PA IN

The fifth vital

sign American Pain

Society 2003
Identifying pain as the

fifth vital sign

suggests that the
assessment of pain
should be as
automatic as taking a
clients BP and pulse

 whatever the

person says it is,

existing whenever
the experiencing
person says it does
McCaffery &
Pasero, 1999
Emphasizes the

highly subjective
nature of pain

 Pain is the most

COMMON reason
clients seek medical
advice
Pain is a protective

mechanism or a
warning to prevent
further injury

TH E PATH O PH YSIO LO GY O F
PAIN

Pain Transm ission

Nociceptors also called as pain

receptors are free nerve endings in

the skin that respond only to intense,
potentially damaging stimuli
(mechanical, thermal, or chemical)
The joints, skeletal muscle, fascia,

tendons and cornea also have

nociceptors

 Large internal organs do not contain

nerve endings
Polymodal nociceptors respond to

all three types of stimulus

Histamine, bradykinin,

acetylcholine, serotonin, and

substance P are chemicals that
increase transmission of pain

 Prostaglandins are chemical

substances that are believed to

increase the sensitivity of pain
receptors by enhancing the pain
provoking effect of bradykinin
There are 2 main types of fibers

involved in the transmission of

nociception:
Myelinated, A delta fibers fast
pain
Type C fibers second pain

 Chemicals that reduce or inhibit the

transmission or perception of pain

include endorphins and
enkephalins

The G ate ControlTheory

Proposed by Melzack and Wall in

1965
Stimulation of the skin evokes

nervous impulses
Stimulation of the large diameter

fibers inhibits the transmission of

pain, thus closing the gate

Types ofPain
Acute Pain usually of recent onset

and commonly associated with

specific injury; lasting from seconds
to 6 months
Chronic Pain constant or

intermittent pain that persists

beyond the expected healing time
and seldom attributed to a specific
cause or injury; lasts for 6 months or

 Cancer Related Pain may be acute

or chronic; can be directly associated

with the cancer, a result of cancer
treatment, or not associated with the
cancer
Pain classified by location - aids in

communication about and treatment of

the pain
Pain classified by etiology to predict

course of pain and plan effective

treatment using this categorization

FACTO RS IN FLU EN CIN G PAIN

RESPO N SE

 Past experience
Anxiety and Depression
Culture
Gender
Genetics
Placebo effect

PAIN ASSESSM EN T

 Obtain a Pain History

Allow the client to describe the pain

to establish a trust relationship

between you and the client
Discover the effects of pain on the

client's quality of life

Assess for emotional and spiritual

distress and coping abilities

 Ask about previous pain experience

and what measures have been

effective as well as those who have
not
Use WHATS UP format or PQRST or

OLDCART in assessing pain

 W where is the pain? Be specific.

Use drawing of body if necessary

H how does the pain feel? Is it

shooting, burning, dull, sharp?

A aggravating and alleviating

factors. What makes the pain better?

Worse?
T timing. When did the pain start?

Is it intermittent? Continuous?

 S severity. How bad is the pain on a

0 to 10 (0 to 5; faces) scale
U useful other data. Are you

experiencing any other symptoms

associated with the pain or pain
treatment? Itching, nausea, sedation,
constipation?
P perception. What is the clients

perception of what caused the pain?

 P provoked
Q- quality
R region/radiation
S severity
T - timing

 O onset
L location
D duration
C characteristic
A aggravating factors
R radiation
T treatment

Sam ple (PQ RST)

With

continuous, drilling, bilateral

knee
pain
that
occurs
upon
ambulation; rated as 8/10 in the
numeric pain rating scale, with 0 as
no pain and 10 as excruciating pain.

