Nursing Continuing Education

Pain Management

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This is Your Course on Pain Management

Syllabus
Effective pain management includes the use of pharmacological and nonpharmacological pain management therapies. Invasive therapies such as nerve ablation can be appropriate for intractable cancer‑related pain. Clients have a right to adequate assessment and management of pain. Nurses are accountable for the assessment of pain. The nurse’s role is that of an advocate and educator for effective pain management. Nurses have a priority responsibility to measure the client’s pain level on a continual basis and to provide individualized interventions. Nurses should assess the effectiveness of the interventions 30 to 60 min after implementation. Assessment challenges can occur with clients who have cognitively impairment, who speak a different language than the nurse, or who receive prescribed mechanical ventilation. Undertreatment of pain is a serious health care problem. Consequences of undertreatment of pain include physiological and psychological components. Acute/chronic pain can cause anxiety, fear, and depression. Poorly managed acute pain can lead to chronic pain syndrome.

Physiology of Pain

How people perceive pain is not completely understood, but one thing is clear: Each individual’s pain experience depends on the interaction between that person’s neurological system and the environment. That interaction is highly complex and demonstrates a vast array of physiologic and pathophysiologic nuances. A basic understanding of how people perceive pain, however, begins with the concept of nociception.

Several theories have been proposed to explain the pain experience. One of the best known of these is the gate-control theory, which, simply stated, suggests that pain varies with the balance between the non-nociceptive information traveling into the spinal cord through large nerve fibers and the nociceptive information traveling into the spinal cord through small nerve fibers. If the large nerve fibers are more active than the small nerve fibers, the “gate” is closed and the person should have little or no pain. But if there is more activity in small nerve fibers, those nerve fibers activate what are called projector neurons and block the inhibitory neurons. That opens the “gate,” and the person feels pain. This theory does not explain everything we know about pain, but it certainly does provide justification for why some nonpharmacologic therapies, like massage and heat, relieve pain. Those modalities stimulate impulses in large nerves and thus close the gate to pain.

Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors).

Transmission occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it.

Pain threshold is the point at which a person feels pain.

Pain tolerance is the amount of pain a person is willing to bear.

Perception or awareness of pain occurs in various areas of the brain, with influences from thought and emotional processes.

Modulation occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli.

  • Substance P
  • Prostaglandins
  • Bradykinin
  • Histamine

Substances that Increase Pain Transmission and Cause an Inflammatory Response

  • Serotonin
  • Endorphins

Pain Categories

Pain is categorized by duration (acute or chronic) or by origin (nociceptive or neuropathic).

Acute pain

  • Acute pain is protective, temporary, usually self‑limiting, has a direct cause, and resolves with tissue healing.
  • Physiological responses (sympathetic nervous system) are fight‑or‑flight responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tension).
  • Behavioral responses include grimacing, moaning, flinching, and guarding.
  • Interventions include treatment of the underlying problem.
  • Can lead to chronic pain if unrelieved.

Chronic pain

  • Chronic pain is not protective. It is ongoing or recurs frequently, lasting longer than 6 months and persisting beyond tissue healing.
  • Physiological responses do not usually alter vital signs, but clients can have depression, fatigue, and a decreased level of functioning. It is not usually life‑threatening.
  • Psychosocial implications can lead to disability.
  • Management aims at symptomatic relief. Pain does not always respond to interventions.
  • Chronic pain can be malignant or nonmalignant.
  • Idiopathic pain is a form of chronic pain without a known cause, or pain that exceeds typical pain levels associated with the client’s condition.

Nociceptive pain

  • Nociceptive pain arises from damage to or inflammation of tissue, which is a noxious stimulus that triggers the pain receptors called nocioceptors and causes pain.
  • It is usually throbbing, aching, and localized.
  • This pain typically responds to opioids and nonopioid medications.

Types of Nociceptive Pain

  • Somatic: In bones, joints, muscles, skin, or connective tissues.
  • Visceral: In internal organs such as the stomach or intestines. It can cause referred pain in other body locations separate from the stimulus.
  • Cutaneous: In the skin or subcutaneous tissue.

Neuropathic pain (ask Andrea about this as a header?)

  • Neuropathic pain arises from abnormal or damaged pain nerves.
  • It includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy.
  • Neuropathic pain is usually intense, shooting, burning, or described as “pins and needles.”
  • This pain typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants).

