The purpose of this module is to provide comprehensive information pertaining to pain treatment.
At the completion of this module, you will be able to:
· Identify two definitions of pain and explain their use when providing client care.
· Explain the gate control theory and how it is applied in client care.
· Discuss the physiology of pain.
· Compare and contrast acute pain and chronic pain.
· Compare and contrast nociceptive and neuropathic pain.
· Identify the components of a pain assessment.
· Identify factors that affect the pain experience
· Discuss the use of nonpharmacological pain management strategies.
· Discuss the use of pharmacological interventions for pain management.
· Explain strategies to reduce the risk of opioid use disorder.
· Identify complications related to pain management and explain associated nursing interventions.
The Pain Experience
Pain is an individual experience for each client. Nurses play an important role in pain management by recognizing that each client is unique and each pain experience is unique. Nurses must recognize their role in pain management and should implement measures to reduce a client’s pain to an acceptable level.
There are two commonly used definitions of pain.
Margo McCaffery, a well- known expert on pain, defines pain this way: “Pain is whatever the experiencing person says it is, existing wherever the experiencing person says it does.”
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Both definitions serve as a foundation for a nurse to understand the meaning of pain and the importance of pain management.
Effective pain management includes the use of pharmacological and nonpharmacological pain management therapies. 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 minutes after implementation. Assessment challenges can occur with clients who have cognitive impairment, who speak a different language than the nurse, or who are receiving prescribed mechanical ventilation. Under treatment of pain is a serious health care problem. Consequences of under treatment of pain include physiological and psychological components. Acute and chronic pain can cause anxiety, fear, and depression. Poorly managed acute pain can ultimately lead to chronic pain syndrome.
Physiology of Pain
There are several processes associated with nociceptors, the sensory impulses that carry pain signals. Knowledge of each of these helps us to understand what causes pain, what symptoms are common and nursing interventions for treatment.
Transduction is the conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors). Mechanical, thermal or chemical stimuli are detected by the nerve endings. Transduction occurs prior to the next process, transmission.
Transmission occurs as the electrical impulse travels along the nerve fibers, where neurotransmitters regulate it. Impulses from afferent, or sensory, neurons carry impulses to the central nervous system (the brain and the spinal cord). Impulses from efferent, or motor, neurons carry impulses away from the central nervous system.
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. There is not one specific pain center in the brain.
Modulation (the final step in the process) occurs in the spinal cord, causing muscles to contract reflexively, moving the body away from painful stimuli.
Neurotransmitters are released as the result of cellular damage. Certain neurotransmitters work to incite during the transmission phase, while others work to inhibit during the modulation phase. Some of the neurotransmitters involved in the pain process include:
Pain is categorized by duration (acute or chronic) or by origin (nociceptive or neuropathic), or by the disease or condition that causes it (e.g. cancer, diabetes, multiple sclerosis).
According to the American Academy of Pain Management, over 100 million Americans live with chronic pain. Common conditions causing pain include low-back pain, headache, post-herpetic neuralgia, trigeminal neuralgia, fibromyalgia, and phantom pain.
Low-back pain is the leading cause of disability in Americans. . Determining the cause of low-back pain can be difficult and costly.
Headaches are another type of common pain. The most common types of headaches are migraine, tension, and cluster headaches. Headaches account for the most common chronic pain condition that lead to loss of productive time. Migraine headaches occur more frequently in women than men.
Post-herpetic neuralgia is a complication of shingles. After the rash recedes a burning pain in the affected area can occur. The risk of this complication increases with age. The Centers for Disease Controls (CDC) recommends vaccination against shingles for all clients age 60 years or older. The current CDC policy recommends the herpes zoster vaccine for the prevention of shingles. The Federal Drug Administration (FDA) has recently licensed a new vaccine for the treatment of shingles, zoster vaccine recombinant, which is awaiting policy approval by the CDC. According to the FDA, zoster vaccine recombinant is the preferred vaccine for the prevention of shingles and can be given to clients starting at age 50 years. The FDA recommends clients who have previously received the herpes zoster vaccine also received the zoster vaccine recombinant.