Sam ple (O LD CART)

With continuous, penetrating, right

flank pain that occurred 1 hour prior

to admission while client was
consuming fried dried fish; rated as
9/10 in the numeric pain rating scale
with 0 as no pain and 10 as
excruciating pain in the pain rating
scale; radiating on the left shoulder;
aggravated with ambulation and
consumption of salty foods such as
dried fish and corned beef and
alleviated with rest, deep breathing

D aily Pain D iary

For clients who experience chronic

pain
May help the client and nurse
identify pain patterns and factors
that exacerbate or mediate pain
The record can include: time or
onset of pain, activity before
pain, pain-related positions or
behaviors, pain intensity level,
use of analgesics or other relief
measures, duration of pain, time

VisualAnalogue Scales
Useful in assessing the intensity of

pain
Includes a horizontal 10cm line, with
anchors indicating the extremes of
pain
The client is asked to place a mark
indicating where the current pain lies
on the line
Left: none or no pain
Right: severe or worst possible pain

Faces Pain Scale

This instrument has six faces

depicting expressions that range

from contented to obvious distress
The client is asked to point to the

face that most closely resembles the

intensity of his or her pain

G uidelines for U sing Pain

Assessm ent Scale
Written pain scale may not be

possible if a person is seriously ill, is

in severe pain, or has just returned
from surgery
The scale should be used

consistently
The nurse teaches the client how to

use the pain scale before the pain

 Numerical rating should be

documented and used to assess the

effectiveness of pain relief
interventions
Pain scale may help assess the

effectiveness of the interventions if

the scale is used before and after the
interventions are implemented

N O N P H A R M A C O LO G IC
IN TER V EN TIO N S

 Non-pharmacologic nursing activities

can assist in pain relief

Not a substitute for medication
Combining nonpharmacologic

interventions with medications may

be the most effective way to relieve
pain

Cutaneous stim ulation and

m assage
The

gate control theory of pain

proposes that stimulation of fibers
that transmit nonpainful sensations
can
block
or
decrease
the
transmission of pain impulses

Rubbing the skin and using heat &

cold are based on this theory

 Massage is a generalized cutaneous

stimulation of the body that often

concentrates on the back and
shoulders
Massage

have an impact in the

descending control system and does
not
merely
stimulate
nonpain
receptors

Promotes comfort through muscle

relaxation

Therm altherapies
Proponents believe that ice and heat

stimulate the nonpain receptors in

the same receptor field as the injury
Ice should be placed on the injury

site immediately
surgery

after

injury

or

Ice therapy after joint surgery can

significantly reduce the amount of

analgesic medication required

 Assess skin first before applying ice

Ice should be applied on an area for

no longer than 15 to 20 minutes at a

time and should be avoided in clients
with compromised circulation
Application

of
heat
increases
circulation to an area and contributes
to pain reduction by speeding
healing

 Both ice and heat therapy must be

applied carefully and monitored

closely to avoid injuring the skin
Neither therapy should be applied to

areas with impaired circulation or

used in clients with impaired
sensation

Transcutaneous electrical
nerve stim ulation (TEN S)
Uses a battery-operated unit with

electrodes applied to the skin to

produce a tingling, vibrating, or
buzzing sensation in the area of pain
Decreases pain by stimulating the

nonpain receptors in the same area

as the fibers that transmit pain

D istraction
Involves

focusing
the
clients
attention on something other than
the pain

Thought to reduce the perception of

pain by stimulating the descending

control system
Effectiveness depends on the clients

ability to receive and create sensory

 Examples are watching TV, listening

to music, complex
mental exercises
Stimulation

physical

and

of sight, sound, and

touch is likely to be more effective
than the stimulation of a single sense

Relaxation techniques
Believed to reduce pain by relaxing

tense muscles that contribute to the

pain
Consists of abdominal breathing at a

slow, rhythmic rate

The client may close both eyes and

breathe slowly and comfortably

G uided im agery
Using ones imagination in a special

way to achieve a specific positive

effect
May

consist of combining slow,

rhythmic breathing with a mental
image of relaxation and comfort

The client is asked to practice guided

imagery for about 5 minutes, three

H ypnosis
Has been effective in relieving or

decreasing the amount of analgesic

agents required in clients with acute
and chronic pain
Mechanism is unclear
Induced by specially skilled people

