Hospitals. …Robin Varela, RN, BSN, for updating and editing the revised version of this continuing nursing education course. Robin has over 20 years experience in critical care and emergency department nursing. During her years as a staff nurse and nurse preceptor she has been certified as CCRN, TNCC, BLS, ACLS, ACLS Instructor, PALS and MICN. As an emergency department Clinical Nurse Manager, Varela took an active role in numerous multi-disciplinary committees and partnered with local EMS to co-ordinate emergency preparedness within the community. She has worked for American Mobile Healthcare as a Clinical Services Clinical Liaison RN and works per diem as a critical care transport nurse. Varela completed her BSN in 2003 and plans to begin graduate school the summer of 2007.

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Purpose & Objectives

The purpose of this continuing nursing education course is to provide healthcare professionals with information about pain assessment and pain management. Post-surgical pain and chronic cancer pain will be the focus. Since managing acute and chronic pain requires astute assessment skills and knowledge of pharmacological and non-pharmacological therapies, healthcare professionals should be aware that the patient’s self-report is the most essential way to assess pain. The course includes principles of pharmacological pain management, a discussion of patient controlled analgesia (PCAs) enquianalgesic dose conversions, the WHO 3-step ladder, as well as information about the needs of special populations that includes the elderly, children, patients with different cultural backgrounds and patients with a history of substance abuse. After successful completion of this course, the participant will be able to: 1. Define pain and describe various pain types. 2. Describe patient, provider, and health system barriers associated with poor pain control. 3. Identify patient and provider misconceptions regarding pain management. 4. Describe how pain is assessed based upon the patient’s self-report. 5. Identify pharmacological and non-pharmacological strategies associated with achieving pain

control particularly in the acute post-surgical patient and chronic pain suffers. 6. Identify special groups that are at risk for under-treatment of pain.

Disclaimer RN.com strives to keep its content fair and unbiased.

The author(s), planning committee, and reviewers have no conflicts of interest in relation to this course. There is no commercial support being used for this course.

There is no "off label" usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com.

The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents

described in the course.

Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or all-encompassing.

You are encouraged to consult with physicians and pharmacists about all medication issues for your patients.

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Defining Pain

Pain is a universal affliction that can affect all of us at some point in our lives. Practically all hospitalized patients experience pain at some point in their stay. The presence of pain negatively affects the patient and family and has significant clinical effect on recovery, morality and quality of life (Jacox et al., 1992). Despite the fact that satisfactory pain relief can occur in approximately 90% of pain suffers, it is still not regularly occurring (Stjernsward & Teoch, 1992). The International Association for the study of pain (IASP) and the American Pain Society adopted the following definition of pain:

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms such as damage” (APS, 1992; Mersky & Bogduk 1994).

When it comes down to assessing for pain, healthcare professionals cannot always determine the source of the patient’s pain or identify any source or damage that could be responsible for a report of pain. Yet, the person is experiencing pain. This does not infer that the pain is not real. McCaffery addresses this perceived incongruence by explaining that, “Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does” (1979). In other words, pain is personal. Only the individual experiencing the pain can fully describe it. Pain may also be induced by the psychic perception of real, threatened, or fantasized injury (Engel, 1970). Therefore, the patient’s meaning of pain may play a significant role in how that person experiences it.

Categorizing Pain Types Healthcare professionals often document pain using a variety of terms. Some of the terms used to describe pain are somatic, visceral, referred, chronic, acute, malignant or non-malignant. It is useful to review the true meanings of these words and categorize them so that a full understanding of pain types is achieved. The physiologic basis of pain is categorized into two major types: nocioceptive and neuropathic.

Nocioceptive Pain Nocioceptive pain results from real or impending tissue damage, either to the viscera or the soma. Nocioceptive, somatic pain usually occurs due to real or impending damage to bone, muscle, skin, or connective tissue. Somatic pain is most commonly described as localized, aching, or throbbing. Nocioceptive visceral pain usually occurs due to real or impending damage to the thoracic, abdominal, or pelvic organs such as the heart, liver, or bowel. Visceral pain is often described as deep, cramping, referred, aching, or gnawing (Griffie, McKinnon, & Heidrich, 2002).

Critical Thinking Tip: The patient’s self-report is the gold standard of the

healthcare provider’s pain assessment.

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Neuropathic Pain Neurophathic pain occurs from damage to peripheral or central nervous tissue or from distorted processing of pain. Examples of neuropathic pain include: peripheral neuropathies, neuralgias, phantom limb pain, and spinal cord injuries. It is often described as burning, piercing, lacerating, and pricking (Griffie, McKinnon, Berry, & Hedrich, 2002).

Nocioceptive Pain Neuropathic Pain

Somatic Localized, aching, throbbing

Central Burning, piercing, lacerating, pricking

Visceral Deep, cramping, aching, referred, gnawing

Peripheral Burning, piercing, lacerating, pricking

Acute Pain versus Chronic Pain Acute pain is usually brief and diminishes as healing occurs. Chronic pain is long standing and can be further classified as either malignant or non-malignant pain (McCaffery & Pasero, 1999). Chronic non-malignant and chronic malignant pain may be either nocioceptive or neuropathic depending upon its origin and dissemination. For example, a patient may experience visceral, nocioceptive pain from liver metastasis but, may also be experiencing neuropathic pain from chemotherapy induced neuropathy. Additionally, a person with chronic pain may have exacerbations of acute pain, known as breakthrough pain.

Referred Pain Referred pain is often nocioceptive in origin and involves visceral organs. It is not well organized. For example, the pain of the gall bladder disease is often referred to the right shoulder and cardiac pain may be felt in the neck, back, jaw or arms. Diaphragmatic and pulmonary pain may also be felt in the neck. Kidney pain is often felt in the associated flank as well as the lateral thigh. Pancreatic pain may be experienced in the back. The exact mechanism of referred pain is not fully understood. It is known, however, that the site of referred pain is linked to the involved nerve root.

Summary of Pain Types In summary, all pain can be categorized as either nocioceptive or neuropathic. Pain descriptors are useful in identifying the origin of pain. Patients may experience only one pain type or all pain types during the course of their illness. It is important to be knowledgeable about these pain types so that effective pain management strategies can be employed.

Types of Pain Include: • Somatic • Visceral • Referred • Acute • Neuropathic • Chronic • Break-through

Critical Thinking Tip: • Acute pain diminishes as

healing occurs. • Chronic pain may be

exacerbated by acute pain. • Referred pain is not well

localized and usually visceral in origin.

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Barriers to Effective Pain Assessments and Management

Patient Barriers Fear is often the most prevalent reason that a patient will not report or under-reports pain. Some of the fears patients experience related to pain control include the fear of addiction (U.S. Department of Health and Human Services, 1994; Cleeland, 1984; McCaffery &Ferrell, 1997), the fear unwanted side effects (U.S. Department of Health and Human Services, 1994; McCaffery & Beebe, 1989), and the fear of the stigma attached to taking narcotics (Twycross, 1982). Patients will often choose not to take pain medications because they fear that when they really need them the medication will be ineffective. Subsequently, many patients wait to ask for pain medication until the pain is so severe that it is much more difficult to control.

Healthcare Professional Barriers Unfortunately, healthcare professionals do not always assess or manage their patient’s complaints of pain effectively. This is sometimes due to misconceptions about pain medications and in particular, misconceptions about the use of opioids. In some instances healthcare professionals may have had little training regarding the pharmacology of opioids, associated side effects (such as respiratory depression), or concepts such as addiction (Health and Policy Committee, 1983), tolerance or physical dependence (Bonica, 1987; Stjernsward & Teoh, 1990). Healthcare professionals also express concern about the regulation of controlled substances and state this to be a factor that influences their pain management decisions (U.S. Department of Health and Human Services 1994).