Trigeminal neuralgia is a type of chronic pain that affects the fifth cranial nerve. Clients who have trigeminal neuralgia report having sharp, excruciating pain. Carbamazepine, a medication used to control seizures, can be used to treat this condition.
Phantom pain is pain felt after the loss of a body part. To reduce a client’s anxiety, the nurse should educate the client who has an amputation that this type of pain might occur. Antiseizure medications are often used to treat phantom pain.
Fibromyalgia is a type of chronic pain that affects five million people in the United States. Clients experience a multitude of symptoms including musculoskeletal pain, fatigue, exercise intolerance and stiffness. The condition affects women more than men and usually appears in midlife.Click here to learn more about fibromyalgia and the medications used to treat it.
As many as 75% of older adults have a condition that causes
chronic pain. But pain does not occur
just because a person is aging. Like back pain, younger adults can also have
pain from osteoarthritis, osteoporosis, and degenerative disk disease.
Unlike acute pain, chronic pain is not protective. It is ongoing or recurs frequently, lasting longer than 6 months and persisting beyond tissue healing. Chronic pain has the following characteristics:
Types of Nociceptive Pain
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Under Treatment of Pain
Populations at Risk for Under Treatment of Pain
Causes of Acute and Chronic Pain
Factors That Affect the Pain Experience
Use anatomical terminology and landmarks to describe the location of pain (superficial, deep, referred, or radiating).
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.
Intensity, strength, and severity are “measures” of the pain.
Timing: onset, duration, frequency
Setting: how the pain affects daily life or how activities of daily living
(ADLs) affect the pain
Document associated findings: fatigue, depression, nausea, anxiety.
Nonpharmacological Pain Management Strategies
Nonpharmacological strategies should not replace pharmacological pain measures, but can be used along with them.
Cutaneous (skin) stimulation: Includes transcutaneous electrical nerve stimulation (TENS), heat, cold, therapeutic touch, massage, acupuncture and acupressure. These physical modalities increase circulation and reduce the level of pain.
Cognitive‑behavioral measures: Changing the way a client perceives pain, and physical approaches to improve comfort. Distraction, relaxation, guided imagery, biofeedback and Reiki are examples of cognitive-behavioral strategies to reduce pain.
Relaxation: Includes meditation, yoga, and progressive muscle relaxation
Guided Imagery involves pleasant mental images such as a lake or the mountains. This technique shifts the client’s thoughts away from the pain. It can be used during painful diagnostic procedures. Clients must be able to concentrate in order to use guided imagery.
Biofeedback is a therapy which uses electric sensors to assist a client to control physiological responses such as heart rate and blood pressure.
Reiki is a natural healing technique in which a therapist channels energy into a client by touch to promote physical and emotional healing.
Other nonpharmacological pain management strategies include reducing painful stimuli in the client’s environment (wrinkled bed linens, tight bandages, lying on invasive tubing, urinary incontinence, constipation) and elevating edematous extremities to promote venous return and decrease swelling.
Analgesics are the mainstay for relieving pain. The three classes of analgesics are nonopioid, opioids, and adjuvants.
Nonopioid analgesics, as a group, have anti-inflammatory, antipyretic and analgesic effects. However, the properties among the different medications vary. Nonopioid analgesics include nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. These medications are appropriate for the treatment of mild to moderate pain.
First generation NSAIDs include aspirin, ibuprofen, indomethacin, diclofenac, ketorolac and meloxicam. These medications inhibit both COX-1 and COX-2, forms of the enzyme cyclooxygenase that converts arachidonic into prostaglandins. Both COX-1 and COX-2 cause the inflammatory process, but COX-1 also protects the gastrointestinal tract and is involved in kidney and platelet function. Therefore, when COX-1 is inhibited by first generation NSAID therapy inflammation, pain, and fever is reduced, but gastric ulceration, renal impairment and bleeding can occur. Along with decreasing inflammation, pain, and fever, first generation NSAIDs are given for prophylaxis of stroke and myocardial infarction, and to treat the discomfort of rheumatoid arthritis and osteoarthritis. Second generation NSAIDs inhibit only COX-2. Celecoxib is an NSAID COX-2 inhibitor. It decreases inflammation, pain and fever, but it does not decrease platelet aggregation. It is administered to treat osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and dysmenorrhea.