Assessment/Data Collection

Video Link: http://media.atitesting.com/RM/Media02/pain_assessment/index.html
  • Noted pain experts agree that pain is whatever the person experiencing it says it is, and it exists whenever the person says it does. The client’s report of pain is the most reliable diagnostic measure of pain.
  • Self‑report using standardized pain scales is useful for clients over the age of 7 years. Specialized pain scales are available for use with younger children or individuals who have difficulty communicating verbally.
  • Assess and document pain (the fifth vital sign) frequently.
  • Use a symptom analysis to obtain subjective data. (41.1)
Pain assessment



A patient’s report is clearly the best indicator of pain. Learning how to perform a thorough pain assessment is essential for evaluating a patient’s level of pain and for developing a plan for pain management. With improved pain control, your patient can get up sooner and breathe deeper, thus preventing a variety of potential complications such as pneumonia and thromboembolism.



To manage pain effectively, you must assess, understand, and treat the patient’s pain and then reassess the pain on an ongoing basis. The Joint Commission emphasizes that every patient has a right to pain assessment and treatment. That means you must assess the nature and intensity of the pain and document your findings in a way that facilitates further assessment and follow-up. In that context, pain is indeed the fifth vital sign.

 

Based on your assessment and the patient’s pain rating or score, you will implement interventions that best alleviate that patient’s pain. The goal is to treat the pain before it becomes moderate or severe. So, be sure you instruct the patient to notify you when pain reaches a mild level. After you implement the appropriate interventions, reassess the pain no later than 1 hour afterwards. For pharmacological interventions, reasonable time frames for reassessment are 30 to 45 minutes for oral medication, 15 to 30 minutes for intramuscular administration of analgesics, and 5 to 15 minutes for intravenous medications. Time frames for reassessment should be based on the onset and peak duration of the intervention, and  individualized to best meet  the patient’s needs.

Pain assessment begins with asking the patient if he has pain. If the answer is yes, perform a thorough pain assessment, including the intensity, quality, location, timing (onset, duration, frequency), symptoms, treatments (prescription, nonprescription complementary and alternative), effects on function/daily activities, and what has and has not worked in the past. Merely asking the patient to rate his pain is not enough. The more information you gather, the better you can manage the patient’s pain. Ask the following questions when your patient reports pain:

·        Describe your pain

·        Where is the pain located? Does it radiate to other areas?

·        Have you had this pain before? If so, when?

·        What do you think is causing the pain?

·        When did the pain start?

·        Does it come and go or is it continuous?

·        Is there a specific factor that triggers the pain, or makes it worse?

·        Does the pain have any specific pattern, or times during the day when it is worse or better?

·        What helps to ease the pain? Are there medications or treatments you are using for the pain? How well do they work?

·        Is the pain associated with any other symptoms?

·        How severe is the pain? (Remember to use a pain scale to determine this.)

·        How does the pain affect your life? Your daily activities?

  • What is your goal for pain relief? (Remember that a pain score of 3 or less is recommended to promote healing.)



A frequently used mnemonic, PQRST, may help you remember to assess pain comprehensively. 

P = Provokes

  • What causes pain?

Q = Quality

  • What does it feel like?

R = Radiates

  • Where does the pain start and radiate to?

S = Severity

  • How severe is the pain?

T = Time

  • When did it start and how long it lasted?

In addition to these questions, consider asking other questions such as how the pain affects the person’s life and activities.


 

Determining pain intensity

 

Many scales have been developed to help patients measure and communicate the intensity of their pain. Use of a pain scale also helps ensure consistency among caregivers in determining the intensity of a patient’s pain. Make sure to use the scale that is right for a specific age group or based on your patient’s ability to communicate. Ask the patient to rate the pain using the appropriate pain scale.



A word of caution, though: It is not always safe to rely only on a number. Just as pain is subjective and individualized, so is each patient’s ability to quantify his own pain, even when you explain what the numbers mean. That’s why the other aspects of communication with a patient about his pain are so crucial. They will help you get more of a sense of how much discomfort the patient has, regardless of which number he selects. For example, you might ask a patient at what “number” he feels he would be able to walk down the hall without assistance. That will help you formulate a realistic goal for pain relief based on how pain affects the patient’s ability to function.

 

The most common pain scales are described below.