Health System Barriers Barriers to effective pain assessment and management related to healthcare systems are also prevalent. Inadequate reimbursement often makes the best treatment modality too costly for patients to afford. Problems with the availability or access to treatment also significantly hinder patients’ abilities to achieve pain control. Finally, restrictive regulations of controlled substances may impact the healthcare professional’s ability or willingness to prescribe such medications (U.S. Department of Health and Human Services, 1994).

Patients may fear addiction tolerance or unwanted side effects

related to pain medications.

Healthcare professions may have unfounded fears due to lack of knowledge about pharmacology.

Barriers that impact control of pain include:

• Fear • Regulatory • Lack of knowledge • Reports of pain

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Addressing Barriers to Pain Relief

Minimizing Barriers Efforts have been made to minimize barriers to pain relief from a national and international perspective for many years. The World Health Organization (WHO) established the problem of inadequate cancer pain relief as an international public policy issue in 1986 (Benoliel, 1995). The WHO responded to this need and subsequently published a set of guidelines for healthcare professionals on the management of cancer pain (WHO, 1986). The Agency for Health Care Policy and Research (AHCPR), part of the United States Public Health Service (Benoliel, 1995), published a set of guidelines in 1994 that are vital to the delivery of pain management services (U.S. Department of Health and Human Services, 1994). Other organizations that have worked toward alleviating pain include the Ad Hoc Committee on Cancer Pain of the American Society of Clinical Oncology, the American Pain Society, the American College of Physicians, the National Cancer Institute, and the Robert Wood Johnson Foundation. Addressing trends associated with patient and provider barriers regarding pain management is paramount in controlling all types of pain. Healthcare professionals, including nurses, must be aware of the barriers to effective pain management and involve the patient in making a decision about analgesia whenever possible. Healthcare professionals must also be proactive in eliciting pain reports or the signs and symptoms of pain in patients that are unable to report that they have pain. As a healthcare professional, assessing and managing a patient’s unique needs to alleviate pain should be an important part of your everyday practice. By being knowledgeable about barriers to pain management, individual assessment techniques, and the pharmacology of pain medications, healthcare professionals can help to reduce their patients discomfort related to pain. Before a healthcare professional can accurately assess pain, a few of the most common fears regarding pain management should be addressed. These fears include misconceptions about addiction, tolerance, physical dependence, respiratory depression, and reservations associated with giving the “last dose.”

Fears about Addiction Many individuals do not understand the concept of addiction. In general, addiction can be described as the overwhelming need to obtain and use a drug for its psychic effects. It is NOT the need to use a drug for its medical benefit. Research indicates that less than 1% of all patients that take an opioid for pain relief ever become addicted (Griffie, McKinnon, Berry, & Heidrich, 2002). It is imperative that nurses learn about and understand this concept. It should also be communicated to the patient if you are concerned about the patients’ fear of addiction. Patients are sometimes stoic and might not share their fears with healthcare professionals or even their families. Be proactive in discussing this common misconception with your patients and be secure in the knowledge that the appropriate medical use of pain medications very rarely, if ever, causes addiction.

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Fears about Opioid Tolerance and Physical Dependence Opioid tolerance can occur after repeated administration of any opioid substance (Griffe, McKinnon, Berry, & Heidrich, 2002). Tolerance to a drug occurs when an individual reports that the initial dosage of medication is no longer effective in managing the pain. Tolerance is not unusual and can often be expected with prolonged use of many types of pain medication. If tolerance does develop, the healthcare provider may wish to increase the dose, prescribe the same dose of the drug to be taken more frequently, or change the drug or route of administration. Physical dependence occurs when, after repeated administration of the drug, withdrawal symptoms appear when it is not taken. These symptoms include: anxiety, irritability, lacrimation (tearing), rhinnorhea (runny nose), cramps, nausea, vomiting, and insomnia (Griffe, McKinnon, Berry, & Heidrich, 2002). Opioid pseudoaddiction may occur when opioid physical dependence occurs due to improper pain management (Weissman & Haddox, 1989).

Exaggerating Fears Related to Respiratory Depression Respiratory depression related to opioid administration is a common fear among healthcare professionals. Morphine is the medication most commonly associated with this fear. Although one of the side effects of opioids is that they act as a depressant on the respiratory center of the brain, this is usually a gradual process and does not occur suddenly. It is more common in those who are opiod naïve, in other words, haven’t received opioids previously. Therefore, careful assessment is indicated during the initial doses of opioid administration. Respiratory depression is rare in patients that are on long-term opioid therapy because the respiratory system becomes tolerant to this effect. Auditory and physical stimulation are often effective in mild opioid-induced respiratory depression. Naloxone (Narcan) is an opioid antagonist that is usually administered to counteract the effects of an opioid overdose. It may be given intravenously and acts within moments (McPhee & Schroeder, 1997). Careful administration of naloxone is warranted in patients with comfort care or chronic pain in order to prevent rebound or uncontrollable pain after the naloxone is administered.

Principle of Double Effect Occasionally healthcare providers, professionals, and even family members that care for their loved one at home are afraid that just one more dose of medication may cause death of the patient. This fear is best addressed by examining the principle of double effect. This principle is based upon the intent of the person administering the medication. In managing pain, the intent is not to hasten death, but rather to provide effective pain relief. While healthcare professionals must be knowledgeable about the side effects of opioids, the fear of giving the last dose should not impair the provider in providing effective pain relief. The American Medical Association (AMA), American Nurses Association (ANA), and numerous other medical experts have addressed this issue by acknowledging that it is ethically acceptable to provide pain relief even if it hastens death. Again, it is not the intent to cause death or respiratory depression in these situations. It is the intent for pain to be controlled in end-of-life situations.

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Misconception that the Doctor or Nurse Knows Best The patient is the only one that can fully describe his or her pain. The patient’s self-report of pain is the standard by which healthcare professionals should base their pain assessments. Often the healthcare provider, families, and patients themselves believe that the provider knows or best understands the patient’s pain. This is not the case. The patient’s reports of pain must be believed first and foremost. In situations when patients are not able to report their pain because of cognitive or motor abilities, pain must be assessed judiciously. Assessments should focus on changes in non-verbal behavior, vocalizations, changes in daily routines, and objective findings. The regular caregiver may also be a valuable resource in assessing pain in these individuals (American Geriatrics Society Panel on Chronic Pain in Older Persons, 1998).

Impact of the Nursing Shortage on Pain Management Nursing shortages have been reported across the nation since 1988 (Buerhaus, Staiger, & Auerbach, 2000). Officials with the Health Resources and Services Administration (HRSA) released projections in April 2006 that the nation's nursing shortage would grow to be more than one million nurses by the year 2020. Analysts state that all 50 states will experience a shortage of nurses to varying degrees by the year 2015 (AACN, 2006). Pain assessment and management has, and will be impacted. Compounding the problem is that hospitalized patients tend to be sicker than ever and people with chronic diseases are living longer. This often results in the need for complex medical care, including pain management. The nursing shortage impacts a healthcare professionals’ ability to provide quality care to all of their patients, especially those that are actively experiencing pain. How does the healthcare professional deal with these challenges? First and foremost make it a priority to be knowledgeable about your patients’ conditions and understand pain mechanisms, barriers, assessments, and management strategies. Secondly, be proactive in assessing pain and effectively communicating pain to the interdisciplinary team. Being knowledgeable of and confident about using pain management strategies is the first step toward providing quality care to your patients.