M usic therapy
An inexpensive and effective therapy

for the reduction of pain and anxiety

P H A R M A C O LO G IC
IN TER V EN TIO N S

Prem edication assessm ent

The

nurse should ask the client

about allergies to medications and
the nature of any previous allergic
responses

The

nurse obtains the

medication history, along
history of health disorders

clients
with a

A P P R O A C H ES FO R U S IN G
A N A LG ES IC A G EN TS

Balanced analgesia
Refers to the use of more than one

form of analgesia concurrently to

obtain more pain relief with fewer
side effects
Using two or three types of agents

simultaneously can maximize pain

relief while minimizing the potentially
toxic effects of any one agent

Pro re nata
The nurse waits for the client to

complain of pain and then administer

analgesia

Preventive approach
Currently considered as the most

effective
strategy
because
therapeutic
serum
level
medication is maintained
Smaller

a
of

doses of medication are

needed
Better pain control can be achieved

 In using this approach, the nurse

should assess the client for sedation

before administering the next dose
The goal is to administer analgesia

before the pain becomes severe

Patient controlled analgesia

Used to manage postoperative pain

as well as persistent pain

Allows

clients
to
control
the
administration
of
their
own
medication within predetermined
safety limits

Is

electronically
timing device

controlled

by

 The timer can be programmed to

prevent additional doses from being

administered until a specified time
period has elapsed (lock-out time)
and until the first dose has had time
to exert its maximal effect
Continue monitor respiratory status
Instruct client not to wait until the

pain gets severe before pushing the

button

 Remind client not to be so distracted

with a visitor or activity so that

he/she will not forget to administer
the drug
If PCA is to be used in the clients

home, he/she and family are taught

about the operation of the pump as
well as the side effects of the
medication and strategies to manage
them

N onopioids
Generally the first class of drugs

used for treatment of pain

Useful for acute and chronic pain

from a variety of causes such as:

surgery, trauma, arthritis, and cancer
Have a ceiling effect to analgesia

 A ceiling effect indicates that there is

a dose beyond which there is no

improvement in the analgesic effect
and there may be an increase in side
effects
Does

not produce
physical dependence

Most

nonopioids

tolerance

have

or

antipyretic

effects
Works primarily at the site of injury,

 NSAIDs block synthesis of

prostaglandin
Examples are salicylates (aspirin);

NSAIDS (ibuprofen, ketorolac,

naproxen); COX-2 inhibitors
(celecoxib); acetaminophen

Celecoxib (Celebrex)
Inhibition of prostaglandin synthesis,

primarily
through
inhibition
of
cyclooxygenase-2
(COX2).
This
results
in
anti-inflammatory,
analgesic, and antipyretic activities
For

osteoarthritis,
rheumatoid
arthritis, and acute pain in adults

 Monitor

CBC, liver/renal function

tests, and for signs and symptoms of
GI bleeding

Remember: NSAIDS!!!

O pioids
The goal of administering this

medication is to relieve pain and

improve quality of life
Opioids are classified as full

agonists, partial agonists, or

mixed agonists and antagonists
Full agonists have complete response

at the opioid receptor site

 Partial agonists has lesser response

The mixed agonists and antagonists

activates one type of opioid receptor

while blocking another
Opioids alone have no ceiling effect to

analgesia
Controlled-release

opioids such as
oxycodone (Oxycontin) and morphine
(MS
Contin)
are
effective
for
prolonged, continuous pain

 Controlled or time-release

medication should never be crushed,

but always taken whole
Common adverse effects of opioids

are: CRINCS!
C- constipation
R- respiratory depression
I- itching
N- nausea, vomiting
C- constricted pupils
S- sedation

M orphine
Is the drug of choice for the

treatment of moderate to severe

pain
Used as a standard against which all

other analgesics are compared

Long acting (4-5 hours)

H ydrom orphone (D ilaudid)

Commonly used for moderate to

severe pain
Shorter acting than morphine but

has a faster onset

Good option for pain management in

most clients

M eperidine (D em erol)
Should

be reserved for healthy

clients requiring opioids for a short
period or for those who have unusual
raections or allergic responses to
other opioids

Produces a toxic metabolite called

normeperidine

 Normeperidine is a cerebral irritant

that can cause adverse effects

ranging from dysphoria and irritable
mood to seizures
Should be avoided in clients over the

age of 65, in those with impaired

renal function, and in those receiving
MAOI antidepressants

Fentanyl(Sublim aze,
D uragesic)
Can be administered parenterally,

intraspinally, or by transdermal
patch

M ethadone (D olophine)
Is a potent analgesic that has a longer

duration of action than morphine

Has

a very long half life

accumulates
in
the
body
continued dosing

and
with

Well absorbed from the GI tract and is

very effective when given orally

also used in drug treatment programs

O pioid Antagonists
Naloxone (Narcan) is a pure opioid

antagonist
that
effects of opioids

counteractsthe

Often

used in the emergency

department setting for treatment of
opioid overdose

Some analgesics are classified as

combined agonist and antagonist.