A numerical rating scale (NRS): This commonly used approach requires that the patient rate his pain on a scale from 0 to 10, with 0 indicating no pain and 10 reflecting the worst possible pain. (Note that numeric rating scales are often misrepresented as a scale from 1 to 10. That does not give the patient a way to indicate no pain at all.) You can use a printed representation of the scale or just administer it verbally. It is appropriate for use with children old enough to understand numbers and with adults. Generally, you would interpret the pain scores as:

·        0 = no pain

·        1-3 = mild pain

·        4-6 = moderate pain

·        7-10 = severe pain

 

A visual analog scale (VAS): This also requires that the patient rate his pain from no pain to the worst possible pain, but without the use of numbers. Using this type of scale, you’d ask the patient to select a point on a line drawn between those two extremes to represent how intense he feels his pain is. Again, this is suitable for use with older children and adults.


 

An image or pictorial scale: For patients who cannot understand or respond to a numeric or visual analog scale, pain assessment scales that present a series of faces are often effective. This includes young children, adults with cognitive difficulties, and patients who do not speak the same language as the nurse. A commonly used scale of this type is the Wong-Baker FACES Rating Scale, which depicts six cartoon-like drawings ranging from a smiling face to a crying face. Another scale of this type is the Oucher pain scale, which presents photos of faces with expressions ranging from neutral to extremely distressed. The Oucher is available in several ethnic variations.


When a patient cannot communicate


 

A pain’s self-report of pain is always your first and best strategy, but when a patient cannot communicate, for whatever reason, try the following approaches, in the order presented here.

1.     See if the patient has a diagnosis or problem that usually causes pain (objective data).

2.     Assess the patient for possible causes of pain.

3.     Look for behavior that might indicate pain, such as crying, diaphoresis, groaning, grimacing, or restlessness (objective data).

4.     Other behaviors that may indicate pain in the nonverbal patient include combativeness, striking out, refusing care and facial expressions of fear (objective data).

5.     Ask family members or others close to the patient if they believe the patient has pain (subjective second-party data).

  1. Check for physiologic responses that might indicate pain, such as elevated pulse and respiratory rates (objective data). Keep in mind that such signs are considered the least reliable because, although they may be elevated initially, they often stabilize quickly. Thus, pain can continue in the absence of vital-sign changes.

 

Effects of unrelieved pain

 

Understanding the harmful effects of pain is just as important as understanding the harmful effects of other problems left untreated, such as hypertension or thrombophlebitis. Physiologically, pain that is not relieved in a timely manner stresses many body systems. The endocrine and cardiovascular systems respond with increased activity, and the body’s metabolism speeds up. The respiratory, genitourinary, and gastrointestinal systems reduce their function. The musculoskeletal system becomes erratic, causing muscle spasms, fatigue, and altered function. Mobility decreases, and the immune system becomes depressed, thus making the patient susceptible to illness and delayed recovery.

 

Unrelieved acute pain can lead to chronic pain. Both reduce the patient’s quality of life. Patients who cannot sleep, eat, or experience life without pain may experience ever-worsening hopelessness.

 

A reminder about bias



It is easy to agree that nursing assessments must be free of bias and preconceived notions and misconceptions about pain and pain relief, but it is not always so easy to put into practice. This is something you might have to remind yourself about often. Some of the more common myths about pain are listed below.

·        Patients who have a history of substance abuse (including alcohol abuse):

◦    are already “medicated” and do not require additional analgesia.

◦    tend to overreact to or exaggerate pain.

◦    are drug seekers.

◦    are not truthful about how they perceive pain.

·        Administering analgesics, especially opioids, regularly will lead to addiction.

·        Patients who have minor illnesses, injuries, or surgery have less pain than those with major alterations.

·        Hospitalized patients should expect to have pain.

·        Chronic pain is psychological.

·        Patients who do not “complain” do not have pain.

·        Patients who are unconscious/asleep do not have pain.

·        Infants, especially newborns, do not feel pain.

·        Patients with dementia cannot feel or accurately report pain.

·        As people age, they should expect to have pain and to report more pain.

·        Strong analgesics are unsafe for older adults.

 

Remember, these are myths. Do not allow them to affect your objective assessment and management of any patient’s pain.


Pain assessment in infants and children

Frequent assessment, treatment, anticipation and prevention of pain is important in infants and children. Parents expect that pain will be prevented, and when their child is in pain, they expect that treatment will be delivered quickly. Pain behaviors such as prolonged or unrelenting crying are commonly a source of stress and even psychological pain for the parents.  At times, unrelenting crying and fussiness has been associated with abuse from parents or caregivers.