JCAHO Standards The Joint Commission (JCAHO) standards clearly outline how healthcare institutions should manage pain. These standards focus on making pain management more of a priority, the critical 5th vital sign. Click on this link to review JCAHO pain standards: www.JointCommission.org

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Pain Assessment

Provocative or Palliative: What makes the pain better or worse? Quality: Describe the pain. Is it burning, shooting, aching, stabbing, crushing, etc.? Radiation: Does the pain radiate to another body part? Severity: On a scale of 0 -10, (10 being the worst) how bas is your pain? (may use other scales also). Timing: Does it occur in association with something else? (e.g. eating, exertion, movement)

Provocation or Palliative Symptoms Assessment of provocative or palliative symptoms gives you clues to the origin of pain. Ask the patient what makes the pain better or worse. For example, exertion may intensify anginal pain and rest may alleviate it. Movement of an injured body part may intensify pain while applying heat or cold to the injured part may ease the pain. Gastrointestinal pain may either improve or worsen with food intake. Additionally, post-surgical pain is often intensified prior to getting out of bed, or while ambulating or coughing and deep breathing. While assessing for provocative or palliative symptoms that accompany the patient’s pain, ask about other associated symptoms as well. Accompanying symptoms provide additional clues to the origin or nature of the patient’s pain. For example, diaphoresis and nausea often accompany cardiac pain. Also, burning and tingling in an ipsolateral limb may accompany sciatic pain.

Quality Pain descriptors such as; aching, throbbing, burning, piercing, shooting, tearing, or crushing can also give clues to the origins of pain. Remember, somatic pain is most commonly described as localized, aching, and throbbing. Visceral pain is often described as deep, cramping, referred, aching, or gnawing. Neuropathic pain is often described as burning, piercing, lacerating, and pricking. Qualifying the patient’s pain allows you and your team to determine the appropriate analgesic or adjuvant treatment.

P Q R S T

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Radiation Ask the patient where the pain on their body is. They can point, describe, or use an outline of a person to shade in areas that are painful. Pain is localized if the patient can point to exactly where it is hurting. If the patient can pinpoint where the pain is, it is often somatic in origin (bone, muscle, or connective tissue). Referred pain or pain that radiates is not well localized and can complicate understanding a person’s pain if a thorough history is not explored. Some common pathologic processes that cause pain to radiate or be referred include acute coronary syndrome, gall bladder disease, appendicitis, and pancreatitis. Depression and anxiety also play key roles in pain processing and may exacerbate pain. When a patient describes their pain as being all over their body, chronic pain syndromes and psychological components of the pain should be explored.

Severity Most patients are able to use a numerical pain rating scale to quantify their pain. When using a numerical scale, ask the patient to rate their pain on a scale from 0 to 10. Zero means no pain. Ten means the worst pain imaginable or that they have ever experienced.

Timing When assessing the timing of pain, ask the patient how long the pain has lasted and how often it occurs. Chronic pain usually lasts for longer than six months. Acute pain is commonly related to a new disease process, bodily injury, post-surgery or post-procedure, or may be an exacerbation of chronic pain. Pain that is always present may be termed baseline pain. Baseline pain may be aggravated by acute increases in intensity throughout the day. This is known as breakthrough pain. Often patients with chronic disease and post-operative patients experience both baseline and breakthrough pain.

Physical Examination: Inspection A physical examination to elicit pain information should be performed only after a thorough history of the pain is obtained. There are observable signs and symptoms of pain including grimacing, withdrawal, clenching of the teeth or hands, assuming a fetal posture, or sleeping due to exhaustion from pain.

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Physical Examination: Auscultation Auscultate for associated physical exam findings prior to palpation or percussion. Auscultation may provide clues to help localize a patient’s pain. For example, hyperactive bowel sounds with a subjective report of cramping abdominal pain may indicate early bowel obstruction. Diffuse abdominal pain with absent bowel sounds may indicate a late bowel obstruction. Wheezing or crackles with a history of cough or localized lateral chest pain may indicate pneumonia or atelectasis.

Physical Examination: Palpation and percussion After inspection and auscultation, palpation and percussion may be useful in determining the cause of the patient’s pain. If one particular area is identified as painful, palpate around the area working towards it. Start gently and increase depth of palpitation. Avoid inducing more pain. Percussion is also useful to assess for pneumonia, ascites, gas, or changes in underlying organs. Dullness is heard over areas of consolidation or over solid surfaces. If dullness is percussed over an area, further examination and diagnostic testing is warranted. Additionally, tympany (a hollow-filled sound) may be heard over a gas-filled abdomen. Summary of Assessment Findings Information obtained from the physical exam should be used to confirm suspicions as to the cause of pain. Often, in the hospital setting, healthcare professionals are faced with managing pain from an already diagnosed origin or an obvious cause such as surgery or invasive procedures. If this is the case, the patient self-report and history is the key factor in monitoring the progression or relief of the pain. Whether the pain is post-surgical, procedural, or chronic in nature, using the pneumonic PQRST will allow the healthcare professional to effectively manage the pain as interventions are delivered. If new pain or symptoms occur, a thorough history and exam are warranted to assess for complications.

Communicating Assessment Findings Communication of assessment findings is crucial in managing pain effectively. If you believe that another intervention may be effective, it is your responsibility to report assessment findings to the healthcare provider and ask about potential alternatives. Communication about pain should be described in terms of the pneumonic, PQRST. Important physical exam findings, whether positive or negative, should also be communicated to the healthcare provider. Another important piece of information to obtain is what interventions have worked well for the patient’s pain and what seemed to work best to relieve it. By using this approach, the healthcare provider can develop a more thorough understanding of the patient’s pain.

Critical Thinking Tip: • Patients history and self-report will

provide the healthcare provider with 80% of the necessary information to treat the patient effectively.

• Listen and ask questions!

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Critical Thinking Activity Review the following three cases and consider what type of pain each patient is experiencing. This exercise will help to promote critical thinking about pain assessment. When finished answering each question, compare and contrast your answers with the answers provided in the case discussion section. Diane Diane is a 27-year-old admitted to your unit for observation with blunt chest and abdominal trauma following a motor vehicle collision earlier today. Her husband and child are at her bedside. Diane appears to be in no distress and is currently taking Tylenol for pain control. Diagnostic tests are pending. Elizabeth Elizabeth is a 77-year-old that has been on your unit for approximately 24-hours after being transferred from a nursing home with a fever of unknown origin. She has a history of Alzheimer’s disease, coronary artery disease, hypertension and a left-sided CVA that occurred in 1999. Blood cultures are pending. Urinalysis is within normal limits. She was eventually diagnosed with right lobar pneumonia following a chest X-ray and physical exam. She has been started on broad-spectrum IV antibiotics and is pleasantly confused. Benjamin Benjamin is a 5-year-old admitted to your unit with a diagnosis of appendicitis. He is currently in the emergency department and is expected to go to surgery within the hour. After his surgery he will be admitted to the pediatric floor. In the meantime, you are responsible for his care until the operating room is available. His parents are at his side but speak very little English. Benjamin speaks English fluently.