 The most commonly used agonist-

antagonist drugs are butorphanol

(Stadol) and nalbuphine (Nubain)
Nalbuphine can be used to treat

itching and nausea that may

accompany the administration of
opioids

Analgesic Adjuvants
Are classes of medications that may

potentiate the effects of opioids or

nonopioids
Are

especially
important
when
treating pain that does not respond
well to traditional analgesics alone

Steroids
May

reduce pain by decreasing

inflammation and the resultant
compression of healthy tissues

Benzodiazipines
Midazolam

(Versed) or diazepam
(Valium) are effective for the
treatment of anxiety or muscle
spasms associated with pain

These drugs do not provide pain

relief except in the treatment of

muscle spasms
May cause sedation

Tricyclic antidepressants
Amitriptyline,

imipramine,
desipramine, and doxepin have been
shown to relieve pain related to
neuropathy and other painful nerve
related conditions

Must be taken for days to weeks

before they are fully effective

 Instruct clients to continue taking the

medications even
ineffective at first

if

they

seem

Additional benefits of this class of

medications may include mood

elevation and improved ability to
sleep

Anticonvulsants
Carbamazepine

(Tegretol)
and
gabapentin (Neurontin) are often
used to relieve the sharp or cutting
pain caused by peripheral nerve
syndromes

These medications must be taken

regularly
realized

before

full

benefit

is

R O U TES FO R A N A LG ES IC
A D M IN IS TR ATIO N

O ral
Preferred route in most cases
Convenient, inexpensive
Slower onset than IV
Can provide consistent blood levels

Rectal
May be used to provide local or

systemic pain relief

Can be used when client is unable to

take oral medication

May be difficult to administer

Transderm alpatch
For chronic pain
Easy to apply; delivers pain relief for

3 days without patch change

12-hour delay before effective drug

level reached, and delay in excreting

once removed

 May be less effective in smokers

owing to circulatory alterations

Absorption may be increased with

fever
Use caution not to touch medication

when applying

Intravenous
Preferred route for post operative and

chronic cancer pain for clients who

cannot tolerate oral route
Provides

rapid relief; continuous

infusion provides steady drug level

Difficult to use in home care setting

Follow instructions for administration

Intram uscular
For acute pain
Rapid pain relief
Painful
Use only if other routes cannot be

used

Subcutaneous
May be used if IV route is

problematic
Can deliver effective pain relief
Injection may be painful
May be effective for treatment of

chronic cancer pain

Intraspinal(epiduralor
subarachnoid)
May be used for traumatic injuries or

chronic pain unrelieved by other

methods
May be able to control pain with

lower doses of opioid because relief

is delivered closer to site of pain;
fewer systemic side effects
Requires single or continuous

S U R G IC A L
IN TER V EN TIO N S

Cordotom y
Is the division of certain tracts of the

spinal cord
May be performed percutaneously,

by the open method after

laminectomy, or by other techniques
Is performed to interrupt pain

transmission

 Care must be taken to destroy only

the sensation of pain, leaving motor

functions intact

Rhizotom y
Sensory nerve roots are destroyed

where they enter the spinal cord

A lesion is made in the dorsal root to

destroy neuronal dysfunction and

reduce nociceptive input
Is

usually performed
severe chest pain

to

relieve

 The spinal roots are divided and

banded with a clip to form a lesion

and produce subsequent loss of
sensation

assignm ent
Write at least 3 nursing interventions

for each of the following side effects

of opioid analgesic agents:
1. Respiratory depression
2. Nausea and vomiting
3. Constipation
4. Itching