 

Assessment of pain in infants and children can be challenging. Infants are not able to verbally express their pain, while young children require approaches to pain assessment that are appropriate to their developmental level. Parents and caregivers know their children better than anyone else, and their input about the child’s pain expressions, changes from baseline, history and other factors should be included in the assessment of any infant or child when possible.

 

As nurses working with children, our job is to assess for pain and relieve it. However, we must also anticipate pain and prevent it, particularly when we are working with children.  Pain in children can be associated with physical causes, and developmentally appropriate assessments should be used to identify these sources of pain. However, it is also important to remember that many of the things we commonly do when providing healthcare to children can cause them pain. This includes giving them immunization “shots”, checking blood pressure and getting blood samples.

 

Premature infants and neonates requiring hospitalization often experience multiple painful procedures each day, and this pain in infancy can have detrimental long-term consequences on neurological development, pain sensitivity emotional and behavioral development and learning.

Children with life-threatening conditions or chronic conditions often need treatments, yet when the child knows that these will cause pain, anxiety and fear of anticipating the pain can make the healthcare experience traumatic and burdensome for the whole family. Assessing children’s and parent’s fears related to procedural pain, and using appropriate interventions to prevent or reduce pain is an important part of pain management in this population. 

 

 

Infants

Assessment of pain in infants can be challenging, as they cannot communicate their pain verbally. The most common manifestation of pain in infants is crying. However, this is also how they communicate most of their needs early in life, making it difficult to determine whether “fussiness” in an infant is caused by pain or a more common factor such as hunger, fatigue, a dirty diaper, gas or overstimulation.

 

Several tools have been developed to assess pain premature infants and neonates in the hospital setting. The CRIES scale uses a score of 0-2 to determine changes from baseline indicating pain. The five factors included in this scale are:

  • Crying
  • Increase in oxygen Requirement from baseline
  • Increase in vital signs from baseline
  • Expression on face
  • Sleeping

 

In infants and children 2 months to 7 years old, the FLACC scale is commonly used to assess pain when the child is not able to express pain verbally. This scale is appropriate to use in any setting, as it relies on behavioral observations, rather than vital signs.  FLACC indicators include observations of

  • Facial expression,
  • Leg movement,
  • Activity
  • Crying
  • Consolability.

Parents can also be taught to use these assessment tools, which can aid in reassessment of the response to pain interventions, and in early identification and treatment of ongoing pain.

 

Children

What a child tells you about her pain is the most important information when assessing a child who can communicate verbally. In a child who is nonverbal, a behavioral or other tool appropriate to the child’s developmental level and communication abilities should be used. Generally, children age 3 and older are able to rate their pain. The Wong-Baker FACES scale is one of the tools that is commonly used and widely available.

Behavioral changes are a common sign that a child is in pain. Behaviors that can indicate a child is in pain include changes in activity level, appearance, behavior and vital signs. Language, ethnic background and cultural issues can also impact pain way that children express pain, as well as assessment findings. In children up to 7 years, the FLACC, described above, can be appropriate as an objective indicator of pain.

An integral part of pain assessment includes determining whether the tool being used is a valid indicator of the child’s pain. If there is any doubt about the information obtained with a particular pain assessment too, other pain tools appropriate to the child’s developmental and cognitive level and communication ability should be used, to ensure that accurate pain assessments are being used to guide pain management interventions. 

Risk Factors

Undertreatment of Pain

  • Cultural and societal attitudes
  • Lack of knowledge
  • Fear of addiction
  • Exaggerated fear of respiratory depression

Populations at Risk for Undertreatment of Pain

  • Infants
  • Children
  • Older adults
  • Clients who have substance abuse disorder

Causes of Acute and Chronic Pain

  • Trauma
  • Surgery
  • Cancer (tumor invasion, nerve compression, bone metastases, associated infections, immobility)
  • Arthritis
  • Fibromyalgia
  • Neuropathy
  • Diagnostic or treatment procedures (injection, intubation, radiation)

Factors That Affect the Pain Experience

  • Age
    • Infants cannot verbalize or understand their pain.
    • Older adult clients can have multiple pathologies that cause pain and limit function.
  • Fatigue
    • Can increase sensitivity to pain.
  • Genetic sensitivity
    • Can increase or decrease pain tolerance
  • Cognitive function
    • Clients who have cognitive impairment might not be able to report pain or report it accurately.
  • Prior experiences
    • Can increase or decrease sensitivity depending on whether clients obtained adequate relief.
  • Anxiety and fear
    • Can increase sensitivity to pain
  • Support systems and coping styles
    • Presence of these can decrease sensitivity to pain.
  • Culture 
    • Can influence how clients express pain or the meaning they give to pain.