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Case Discussion Describe the focus of your pain assessment with each patient and discuss how you would assess the pain. Diane: The focus of Diane’s pain assessment should center on looking for complications from her blunt chest and abdominal trauma. Using the pneumonic, PQRST, you discover Diane’s pain worsens with coughing or palpation of her upper abdomen. Her pain is a dull ache that is diffuse across her abdomen and chest. It does not radiate. It is a 7 on a numeric scale of 0-10. It has been present for the past few hours and is not worsening. She is alert and oriented x 3. Lungs are clear to auscultation bilaterally. Heart rate is regular S1 and S2 are heard. Abdomen is soft and slightly tender with hypoactive bowel sounds. Extremities are warm and pink. BP = 106/74, HR = 88, Respirations = 22 Temp = 37.5 °C orally. Elizabeth: Elizabeth’s pain assessment is complicated due to her cognitive impairment. There is no family available to discuss her pain with you. Elizabeth can only nod her head “yes” when asked if she hurts. The responses to all other assessment questions are a blank stare. You notice that when Elizabeth coughs, she grimaces and pulls her right arm to midline. The focus of Elizabeth’s pain assessment should center on her non-verbal cues and physical exam findings. She continues to be febrile with a current temperature of 38.0 °C orally. BP=148/90, HR = 92, Respirations = 24. Her lungs have crackles in the right lower and middle lobes and are diminished bilaterally. She has a frequent productive cough of yellow sputum. Heart rate is regular. S1 and S2 are normal. Abdomen is soft, non-tender with normal bowel sounds. Extremities are warm but, pale with a capillary refill of 5 seconds. Benjamin: Benjamin’s pain assessment should be appropriate for his age. The patient, if possible, is the best person to report the pain. In this case, Benjamin’s self report is especially important to elicit since his parents speak little English. His pain assessment should be focused on his abdominal region. When asked about provocative or palliative factors, Benjamin does not respond. He clings tightly to his mother. When asked about how his pain feels, he replies, “like something poking me really hard.” Benjamin points to the face that corresponds with the number 8 on the faces pain rating scale. There is no radiation of the pain. He is alert and oriented x 3. His breath sounds are clear to auscultation bilaterally. Heart rate is regular. S1 and S2 are normal. His abdomen is soft with hypoactive bowel sounds. BP= 90/64, HR = 90, Temperature = 38.2 °C orally, Respirations = 24.

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How will a baseline pain assessment and physical exam will determine your care for each patient. Diane: A baseline pain assessment in Diane’s case is imperative to monitor for signs and symptoms of complications of blunt chest and abdominal trauma. Complications that may manifest in pain or other symptoms related to blunt chest or abdominal trauma include pneumothorax, rib fractures, pericardial tamponade, aortic tear, and intra-abdominal bleeding. The pain characteristics assessed in combination with other physical exam findings, such as quality of breath and heart sounds and a detailed abdominal exam will help to identify the cause of your patient’s pain and the potential for the development of other complications. Elizabeth: Given Elizabeth’s pain assessment, you can most likely surmise that Elizabeth is having some degree of pain upon coughing, probably due to pneumonia. A thorough history and physical exam provides you with the clues needed to create a tentative judgment about the patient’s pain source and will aid the physician in correctly diagnosing this patient. Benjamin: Increased pain, radiation, or changes in his abdominal exam are especially important for Benjamin and should be reported to his physician immediately. His initial complaints of periumbilical pain are still present, but you notice that he is now guarding his right lateral abdomen. When asked to cough or jump (which would elicit peritoneal irritation), Benjamin continues to cling to his mother and whimpers slightly. Correlating new physical exam findings will help to confirm the diagnosis of appendicitis or point the healthcare provider in another direction. Example of Effective Nurse to Physician Communication: This communication pertains to Diane’s case. Read the following excerpt from a phone conversation between the healthcare provider and Diane’s nurse.

Nurse: Dr. Jones? Physician: Yes? Nurse: This is Betty on 8-East, Diane Richmond’s nurse. Diane is status post a MVC 6 hours ago, with blunt chest and abdominal trauma. During my initial assessment of Diane, I discovered she is experiencing a significant amount of pain in her upper abdomen. She rates it as a 7 on a numeric scale of 1-10. Coughing significantly increases her pain. Her abdomen is soft and tender with hypoactive bowel sounds. Other assessment findings are negative. Her BP = 106/74, HR = 88, Respirations = 22 Temp = 37.5 orally. I am worried about her abdominal pain and vital signs. Can you come and assess her please? Physician: Thank you for calling. Why don’t you give her 4 milligrams of IV morphine & see if that helps. Nurse: It may help her pain. However, I am reluctant to do that since her BP is already borderline low. I am really worried she may be bleeding internally. Can you come see her now? Physician: I will be right up. Thanks.

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Pain Management Pharmacological treatment is largely determined based upon the type of pain the patient is experiencing. Determining whether the pain is nocioceptive or neuropathic in origin will allow the healthcare professional to accurately prescribe the right drug and administer it via the right route. In addition, the healthcare professional should assess whether the pain is somatic, visceral, acute, chronic, or any combination thereof. As mentioned previously, a large amount of pain experienced by hospitalized patients is either post-surgical or procedural. Also important to note is that hospitalized patients might already have a history of chronic pain; pain that they had before a procedure or surgery. Therefore, it is useful to discuss pain management in this context.

Understanding Opioids Opioids are commonly administered through enteral and parenteral routes. Some may even be administered transdermally, subcutaneously, intrathecally, and epidurally. Around the clock oral dosing is the preferred mechanism for managing chronic pain. Alternatively, parenteral administration is usually a good choice for acute, surgical pain and breakthrough pain. Opioids can be divided into two main groups, mu-agonists and agonist-antagonists, based upon their mechanism of action. Mu-Opioid Agonist Mu-agonist opioids (also referred to as narcotics) are the most commonly used and include morphine, codeine, hydromorphone (Dilaudid), fentanyl, methadone, oxycodone, levorphanol, and meperidine (Demerol) (McCaffery & Pasero, 1999). These drugs are used most effectively in malignant, breakthrough, and acute pain, including surgical pain. Adverse effects of these opioids include constipation, nausea, vomiting, sedation, respiratory depression, and pruritus. These effects are usually visible in the opioid-naive patient and diminish as tolerance develops. Tolerance to constipation does not diminish; therefore an appropriate stool softener or bowel regimen should be prescribed concurrently with any opioids. The following table gives common dosages of common mu-opioid agonists.

Rectal Transmucosal

(Skidmore-Roth, 2002)

Drug Morphine Fentanyl Hydromorphine Meperidine

Normal PO Dose

10-30 mg q 4 hours

5/mcg/kg 1-6 mg q 4-6 hours

50-150 mg q 3-4 hours

Normal IV Dose 1.0-2.0 mg/kg; Up to 0.1 mg/kg

0.5-2.0 mg 2-4 mg q 4-6 hours

50-100 mg q 3-4 hours

Other forms or routes

Ext. release SC IM

IM Transdermal Oral

Rectal IM SC

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Agonist-Antagonist Opioids Agonist-antagonist opioids are most appropriately used for acute, non-malignant pain and may be particularly helpful in nocioceptive (visceral or somatic) pain. Some examples of agonist-antagonists are butorphanol (Stadol), Nalbuphine (Nubain), and Pentazocine (Talwin) (McCaffery & Pasero, 1999). Their side effects are limited. They also produce less analgesia and have a lower dependency potential than opioids. This group is not useful in the management of chronic pain. Agonist-antagonists displace opioids from their mu-receptor sites and often produce withdrawal reactions and further prevent adequate pain control in chronic pain sufferers (McKenry & Salermo, 2003). Therefore, they are contraindicated in patients taking long-term opioids or are physically dependant on opioids because they will displace the opioid at its binding site — possibly leading to physical withdrawal symptoms (Skidmore-Roth, 2002).