Aspirin is the prototype for NSAIDs and is the oldest medication in this category. Aspirin, also known as acetylsalicylic acid (ASA) was introduced in 1899 and soon became the most widely used medication in the world. Because of its antiplatelet properties, many providers prescribe a dose of 81 to 325 mg once daily as prophylaxis of myocardial infarction. Additionally, the emergency treatment protocols in many locations includes having the client chew and swallow a 325 mg dose of aspirin when the symptoms of a myocardial infraction occur.
Salicylism syndrome is a serious condition that occurs when aspirin levels rise above the therapeutic range. It can occur when large doses of aspirin are given at one time or when small to large doses are given over a long period of time. Ringing in the ears, or tinnitus, is the most common manifestations of salicylism in adults. Other manifestations include dizziness, disorientation and headache. Manifestations of salicylism in children are similar to those of the adult and include dizziness, drowsiness, and disorientation. When manifestations of salicylism occur aspirin is discontinued until the symptoms reside. In some cases, aspirin therapy is resumed, typically in a lower dose once symptoms are no longer present. Overdose of other NSAIDs such as ibuprofen can occur and present with manifestations similar to those of aspirin; however, generally they are not as severe.
Reye syndrome is a rare but serious complication that occurs when aspirin is used for fever reduction in children and adolescents who have a viral illness, such as chicken pox or influenza. Awareness of this syndrome has greatly reduced its occurrence.
Acetaminophen is currently the most popular analgesic in the United States. Often it is an ingredient in over-the-counter cough and cold remedies. Additionally, acetaminophen is frequently combined with an opioid in some pain medications. Examples are hydrocodone/acetaminophen and oxycodone/acetaminophen). Some combination products contain as much as 650 milligrams per tablet. Clients are not always aware that acetaminophen is an ingredient in the combined tablets.
Like aspirin, acetaminophen blocks pain by inhibiting prostaglandin synthesis of COX-1 and COX-2. Also, like aspirin, it suppresses pain and fever, but acetaminophen does not suppress inflammation or platelet aggregation. An adverse effect of acetaminophen is that large doses can cause severe liver damage. Because of this risk, intake of acetaminophen should not exceed 4 grams per day. Clients should be taught that frequent alcohol use while taking large doses of acetaminophen contributes to the risk of developing liver damage. Clients who consume more than three alcoholic drinks per day should consult their provider before taking acetaminophen. Clients should also be advised to check the label of combination analgesics to determine the amount of acetaminophen content contained in the product. Instruct clients to follow their providers advise before taking any products that contain acetaminophen. Parents should be cautious when giving children acetaminophen and should follow the recommendations of their provider or pharmacist.
Acetaminophen overdose is the principle cause of acute liver failure in the United States. Acetylcysteine is the antidote for acetaminophen overdose. Acetylcysteine decreases the build-up of hepatotoxic metabolites from the acetaminophen overdose to prevent or lessen the damage to the liver. . It can be given orally or intravenously. Ideally, it should be given within 10 hours of the overdose. Oral acetylcysteine smells like rotten eggs and this might induce the client to vomit. If the client is unable to take it orally, then it can be administered by a nasogastric tube or intravenously.
Opioid Analgesics and Antagonists
Opioid analgesics, such as morphine sulfate, fentanyl, and codeine, are appropriate for treating moderate to severe pain (postoperative pain, myocardial infarction pain, cancer pain). Most opioid analgesics reduce pain by attaching to a receptor in the central nervous system, altering perception and response to pain. Opioids are classified as agonist, agonist-antagonists, and antagonists. An agonist attaches to a receptor and produces a response. The agonist can be split into two groups: strong opioid agonists and moderate to strong opioid agonists. The prototype for strong opioid agonists is morphine. The prototype for moderate to strong opioid agonists is codeine. An agonist-antagonist binds to one receptor creating a response and binds to another receptor to prevent a response. Pentazocine is the prototype of the opioid agonist-antagonists.
