1. Chapter 5
Pain: The Fifth Vital Sign
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

2. Definitions of Pain
 Pain is an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage.
 Pain is whatever the experiencing person says it
is and exists whenever he or she says it does
(McCaffery, 1999).
 Self-report is always the most reliable indication
of pain.
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 2

3. Types of Pain
 Types of pain:
 Acute pain – usually from injury, disease, or surgery
 Chronic pain:
• Chronic cancer pain - cancer, HIV
• Chronic non-cancer pain– usually associated with tissue injury
that has healed, chronic back pain, arthritis
 Sources of pain:
 Nociceptive
• Somatic pain – cutaneous, superficial, sharp, burning (acute-
incisional, chronic-bone mets)
• Visceral pain – organs and linings of cavities, dull, aching,
cramping (acute-chest tubes, chronic-pancreatitis)
• Neuropathic pain – nerve fibers, spinal cord, shooting, burning,
fiery, painful numbness (acute-phantom limb pain, chronic-
diabetic neuropathy)
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 3

4. Characteristics of Acute/Chronic
Acute Chronic
 Short duration  Lasts longer than 3 months
 Well-defined cause  May not have defined cause
 Decreases with healing  Begins gradually and
 Is reversible persists
 Ranges from mild to severe  Exhausting and useless
 May be accompanied by  Ranges from mild to severe
restlessness and anxiety  May be accompanied by
depression, fatigue,
decreased functionality
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 4

5. Attitudes and Practices Related to Pain
 Attitudes of health care providers and nurses
affect interaction with patients experiencing pain
 Many patients are reluctant to report pain:
 Desire to be a ―good‖ patient
 Fear of addiction
 Fear of falling
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 5

6. Addiction, Pseudoaddiction, Tolerance,
and Physical Dependence
 Addiction—primary, chronic neurobiologic
disease with genetic, psychosocial, and
environmental factors influencing its
development and manifestations
 Pseudoaddiction—iatrogenic syndrome created
by the undertreatment of pain
 Tolerance—state of adaptation in which
exposure to a drug results in a decrease in one
or more the drug’s effects over time
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 6

7. Addiction, Pseudoaddiction, Tolerance,
and Physical Dependence (Cont’d)
 Physical dependence—adaptation manifested by a
drug-class–specific withdrawal syndrome that can be
produced by abrupt cessation, rapid dose reduction,
decreasing blood level of the drug, and/or
administration of an antagonist
 Withdrawal or abstinence syndrome—N&V, abdominal
cramping, muscle twitching, profuse perspiration,
delirium, and convulsions
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 7

8. Collaborative Management
 History
 Any precipitating factors, aggravating factors,
character and quality of pain, location, duration
 Physical assessment/clinical manifestations:
 Location of pain:
• Localized pain – confined to the site of origin
• Projected pain – along a specific nerve root
• Radiating pain – diffuse pain around site of origin not well
localized
• Referred pain – perceived in an area distant from the site
of painful stimuli
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 8

9. Assessing Nonverbal Patients
 Six common indicators
 Facial expressions – grimacing, crying
 Vocalizations – moaning, screaming
 Body movements – restlessness
 Changes in interpersonal interactions
 Changes in activity patterns or routines
 Mental status changes – confusion, increased
confusion
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 9

10. Pain Pharmacologic Therapy—
Non-Opioid Analgesics
 Acetylsalicylic acid (aspirin) and acetaminophen
(Tylenol) are most common
 Most are NSAIDs, including aspirin:
 Can cause GI disturbances
 COX-2 inhibitors for long-term use
 Acetaminophen (Tylenol):
 Available in liquid form; can be taken on empty stomach
 Preferable for patients for whom GI bleeding is likely
 Can cause renal or liver toxicity if used long-term
 Ketorolac – toradol
 Popular NSAID for short term use
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 10

11. Pain Pharmacologic Therapy—
Opioid Analgesics
 Block the release of neurotransmitters in the spinal
cord
 Drugs include codeine, oxycodone, morphine,
hydromorphone, fentanyl, methadone, tramadol,
meperidine, oxymorphone – morphine is the gold
standard
 There is no ceiling in the dose of a pure opioid agonist
 Can be administered via all available routes
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 11

12. Side Effects of Opioids
 Nausea and vomiting – early side effects, often
antiemetic give concurrently
 Constipation – inhibits peristalsis, initiate
measures such as stool softeners and laxatives
 Sedation – depress CNS, monitor sedation levels
 Respiratory depression – more apt to occur in an
opioid naïve patient, reversal agent (Narcan)
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 12

13. WHO Analgesic Ladder
 World Health Organization’s recommended
guidelines for prescribing, based on level of
pain (1-10, 10 is most severe pain)
 Level 1 pain (1-3 rating)—Use non-opioids
 Level 2 pain (4-6 rating)—Use weak opioids
alone or in combination with an adjuvant drug
 Level 3 pain (7-10 rating)—Use strong opioids
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 13

14. Nursing Interventions to Prevent SE of
Opioids
 Constipation
 Assess bowel habits, push fluids, encourage activity, bulk,
roughage, track BMs, administer stool softeners, laxatives,
suppositories
 Nausea and Vomiting
 Assess actual cause, temporary SE, antiemetic
prophylactically, oral compazine, reglan before meals and
at bedtime
 Sedation and Confusion
 Assess actual cause, may occur after 2-3 days, caffeine
may counteract effect, consider opioid rotation
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 14