Drug Nalbuphine Butorphanol Pentazocine

Normal PO Dose Not applicable Not applicable 50-100 mg q 3-4 Not to exceed 600 mg/day

Normal IV Dose 10-20 mg q 3-6 hours Not to exceed 160 mg/day

0.5-2.0 mg IV Every 3-4 hours

IV 30 mg q 3 hours Not to exceed 600 mg/day

Other IM & SQ = 0-20 Mg q 3-6 hours Not to exceed 160 mg/day

IM = 1-4 mg q 3-4 hours Intranasal = 1 spray In 1 nostril q 3-4 hours

IM & SC = 30 mg q 3 hours Not to exceed 360 Mg/day

Major Considerations

Respiratory Depression

Respiratory Depression Geriatrics – give ½ dose

Respiratory Depression

(Skidmore-Roth, 2002)

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Opioid Antagonists Opioid antagonists reverse the effects of opioid mu-agonists such as morphine, fentanyl, and meperidine. Naloxone (Narcan) is the primary opioid antagonist. Its main purpose is to rapidly reverse opioid induced-respiratory depression. The standard dose for naloxone is .4 mg diluted in 9 ml’s of IV fluid. It can be given as .4 mg every 2 minutes up to 4.0 mg. It onset is 1-2 minutes with a peak effect of 5-15 minutes.

Elimination half-life is 90 minutes and duration of action is approximately 45 minutes. If this drug is given to opioid-dependant patients, it may result in severe physical withdrawal (American Pain Society, 1999; Skidmore & Roth, 2002). Patient-Controlled Analgesia (PCA) Most post-surgical, post-procedural, and acute or breakthrough pain is managed initially via the parenteral route. Parenteral administration of opioids is usually via IV injection, or often by a PCA (patient controlled analgesia) pump. The greatest advantage of PCAs is that, within parameters, they give patients the chance to be involved in their own care by allowing them to control the dosing of their pain medication. PCA pumps deliver a set amount of an opioid at given intervals, by continuous dosing or by a combination of both. Patients do not have to wait for a caregiver if they need additional medication and can administer a pre-determined dose of medication at any time they desire. Because the patient is the only one who administers the dose, respiratory depression rarely occurs. Since sedation is a precursor to respiratory depression, the patient will usually fall asleep prior to administering too much opioid. Thorough patient teaching, as well as teaching for the family is imperative. The family should be warned against administering doses while the patient is sleeping to prevent accidental overdose. Eventually, the post-surgical patient will be transitioned to an oral route of pain medication. This transition to oral prn dosing usually begins within the first 48 hours post-surgery depending on the patient’s condition and surgical procedure. Chronic pain sufferers may also receive opioids parenterally to control breakthrough pain. They too, will eventually be transitioned to the oral route. Oral around-the-clock dosing is the best way to effectively manage chronic, malignant, and non-malignant pain. This transition between opioid delivery routes is often what causes healthcare providers and patients the most distress in the pain management process, partially because providers do not fully understand equianalgesic dose conversions and patient barriers are prevalent.

FYI… Care must be taken in administering the right opioid for the right patient. For instance,

meperidine is not used for chronic pain due to its ceiling effect and potential for accumulation of metabolites, which may lead to seizures. Propoxyphene (Darvon) is appropriate for short-term, non-malignant pain due to renal toxicity with long-term use. Transdermal fentanyl is not a good

choice for acute, surgical pain as its peak effect is delayed (McCaffery & Pasero, 1999). It is however an excellent choice for chronic pain in individuals that cannot tolerate oral dosing, but

must be applied over dry, non-edematous skin.

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Equianalgesic Dose Conversions Equianalgesic dosing means using different medications or routes of delivery that provide similar effectiveness of pain control. Often nurses are responsible for managing a patient’s pain when converting from one opioid to another or converting from different routes of delivery. Equianalgesic dose charts should be used to help you determine if the patient is receiving the appropriate dose of medication via the appropriate route when therapy changes are made. Equianalgesic charts such as the one in the following table, adapted from McCaffery & Pasero (1999), provide an equialgesic conversion tool that converts common dosages of opioids quickly and efficiently. Remember, this chart is a tool. Clinical judgment and patient response should always guide your practice first and foremost. These doses are adult approximations. Doses should be reduced for children or the elderly as clinically indicated.

Equianalgesic Dose Chart

Drug Dose (mg) Parental

Dose (mg) Oral Duration (Hour)

Morphine 1.0 30 3-4

Hydromorphone (Dilaudid) 1.5 7.5 3-4

Oxycodone (Oxycotin) NA 30 3-4

Levorphanal (Levo-Dromoran) 2 4 6-8

Methadone NA 2-5 6-12

Codeine NA 200 3-4

Hydrocodone (Vicodin) NA 30-75 3-4

Meperidine (Dermerol) 100 300 3-4

Fentanyl (Duragesic)

0.1-0.25 mg (100-250 mcg)

Microgram per hour dose of transdermal

fentanly approximates ½ of the milligram per day dose of oral morphine up to 200

mg per day

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Doses of drugs in this chart are listed as compatible doses. For example 30 mg of oral morphine = 7.5 mg of oral hydromorphone = 1.5 mg of IV hydromorphone (McCaffery and Pasero, 1999).

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Dose Conversion Practice A Few Rules…

• Tape your equianalgesic table to your clipboard or other easily accessible place. • Know where to find your equianalgesic dose chart. • Use a calculator • Don’t be afraid. It is easier than you think! Converting from the “OLD” drug to the “NEW” drug

1. Calculate the total dose of the “old” opioid in a 24-hour period. 2. Set up the following ratio:

mg “old” opioid = mg “new” opioid Current mg of (old) in 24 hr. X Where X = mg of “new” opiod you are trying to calculate in a 24 hours period.

3. Divide the 24-hour dose of the “new” opioid to obtain the desired interval dose (e.g., q4th, q12h, etc.)

4. When converting from PO to IV, you may want to consider reducing the dose by one third to one half to accommodate for the first pass effect of oral agents through the liver. Since IV agents enter the bloodstream directly, a smaller initial dose is indicated.

For Example… Elizabeth who been taking 30 mg of oxycontin q 4 hours PO can no longer swallow. You want to start a continuous IV morphine infusion at an equianalgesic dose.

1. 30 mg oxycontin q4h = 30 mg x 6 doses in a 24-hours period = 180 mg oxycontin in a 24-hour period.

2. Your equianalgesic dose table says that 30 mg PO oxycontin = 30 mg of oral morphine = 10 mg of IV morphine

30 mg PO Oxycontin = 10mg IV morphine 180 mg PO oxycodone/24 hrs X mg IV morphine/24 hrs

X= 60 mg IV morphine in 24 hrs 3. The hourly infusion rate = 60 mg in 24 hrs = approximately 2.5 mg IV morphine per hour. 4. Since we are converting from PO to IV – we should reduce the dose by 1/3 to ½ to

accommodate for the first pass effect of oral agents through the liver.

2.5 mg/hour /2 = 1.25 mg per hour 2.5 mg/hour /3 = 0.8333 = 2.5 – 0.833 = 1.67mg/hour

New dose of IV Morphine should be between 1.25-1.67 mg/hour based upon your patient’s

specific needs.

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Another Example… Diane, a status post MVA patient, has had satisfactory relief of pain with an IV hydromorphone infusion of 1 mg per hour. You want to send her home on an equianalgesic dose of sustained release oral morphine (MS Contin or OraMorph SR given q12h, or Kadian q day). 1. mg hydromorphone per hour = 24 mg IV hydromorphone in 24 hrs 2. Your equiananalgesic dose table says that 1.5 mg IV hydromorphone = 7.5 of oral

hydromorphone = 30 mg of oral morphine. Make the dosage ratio:

1.5 mg IV hydromorphone = 30 mg PO morphine 24 mg IV hydromorphone/24 hrs X mg PO Morphine/24 hrs

X = 480 mg PO morphine/24 hrs

3. q12h dose = 240 mg sustained-release morphine PO q12h 4. Since we are not converting from PO to IV reduction in the dose is not needed. Careful

assessment of this patient is needed to ensure this dose is enough however, given liver and renal function.