Symptom Analysis

Use anatomical terminology and landmarks to describe location (superficial, deep, referred, or radiating). 
  • “Where is your pain? Does it radiate anywhere else?”
  • Ask clients to point to the location.

Quality refers to how the pain feels: sharp, dull, aching, burning, stabbing, pounding, throbbing, shooting, gnawing, tender, heavy, tight, tiring, exhausting, sickening, terrifying, torturing, nagging, annoying, intense, or unbearable.
  • “What does the pain feel like?”
  • Give more than two choices: “Is the pain throbbing, burning, or stabbing?”

Intensity, strength, and severity are “measures” of the pain.
  • Use a pain intensity scale (visual analog, description, or number rating scales) to measure pain, monitor pain, and evaluate the effectiveness of interventions.
  • “How much pain do you have now?”
  • “What is the worst/best the pain has been?”
  • “Rate your pain on a scale of 0 to 10.”
 
Timing: onset, duration, frequency
  • “When did it start?”
  • “How long does it last?”
  • “How often does it occur?”
  • “Is it constant or intermittent?”

Setting: how the pain affects daily life or how activities of daily living (ADLs) affect the pain
  • “Where are you when the symptoms occur?”
  • “What are you doing when the symptoms occur?”
  • “How does the pain affect your sleep?”
  • “How does the pain affect your ability to work or interact with others?”

Document associated findings: fatigue, depression, nausea, anxiety.
  • “What other symptoms do you have when you are feeling pain?”

Aggravating/relieving factors
  • “What makes the pain better?”
  • “What makes the pain worse?”
  • “Are you currently taking any prescription, herbal, or over‑the‑counter medications?”


Fundamentals for Nursing, Chapter 41, Pain Management 229

Expected Findings

  • Behaviors complement self‑report and assist in pain assessment of nonverbal clients.
  • Facial expressions (grimacing, wrinkled forehead), body movements (restlessness, pacing, guarding)
  • Moaning, crying
  • Decreased attention span
  • Blood pressure, pulse, and respiratory rate increase temporarily with acute pain. Eventually, increases in vital signs will stabilize despite the persistence of pain. Therefore, physiologic indicators might not be an accurate measure of pain over time

Patient-Centered Care

Nonpharmacological Pain Management Strategies

Nonpharmacological strategies should not replace pharmacological pain measures, but can be used along with them.

Cognitive‑behavioral measures: changing the way a client perceives pain, and physical approaches to improve comfort

Cutaneous (skin) stimulation: transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, and massage

  • Interruption of pain pathways
  • Cold for inflammation
  • Heat to increase blood flow and to reduce stiffness
Distraction
  • Includes ambulation, deep breathing, visitors, television, games, prayer, and music
  • Decreased attention to the presence of pain can decrease perceived pain level.

Relaxation: Includes meditation, yoga, and progressive muscle relaxation

Imagery

  • Focusing on a pleasant thought to divert focus
  • Requires an ability to concentrate

Acupuncture and acupressure: Stimulating subcutaneous tissues at specific points using needles (acupuncture) or the digits (acupressure)

Reduction of pain stimuli in the environment

Elevation of edematous extremities to promote venous return and decrease swelling

Pharmacological Interventions

Analgesics are the mainstay for relieving pain. The three classes of analgesics are nonopioids, opioids, and adjuvants.

Nonopioid analgesics

Nonopioid analgesics (acetaminophen, nonsteroidal anti‑inflammatory drugs [NSAIDs], including salicylates) are appropriate for treating mild to moderate pain.

  • Be aware of the hepatotoxic effects of acetaminophen.
  • Clients who have a healthy liver should take no more than 4 g/day. Make sure clients are aware of opioids that contain acetaminophen, such as hydrocodone bitartrate 5 mg/acetaminophen 500 mg.
  • Monitor for salicylism (tinnitus, vertigo, decreased hearing acuity).
  • Prevent gastric upset by administering the medication with food or antacids.
  • Monitor for bleeding with long‑term NSAID use.

Opioid analgesics

Opioid analgesics, such as morphine sulfate, fentanyl, and codeine, are appropriate for treating moderate to severe pain (postoperative pain, myocardial infarction pain, cancer pain).