15. Nursing Interventions to Prevent SE of
Opioids
 Respiratory Depression
 Rarely seen in patients with severe pain caused by cancer
 Recognize pain and stress counteract respiratory
depression
 Respiratory depression usually preceded by sedation
 Monitor sedation level and respiratory status frequently for
the first 24-48 hours
 Respiratory rate alone is NOT indicative of respiratory
status
 In an unresponsive patient administer Narcan and observe
the patient
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 15

16. Pain Management in End of Life
 Opioid regimen should stay consistent with dose
in weeks before last weeks of life
 Generally believed that patient still feels pain
when unconscious
 Does not hasten death unless the dose was not
properly and gradually titrated
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 16

17. Routes of Opioid Administration
 Can be administered by every route used
 Oral
 Rectal
 Intramuscular
 Transdermal
 Topical
 Sublingual
 Subcutaneous
 Intravenous
 PCA
 Spinal (Epidural and Intrathecal)
 PRN range orders
 Prescribing guidelines
 Monitoring guidelines
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 17

18. Spinal Analgesia
 Epidural Analgesia
 Intrathecal Analgesia
 Intrathecal catheter and infusion pump placement is
surgery to insert a catheter into the spinal fluid of the
lumbar region and connect it to a pump underneath the
abdominal skin that delivers medicine to the catheter.
This procedure is used to control pain or other
conditions that cannot be adequately treated by oral
medication or treatments.
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 18

19. Disks, Spurs, Stenosis: Slippage, and Osteoporosis
Chapter 6
Oxford
Aaron Filler, Dermatome Map of the Body University
MD, PhD Press On-
FRCS (SN) Line
About the Illustrations Table of Gloss Index
Book Contents ary
S
e
ar
c
h
th
is
si
te
Sponsored Links
Spine Links Search: Buy from Find a
Each of the spinal nervesAmazon.c Doctor to
National provides sensation at
a predictable areaof skin. Pain radiating down
Library of om SpineUni Center for Advanced Spinal
the leg to the small toe in the general pattern of
Medicine verse.co Neurosurgery - visit
the S1 dermatome suggests that a herniated
disk may be pinching the S1 nerve root in m the Neurography Institute -
spine. Reproduced from Atlas of Human visit
Anatomy by Frank Netter, MD, with permission
of Icon Learning Systems/Elsevier.
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 19

20. Ramsey Sedation Scale
Score Response
1 Anxious or Restless or Both
2 Cooperative, Oriented, and Tranquil
3 Responding to Commands
4 Brisk Response to Stimulus
5 Sluggish Response to Stimulus
6 No Response to Stimulus
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 20

21. Implantable Devices
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 21

22. Adjuvant Analgesics
 Antiepileptic drugs
 Tricyclic antidepressants
 Antianxiety agents
 Local anesthetics
 Dextromethorphan, ketamine
 Local anesthesia infusion pumps
 Topical medications
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 22

23. Nonpharmacologic Interventions
 Used alone or in combination with drug
therapy
 Physical measures
 Physical and occupational therapy
 Cognitive/behavioral measures
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 23

24. Physical Interventions
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 24

25. Cognitive/Behavioral Measures
 Strategies that can be used to relieve pain
as adjuncts to drug therapy:
 Distraction
 Imagery
 Relaxation techniques
 Hypnosis
 Acupuncture
 Glucosamine
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25

26. Invasive Techniques for Chronic
Pain
 Nerve blocks
 Spinal cord stimulation
 Surgical techniques:
 Rhizotomy
 Cordotomy
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 26

27. Community-Based Care
 Home care management
 Health teaching
 Health care resources
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 27

28. Pediatric Analog Sedation Score.
Elsharkawi N G Anesth Analg 1999;88:227-227
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 28
©1999 by Lippincott Williams & Wilkins

29. Question
 The nurse assesses the sedation level of a patient
receiving epidural morphine analgesia after a knee
replacement. When assessing the patient for side
effects of the drug, the nurse notes that the patient
is slightly drowsy but can be easily aroused. What
is the nurse's best action at this time?
A. Stop the morphine infusion immediately.
B. Document the assessment on the sedation scale.
C. Notify the charge nurse on the unit.
D. Ask another nurse to assess the patient.
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 29

30. LEARNING OUTCOMES
 Safe and Effective Care Environment
 Act as an advocate for patients in acute and chronic pain.
 Develop a teaching/learning plan for managing pain as part of community-based care.
 Health Promotion and Maintenance
 Teach patients in pain about complementary and alternative therapies as additions to their established
plan of care.
 Perform a complete pain assessment, and document per agency policy.
 Psychosocial Integrity
 Discuss the attitudes and knowledge of nurses, physicians, and patients regarding pain assessment
and management.
 Physiological Integrity
 Differentiate between addiction, pseudoaddiction, tolerance, and physical dependence.
 Compare and contrast the characteristics of the major types of pain and examples of each.
 Explain the role of non-opioid analgesics in pain management.
 Compare common opioid analgesics, using an equianalgesic chart.
 Develop a plan of care to prevent common side effects of opioid analgesics.
 Compare the advantages and disadvantages of drug administration routes.
 Determine the patient’s need for pain medication, including PRN and adjuvant therapy.
 Prioritize care for the patient receiving patient-controlled analgesia.
 Provide care for a patient receiving epidural analgesia.
 Identify special considerations for older adults related to pain assessment and management.
 Incorporate complementary and alternative therapies into the patient’s plan of care as needed to
control pain Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 30