Now it is your turn… Jerry is a 54-year-old male returning to the hospital 2 weeks after port placement for initial doses of chemotherapy. While receiving chemotherapy in the outpatient setting, he became significantly nauseated, with uncontrolled episodes of emesis. He is admitted to your facility for re-hydration, nausea and pain control. Calculate a satisfactory dose of IV morphine for Jerry to control his pain. At home, he had been taking 100 mg of MS Contin every 12 hours. Step 1: Calculate the total dose of the “old” opioid in a 24-hour period Step 2: Set up the following ratio

Mg “old” opioid = mg “new” opioid Current mg of “old” in 24 hr X

Where X = mg of “new” opioid you are trying to calculate in a 24 hour period. Step 3: Divide the 24-hour dose of the “new” opioid to obtain the desired interval dose (e.g., q4h, q12h, etc.)

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Answer: 1. Jerry has been taking 200mg of MS Contin in a 24-hour period. 2. 30 mg of PO morphine = 10 mg IV morphine

Ratio: 10mg IV morphine = 30 mg PO morphine X mg IV morphine/24 hrs 200 mg PO morphine/24hrs

X = 66.6 mg IV morphine/24hrs 3. The q1hr dose of the IV morphine is 67 mg / 24 hours = 2.79 mg/hr 4. When converting from PO to IV, you may want to consider reducing the dose by 1/3 to ½ to

accommodate for the first pass effect of oral agents through the liver. Since IV agents enter the bloodstream directly, a smaller initial dose is indicated

So, 2.8 mg / 2 = 1.4 mg/hour; 2.8 mg / 3 = .933; 2.8 .933 = 1.867 mg

New IV dose should be between 1.4mg and 1.8 mg per hour IV.

The information above is for informational purposes only, and should be used solely as a reference. It should not be used as a substitute, or in lieu, of professional judgment. RN.com disclaims all warranties, express or implied, related

to the contents of this tool. Always refer to specific facility medication guidelines/standards on medication administration.

Non-Opioid Analgesia: Acetaminophen and NSAIDs Another class of analgesics used for controlling pain is the non-opioids. Non-opioids consist of acetaminophen (Tylenol), NSAIDs, and Cox-2 Inhibitors. Recent information about risks of Cox-2 Inhibitors has severely limited their use. Acetaminophen has antipyretic and analgesic effects. Often acetaminophen has fewer adverse affects and may be used safely in patients with decreased platelets or gastrointestinal disorders. However, acetaminophen has very little effect against inflammation, may cause liver toxicity and has a maximum dose of 4000 mg/day in most adult patients (McKenry & Salermo, 2003; McCaffery & Pasero, 1999). NSAIDs have analgesic, antipyretic and anti-inflammatory effects. The adverse effects of NSAIDs include gastrointestinal dysfunction (nausea, vomiting, diarrhea, cramps, and gas), gastric ulcers, gastric bleeding, and interference with platelet aggregation. NSAIDS should be used with extreme caution in patients with a history of gastrointestinal bleeding or ulcers, those with low platelet counts, or those with renal insufficiency. Examples of commonly used NSAIDs include: aspirin, choline magnesium trisalicylate (Trilisate), ibuprofen (Motrin, Advil), ketoralac (Toradol), ketoprofen (Orudis), and naproxen (Naprosyn) (McKenry & Salermo, 2003; McCaffery & Pasero, 1999).

Critical Thinking Tip: • Avoid acetaminophen in patients with

liver disease • Avoid NSAIDs in patients with platelet

disorders, bleeding tendencies, history of gastric ulcers or renal disease.

• Some Cox-2 Inhibitors have been taken off the market, the use of others is now limited in patients with heart disease.

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The following table represents commonly used non-opioid analgesics (AHCPR, 1992; Roth, 2002). Please note that all doses are approximate and the patient’s clinical condition must be taken into consideration prior to administration of these drugs.

Commonly Used Non-Opioids Non-Opioid Adult Dose Pediatric Dose Issues

Acetaminophen (Tylenol)

650-975 mg q 4hr 10-15 mg/kg q 4 hr Acetaminophen does not have anti-inflammatory properties Contraindicated in liver failure or disease

Aspirin 650-975 mg q 4 hr 10-15 mg/dg q 4 hr

Inhibits platelet aggregation

Choline magnesium trisalicylate (Trilisate)

1000-1500 mg bid 25 mg/kg bid May have minimal anti-platelet activity Available as an oral liquid

Ibuprofen (Motrin, others

400 mg q 4-6 hr 10 mg/kg q 6-8 hr Available as several brand name and generic Available in oral suspension

Ketoprofen(Orudis) 25-75 mg q 6-8 hr

Magnesium salicylate 650 mg q 4 hr Many brands and generic forms available

Naproxen (Naprosyn)

500 mg initial dose followed by 250 mg q

6-8 hr

5 mg/kg q 12hr Available as oral liquid

Naproxen sodium (Anaprox)

550 mg initial does followed by 275 mg q

6-8 hr

Ketorolac tromethamie

(Toradol)

30 or 60 mg IM/IV initial dose followed by

15 or 30 mg q 6 hr Oral dose following

IM/IV dosage: 10 mg q 6-8 hr

Intramuscular/Intravenous dose not to exceed 5 days

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COX-2 Inhibitors COX-2 inhibitors were developed to reduce inflammation by selectively blocking the COX-2 enzyme. Blocking this enzyme halts the production of prostaglandins that cause the pain and swelling. The COX-2 inhibitors represent a new class of drugs that do not affect COX-1, but selectively block only COX-2. This selective action provides the benefits of reducing inflammation without irritating the stomach. The only COX-2 inhibitor that is now on the market is celecoxib (Celebrex). The analgesic efficacy of COX-2 selective inhibitors is comparable to non-selective NSAIDs such as naproxen, ibuprofen, and sulindac and seem to be of great value to people with arthritis. Vioxx, known generically as rofecoxib, was recalled in on October 1, 2004, in the largest prescription drug withdrawal in history. The withdrawal was prompted after a new study examining Vioxx's impact on bowel cancer found the drug caused an almost twofold increase in heart attacks and strokes. However, the controversy does not end there. The FDA asked Pfizer to withdraw Bextra (valdecoxib) from the market because the overall risk of heart disease and life-threatening skin reactions outweighed its therapeutic benefits. Celebrex is now the only Cox-2 drug on the market and it carries a very strong warning against cardiovascular and skin complications. One other Cox-2 inhibitor, lumiracoxib, has been made available outside of the U.S. and is being marketed under the name Prexige. As of 2007, the drug is still not approved for use in the U.S.

Adjuvant Analgesia Adjuvants are drugs that are used to treat other disorders but also have analgesic properties. Adjuvants are most effective against neuropathic pain. They are generally grouped into antidepressants (amitriptyline [Elavil], desipramine [Norpramin], nortriptyline [Pamelor]), corticosteroids (dexamethasone [Decadron]), anticonvulsants (gabapentin [Neurontin], carbamazepine [Tegretol]), and psychostimulants (dextroamphetamine [Dexedrine] and methylphenidate [Ritalin]) (McKenry & Salermo, 2003). Almost all adjuvants can be given orally, however some may be given parenterally, transdermally, intrathecally, or epidurally. Most adjuvants have ceiling effects and must be titrated upward. A delayed response is common until the drug is at an effective dose and has reached its peak efficacy. Therefore, adjuvants are most commonly used in chronic pain (McKenry & Salermo, 2003; McCaffery & Pasero, 1999).

Critical Thinking Tip: • Anticonvulsants and antidepressants are best used to treat neuropathic, chronic pain. • Titrate adjuvants upwards to achieve desired effect, keeping ceiling doses in mind.