An opioid antagonist acts as a competitor at opioid receptors and reverses the effect of an opioid. The manifestations of opioid toxicity are respiratory depression, coma and pinpoint pupils (also referred to as the opioid triad). Naloxone is the prototype for opioid antagonists. It can be administered IV, IM or subcutaneously. When administered IV, effects began almost instantly and last for about an hour. With IM and subcutaneous administration, the medication begins to take effect in 2 to 5 minutes and lasts for several hours. When administering naloxone care should be taken to titrate the dosage to achieve reversal of respiratory depression without full reversal of the analgesic effects. Rapid infusion should be avoided to reduce the risk of hypertension, tachycardia, nausea and vomiting. Vital signs should be monitored, especially respirations, and naloxone administration repeated until the manifestations of opioid toxicity have subsided.
Additional opioid agonists are naltrexone, methylnaltrexone, and alvimopan. All of these medications compete with opioids at opioid receptor sites.
Naltrexone is used to treat substance use disorders, namely alcohol and opioids. It is also used to treat postoperative respiratory depression that is due to the use of opioids during the operative period. When used for opioid addiction, its use is to prevent euphoria and thus, the client’s desire to use opioid. The client should be opioid free for a week to 10 days prior to beginning the medication to prevent opioid withdrawal.
Methylnaltrexone is an opioid antagonist that is used for opioid-induced constipation. It is reserved for clients who traditional laxatives have been ineffective. Another medication that affects bowel function is alvimopan. It is used to treat postoperative ileus and opioid-induced constipation. Alvimopan is for short-term use only because long term use has been linked to an increased risk of myocardial infarction.
There are a number of nursing responsibilities that are critical to providing safe, effective care for the client who is receiving an opioid medication.
When using this scale, your client goes to sleep while you are talking to him. What score is appropriate for this client?
Analgesic Routes of Administration
Analgesics can be administered intravenously, intramuscularly and subcutaneously. The intramuscular route and the subcutaneous routes were used frequently in the past, but use of these routes has diminished. Information about oral, transnasal, topical, transmucosal, rectal, and transdermal administration as well as epidural analgesia is provided below:
The oral route for administration of analgesics is preferred. However, the duration of action for oral opioids is only about 4 hours. Extended release forms of morphine can provide pain control for 8 hours or more.
Transnasal analgesic administration is advantageous because the medication is rapidly absorbed. Butorphanol is a mixed opioid agonist-antagonist available as a spray for the treatment of migraine headaches.
Topical analgesics are applied directly to the skin and are absorbed by vascular uptake. Frequently, this route is used to reduce pain during a painful procedure such as a lumbar puncture. A cream that contains lidocaine and prilocaine is used for dental procedures. . A lidocaine topical patch is available for treatment of post-herpetic neuralgia.
The transmucosal route for administration of analgesics is frequently used for hospice clients who have breakthrough pain. The oral mucosa is highly vascular providing rapid absorption. Fentanyl is available in a transmucosal form.
The rectal route for administration of analgesics can be use when rapid pain control is desired because the mucous membranes of the rectum are highly vascular causing quick absorption of the medication. This route can be used for clients who are unconscious, have difficulty swallowing or are experiencing nausea and vomiting.
When epidural analgesia is used, an anesthesiologist or nurse anesthetists inserts a catheter into the epidural space near the spine. An analgesic such as morphine or fentanyl is infused through the catheter. The nurse should monitor the client for respiratory depression, excessive sedation, hypotension, bradycardia, and urinary retention. Avoid using other opioids or CNS depressants during the use of epidural analgesia. Be prepared to administer naloxone for respiratory depression or excessive sedation.
The transdermal route for administration of analgesics is used to treat chronic pain. The medication is absorbed through the skin and provides pain control for several hours to days. The patch should be applied to the trunk or the abdomen. Transdermal fentanyl is indicated for clients who have severe pain and are opioid tolerant. There are numerous responsibilities related to providing safe, quality care when caring for a client who is using a fentanyl transdermal patch as fentanyl is 50 to 100 times more potent than morphine. Use the links below to learn about the administration of transdermal fentanyl.
Facing Concerns about Opioid Use Disorder
One in three Americans currently experience ongoing pain. Providing adequate pain management without promoting opioid use disorder is a challenge for health care providers. Concerns about opioid use disorder should not be minimized. According to the United States Department of Health and Human Services, in 2015, 12.5 million Americans misused prescription opioids, 2.1 million for the first time. Two million people were diagnosed with prescription use disorder and 33,091 people died from overdosing on opioids in that year.