  • Managing acute severe pain with short‑term (24 to 48 hr) around‑the‑clock administration of opioids is preferable to following a PRN schedule.
  • The parenteral route is best for immediate, short‑term relief of acute pain. The oral route is better for chronic, no fluctuating pain.
  • Consistent timing and dosing of opioid administration provide consistent pain control.
  • It is essential to monitor and intervene for adverse effects of opioid use.
    • Sedation: Monitor level of consciousness and take safety precautions. Sedation usually precedes respiratory depression.
    • Respiratory depression: Monitor respiratory rate prior to and following administration of opioids (especially for clients who have little previous exposure to opioid medications). Initial treatment of respiratory depression and sedation is generally a reduction in opioid dose. If necessary, slowly administer diluted naloxone to reverse opioid effects until the client can deep breathe with a respiratory rate of at least 8/min.
    • Orthostatic hypotension: Advise clients to sit or lie down if lightheadedness or dizziness occur. Instruct clients to avoid sudden changes in position by slowly moving from a lying to a sitting or standing position. Provide assistance with ambulation.
    • Urinary retention: Monitor I&O, assess for distention, administer bethanechol, and catheterize.
    • Nausea/vomiting: Administer antiemetics, advise clients to lie still and move slowly, and eliminate odors.
    • Constipation: Use a preventative approach (monitoring of bowel movements, fluids, fiber intake, exercise, stool softeners, stimulant laxatives, enemas).

230 Chapter 41 Pain Management Content Mastery Series

Adjuvant analgesics

Adjuvant analgesics enhance the effects of nonopioids, help alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are useful for treating neuropathic pain.

Anticonvulsants: carbamazepine, gabapentin

Antianxiety agents: diazepam, lorazepam

Tricyclic antidepressants: amitriptyline, nortriptyline

Anesthetics: infusional lidocaine

Antihistamine: hydroxyzine

Glucocorticoids: dexamethasone

Antiemetics: ondansetron

Bisphosphonates and calcitonin: for bone pain

Patient-controlled analgesia

Patient‑controlled analgesia (PCA) is a medication delivery system that allows clients to self‑administer safe doses of opioids.

  • Small, frequent dosing ensures consistent plasma levels.
  • Clients have less lag time between identified need and delivery of medication, which increases their sense of control and can decrease the amount of medication they need.
  • Morphine, hydromorphone, and fentanyl are typical opioids for PCA delivery.
  • Clients should let the nurse know if using the pump\ does not control the pain.
  • To prevent inadvertent overdosing, the client is the only person who should push the PCA button.

Other Interventions

Additional Pharmacological Pain Interventions

Local and regional anesthesia and topical analgesia

Other Strategies for Effective Pain Management

  • Take a proactive approach by giving analgesics before pain becomes too severe. It takes less medication to prevent pain than to treat pain.
  • Instruct clients to report developing or recurrent pain and not wait until pain is severe (for PRN pain medication).
  • Explain misconceptions about pain (medication dependence, pain measurement and perception).
  • Help clients reduce fear and anxiety.
  • Create a treatment plan that includes both nonpharmacological and pharmacological pain‑relief measures.

Chronic Pain Relief Strategies (uncertain about this header level)

Strategies specific for relieving chronic pain include the above interventions, plus the following:

  • Administering long‑acting or controlled‑release opioid analgesics (including the transdermal route).
  • Administering analgesics around the clock rather than PRN.

Complications and Nursing Implications

Undertreatment of pain is a serious complication and can lead to increased anxiety with acute pain and depression= with chronic pain. Assess clients for pain frequently, and intervene as appropriate.

Sedation, respiratory depression, and coma can occur as a result of overdosing. Sedation always precedes respiratory depression.

  • Identify high‑risk clients (older adult clients, clients who are opioid‑naive).
  • Carefully titrate client dose while closely monitoring respiratory status.
  • Stop the opioid and give the antagonist naloxone if respiratory rate is below 8/min and shallow, or the client is difficult to arouse.
  • Identify the cause of sedation.
  • Use a sedation scale in addition to a pain rating scale to assess pain, especially when administering opioids.

References

  1. PN Mental Health Nursing REVIEW MODULE EDITION 10.0 2017 Assessment Technologies Institute, LLC.
  2. Fundamentals for NursingREVIEW MODULE EDITION 9.0 2017 Assessment Technologies Institute, LLC.

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