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Commonly Prescribed Adjuvants for Pain

Drug Class Drug Name Normal Adult Dose Comments

Corticosteroids Dexamethasone (Decadron)

4-16mg per day May cause hyperglycemia Do not abruptly stop use.

Antidepressants Amitriptyline (Elavil)

25-150 mg qhs

25-150 mg qhs

Titration upwards should occur every 3-5 days by 25 mg increments for desired dose. Titration upwards should occur every 3-5 days by 25 mg increments for desired dose. Imipramine is less sedating

Anticonvulsants Gabapentin (Neurontin)

Valproic Acid (Depakote)

300mg once daily Then 300mg twice a day,

titrate to pain relief.

Begin with 250mg TID and titrate.

Maximum dose = 3600 mg/day

May be given rectally

Other routes such as intranasal, rectal, and topical are also effective for pain relief in certain conditions. Consider what is appropriate for your patient and the best drug for their needs when advocating pain management strategies.

Non-pharmacological Therapies In addition to pharmacological therapies, non-pharmacological therapies can augment pain relief in all pain types. Heat, cold, massage, and repositioning in combination with acetaminophen or a NSAID may control mild pain. Other useful non-pharmacological measures include talking with a caregiver, relaxation, distraction, guided imagery, and changing the meaning of one’s pain. Relaxation is an active process and requires concentration but has a direct physical and mental effect on how the patient perceives pain. Distraction and guided imagery allow the mind to concentrate on things other than the pain. Changing the meaning of pain counteracts the negative thoughts patients have about pain (Davis, 2000). Talking with a caregiver allows the patient to explore the meaning of their pain and may also provide distraction from the pain. Whichever non-pharmacological intervention is used to manage the patient’s pain, assessment of the effectiveness of these therapies must be based upon the patient self-report and re-assessment must occur.

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The WHO Ladder to Manage Chronic Malignant Pain The World Health Organization (WHO) has advocated using pharmacological and non-pharmacological strategies in combination for chronic cancer pain with around-the-clock oral dosing as the basis for effective pain control. The rationale behind around-the-clock oral dosing stems from the fact that steady drug states are achieved more quickly with around-the-clock dosing compared to dosing on a PRN only basis. WHO advocates for a three-step approach to managing pain (WHO, 1996). A visual representation of this method for managing pain is illustrated below. When pain is not effectively controlled or pain increases, move up the ladder using the treatments recommended. Multiple studies have illustrated the effectiveness of this approach. Using the WHO guidelines for cancer pain results in clinically significant pain reduction and reduces the need for invasive pain control procedures. At a minimum, adequate analgesia was observed in two-thirds to all patients using this approach (Zech, Grond, Lynch et al., 1995; Jadad & Browman, 1995).

WHO Ladder

Critical Thinking Tip: • Around-the-clock oral dosing is the most effective pain relief strategy in controlling

chronic pain. • Advocate for the patient using your knowledge of WHO ladder’s 3-Step Approach to

Freedom from Cancer pain

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Special Populations Treating pain in special populations is based upon individual assessment and knowledge of unique characteristics of these populations. Infants and children, the elderly, people from different cultures, and those with a prior history of substance abuse are most likely to experience inadequate pain control. Therefore, it is useful to discuss pain management in terms of the specific beliefs and actions of the healthcare provider toward these populations.

Infants & Children Pain in infants and children is particularly challenging. A popular misconception is that infants’ pain cannot be measured. In fact, infants can express pain through cries and experience an increase in heart rate and drop in oxygenation as painful as stimuli is received. Additionally, some healthcare professionals often believe that infants do not experience pain as fully as a child or an adult. In reality, at birth the infant’s nerve ending are similar if not greater than adults. The infant’s cortex has a complete set of neurons at 20-weeks gestation. Research shows that in adults, myelination is not a factor in the infant’s ability to process pain either (McCaffey & Pasero, 1999). Likewise, children often do not report their pain and may have difficulties describing or quantifying their pain experience. Utilizing age specific assessments pain tools and knowing common behaviors in infants and children is paramount to understanding and managing their pain. Parent or guardian support and interpretation of their child’s pain can be critical however, in the absence of a parent or guardian how do we safely treat pain in infants and children – without under-treating? There are many pain scales that can be utilized in this population to qualify and quantify their pain. Some of these scales are the FLACC, CRIES, NIPS, Faces, and CHEOPS. FLACC Evaluation of each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolably is scored from 0-2, which in total score between zero and ten.

Scoring Category 1 2 3

Face No particular expression or smile

Occasional grimace or frown, withdrawn,

disinterested

Frequent to constant quivering chin, clenched jaw

Legs Normal position or relaxed Uneasy, restless, tense Kicking , or legs

drawn

Activity Lying quietly normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid or jerking

Cry No cry (awake or asleep) Moans or whimpers; occasional complaint

Crying steadily screams or sobs,

frequent complaints

Consolability Content, relaxed

Reassured by occasional touching,

hugging or being talked to, distractible

Difficult to console or comfort

Adapted from The FLACC: A behavioral scale for scoring postoperative pain in young children, by S. Merkel and others, 1997, Pediatric Nurse 23(3), p. 293-297.

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CRIES The CRIES tool has been well received by health professionals. The five parameters represented are below. The maximum score of 10 points is calculated in a similar manner as the Apgar score – a score of four or more represents pain requiring intervention to reduce pain and maintain comfort. For example, a grimace, the facial expression most often associated with pain, gains a score of 1 but if associated with a grunt will be scored a 2. The scale is particularly useful for neonatal postoperative pain. Researchers concluded that CRIES postoperative pain assessment scale was a valid and reliable measure of postoperative pain in neonates 32 to 60 weeks gestation.

Crying

Requires oxygen to maintain saturation greater than 95%

Increased vital signs

Expression

Sleepless (See Appendix A for the entire scale and scoring criteria) NIPS Neonatal/Infants Pain Scale has been used mostly in infants less than one year of age. Facial expression, cry, breathing pattern, arms, legs, and state of arousal are observed for one minute intervals before, during and after a procedure and a numeric score is assigned to each. A score >3 indicates pain. (See Appendix B for entire scale.) FACES Children or persons with cognitive impairment may better quantify their pain using a faces pain rating scale instead of a numeric scale. A faces pain scale allows the patient to express their pain using graphical representations of their pain instead of numbers. The Wong and Bakers Faces of Pain Scale is an alternative to the numerical scale (Wong, 1997).

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CHEOPS CHEOPS stands for Children's Hospital of Eastern Ontario Pain Scale. It is intended for children ages 1-7 yrs old. It assesses cry, facial expression, verbalization, torso movement, if child touches affected site, and position of legs. Very basically, a score >= 4 signifies pain. (See Appendix B for entire scale.)

The Elderly The elderly are also at risk for the under-treatment of pain. This is largely because of their inability or reluctance to report pain and healthcare professionals fear of “overdosing” this type of patient. The elderly may also have varying levels of cognitive impairment. Careful assessment of the cognitively impaired elder through observable indicators and family information about their loved one’s pain is very useful in recognizing pain in the elderly (see section on Cognitively Impaired). When providing opioids for pain control, the key is to start at a low dose and titrate upward until a desired effect is reached. Renal dysfunction in the elderly may also inhibit adequate pain management. Therefore, monitoring of appropriate laboratory values is indicated.

The Cognitively Impaired The cognitively impaired is another population at risk for the under-treatment of pain. Successful and safe pain control in these patients can be particularly challenging. If your cognitively-impaired patient can self-report pain, this is the most reliable indicator of pain, and should be believed. If a person can not understand or use a numerical rating scale, sometimes a verbal descriptor scale can be utilized effectively. These scales use vague words such as mild, moderate, and severe to help the practitioner understand their patient’s pain. Other scales that may be useful include the pain thermometer and the Faces pain scale (Herr & Garand, 2001). The pain thermometer is diagram of a thermometer with word descriptors that shows increasing pain intensities.

Critical Thinking Tip: No matter what scale your institution uses, it is important to try to get a self-report from the child first. Children older than 3 years old can often give an accurate self-report. If a self-report is not possible, then one of the aforementioned scales can be used or another scale. Be sure you use the scale appropriate to the age you are trying to assess and you understand how to score and

what the score means.

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The Critically Ill When caring for critically ill, mechanically ventilated patients, one of the most important priorities is to relieve any pain that the patient might be experiencing. Mechanically ventilated patients can often still self-report pain, either by blinking or raising a finger with some yes/no questions. Puntillo (1990) found that 63% of 24 critically ill patients in the ICU experienced moderate to severe pain. Another study by Stanick-Hutt et al. (2001) showed that of 30 traumatically injured patients in the ICU, 96% reported pain from their injuries and 36% reported pain related to central lines, chest tubes, nasogastric tubes, Foley catheters, wound drains, and orthopedic fixation devices. Additionally, the Thunder Project II, sponsored by the American Association of Critical Care Nurses (Puntillo et al., 2001) in a study of over 6,000 patients, ages 4 to 97, revealed that even simple procedures in the ICU were associated with various levels of pain. These procedures include turning, wound drain removal, femoral catheter removal, central line placement, and non-burn wound dressing changes. Mechanically ventilated patients often try to communicate pain to their nurses. Some techniques used to report pain in a mechanically ventilated patient include grabbing the healthcare professionals arm, signaling with their eyes, and moving their legs up and down (Puntillo, 1990). Some conscious, intubated patients can self-report and provide some information regarding their pain. This self-report is the most accurate indicator of pain and should be taken seriously. Pain relief measures should also be considered in the presence of pathologic conditions or when procedures that might cause pain are performed. Healthcare professionals should be aware of and consider behaviors (e.g. facial expressions, body movements, crying), reports from family members, and physiologic measures such as blood pressure and respiratory rate when assessing for pain (Pasero & McCaffery, 2000).

Culture Issues People from different cultures experience pain largely based on their meaning of pain. Be aware of your own cultural uniqueness and seek to accept the distinct perspectives of others. Be cognizant of your approach to the patient, including the use of non-verbal communication styles. The patient’s comfort with eye contact, various body postures, amount of physical space, and appropriateness of touch are individual to various cultures. It is often difficult for you to be knowledgeable about all of the possible cultural norms of patients; however, you can be alert to the patient’s verbal and non-verbal cues. A careful approach to the patient in these instances will often set the stage for successful pain management.

Patients with Prior History of Substance Abuse Treating patients with a prior history of substance abuse can be challenging. You may be torn between providing adequate pain control for the patient and your own reluctance to provide an adequate dose of an opioid due to fear of future addiction or the thought that you are supporting “drug-seeking” behavior. Regardless of the drug abused, the disease of addiction increases the patient’s pain experience through changes in the endogenous opioid pathways, stimulation of the sympathetic response, and by decreasing the patient’s pain threshold (Savage, 1994; Miller & Gold, 1993; Mao, Price & Mayer, 1995). While this population may be difficult to treat for numerous reasons, withholding an opioid for pain relief must not occur. This may even cause the patient to seek their “old habits” to reduce pain. Instead, judicious assessment and monitoring of the patient’s pain must be basis in which healthcare providers initiate and adjust pharmacologic therapies.

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Conclusion

In conclusion, pain is a multifaceted symptom that must be accurately assessed to be managed successfully. Healthcare professionals must actively participate in continuing to learn about new theories and techniques in pain management. Barriers must be addressed at the patient, provider and system level. A thorough patient history and assessment should be conducted for all existing and new pain; recognizing that the patient is the best equipped to describe the pain. Successful pain control is often achieved by providing both pharmacological and non-pharmacological therapies. Finally, healthcare professionals must be aware of those at risk for under-treatment of pain and current strategies in managing pain. Pain is a universal affliction and all healthcare providers must take initiative to appropriately manage pain and alleviate suffering.

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Appendix A

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Appendix B

Pain Assessment Tools Neonatal/Infant Pain Scale (NIPS)

(Recommended for children less than 1 year old) - A score greater than 3 indicates pain.

Pain Assessment Score Facial Expression 0 – Relaxed Muscles 1 – Grimace

Restful face, neutral expression Tight facial muscles; furrowed brow, chin, jaw, (negative facial expression—nose, mouth, and brow)

Cry 0 – No Cry 1 – Whimper 2 – Vigorous Cry

Quiet, not crying Mild moaning, intermittent Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidence by obvious mouth and facial movement).

Breathing Patterns 0 – Relaxed 1 – Change in Breathing

Usual pattern for this infant Indrawing, irregular, faster than usual; gagging; breath holding

Arms 0 – Relaxed/Restrained 1 – Flexed/Extended

No muscular rigidity; occasional random movements of arms Tense, straight legs; rigid and/or rapid extension, flexion

Legs 0 – Relaxed/Restrained 1 – Flexed/Extended

No muscular rigidity; occasional random leg movement Tense, straight legs; rigid and/or rapid extension, flexion

State of Arousal 0 – Sleeping/Awake 1 – Fussy

Quiet, peaceful sleeping or alert random leg movement Alert, restless, and thrashing

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Children's Hospital Eastern Ontario Pain Scale (CHEOPS) (Recommended for children 1-7 years old) - A score greater than 4 indicates pain.

Item Behavioral Definition Score

Cry

No cry

Moaning

Crying

Screaming

1 2 2 3

Child is not crying

Child is moaning or quietly vocalizing silent cry

Child is crying, but the cry is gentle or whimpering

Child is in a full-lunged cry; sobbing; may be scored with complaint or without complaint

Facial Composed

Grimace

Smiling

1 2 0

Neutral facial expression

Score only if definite negative facial expression

Score only if definite positive facial expression

Child Verbal

None

Other complaints

Pain complaints

Both complaints

Positive

1

1

2

2

0

Child not talking

Child complains, but not about pain, e.g., “I want to see mommy” or “I am thirsty.”

Child complains about pain

Child complains about pain and about other things, e.g., “It hurts; I want my mommy.”

Child makes any positive statement or talks about other things without complaint.

Torso

Neutral

Shifting

Tense

Shivering

Upright

Restrained

1 2 2 2 2 2

Body (not limbs) is at rest; torso is inactive

Body is in motion in a shifting or serpentine fashion

Body is arched or rigid

Body is shuddering or shaking involuntarily

Child is in a vertical or upright position

Body is restrained

Touch

Not touching

Reach

Touch

Grab

Restrained

1 2 2 2 2

Child is not touching or grabbing at wound

Child is reaching for but not touching wound

Child is gently touching wound or wound area

Child is grabbing vigorously at wound

Child’s arms are restrained

Legs

Neutral

Squirm/kicking

Drawn up/tensed Standing

Restrained

1

2

2

2 2

Legs may be in any position but are relaxed; includes gentle swimming or separate-like movements Definitive uneasy or restless movements in the legs and/or striking out with foot or feet

Legs tensed and/or pulled up tightly to body and kept there

Standing, crouching, or kneeling Child’s legs are being held down

UCLA Pediatric Pain Assessment Tools. (2005). Retrieved September 10, 2005 from http://www.anes.ucla.edu/pain/assessment_tools.html

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© Copyright 2004 AMN Healthcare, Inc.

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