The American Academy of Pain Management reports that 100 million Americans are experiencing chronic pain, more people than diabetes, heart disease and cancer combined. In response to concerns about under treated pain, , providers began to increase the frequency of prescribing opioid analgesics. Data from the CDC report that the number of opioid prescriptions nearly quadrupled from 1999 to 2010. Deaths from opioid overdoses have also quadrupled since 1999.
To address the current epidemic of opioid use disorder in the U.S., the FDA and the CDC have developed actions plans to reduce the impact of this public health crisis. The FDA’s strategic plan includes:
· Expanding advisory committees to study new opioids that do not have abuse-deterrent properties.
· Establish a more extensive framework for pediatric opioid medication labeling.
· Create additional labeling for extended-release/long-acting (ER/LA) opioids to include more warnings and safety information.
· Charge pharmaceutical companies with the task of performing more post-market research on the long-term impact of using ER/LA opioids.
· Increase training to providers in pain management and safe prescribing of opioids.
· Encourage pharmaceutical companies to develop generic abuse-deterrent products for pain.
· Expand over-the-counter access to intranasal naloxone.
The CDC’s Guideline for Prescribing Opioids for Chronic Pain includes guidance for providers in initiating or continuing opioid use for clients who experience chronic pain. The recommendations include:
· Provide nonpharmacological and nonopioid therapy for chronic pain, using opioids only as a last resort.
· Establish realistic treatment goals with clients.
· Prior to prescribing, and periodically throughout treatment, educate clients on the risks and benefits of opioid therapy.
· Begin therapy with immediate-release rather than ER/LA opioids.
· Prescribe lowest possible doses of opioids.
· For acute pain, limit opioid prescription duration to no more than 3 to 7 days.
· For chronic pain, evaluate use of opioids within 1 to 4 weeks of initiating therapy, and at least every 3 months thereafter.
· Before prescribing opioid therapy, evaluate risk potential for opioid use disorder.
· Utilize state prescription drug monitoring programs to track other controlled substance prescription clients may be taking.
· Before prescribing opioid therapy, and at least annually, evaluate urine drug testing for other controlled substances or illicit drug use.
· Avoid prescribing opioids and benzodiazipines concurrently
· Offer or arrange treatment for clients who experience opioid use disorder.
Nursing’s role in combating this public health issue begins with the realization that opioids pose a risk to all clients. Other actions nurses should take include:
· Being aware of the latest clinical practice guidelines
· Practice nonpharmacological methods of managing clients’ pain
· Identify the major risk factors associated with opioid use disorder
· Become an advocate and educator in managing clients’ pain
Adjuvant analgesics are used with a primary analgesic, such as an opioid analgesic, to improve pain relief while reducing the dosage of the opioid agonist. Reduced dosage of the opioid reduces adverse effects such as sedation, respiratory depression and constipation and decreases the risk of opioid dependency. The adjuvant medications canhelp alleviate other manifestations that aggravate pain (depression, seizures, inflammation), and are useful for treating neuropathic pain.
Antiseizure agents: carbamazepine, gabapentin
Antiseizure agents are useful in the reduction of neuropathic pain (sharp, stabbing pain). Carbamazepine is prescribed more frequently that other agent in this category. Use caution when the client is taking carbamazepine in combination with anticancer medications that suppress the bone marrow because carbamazepine can cause myelosupression. Clients who are of Asian descent are at risk increased risk for Stevens-Johnson syndrome and toxic epidermal necrolysis. Instruct clients to avoid drinking grapefruit juice while taking carbamazepine because it inhibits the metabolism of the agent and can increase its effects as well as the adverse effects.
Tricyclic antidepressants: amitriptyline, nortriptyline
Tricyclic antidepressants (TCAs) are also helpful in reducing pain that is neuropathic in origin. TCAs have independent analgesic properties that enhance the effects of opioids. By potentiating the effect of serotonin and norepinephrine, TCAs also treat depression, a major factor associated with chronic pain. TCAs have a number of disturbing side effects including orthostatic hypotension, anticholinergic effects, weight gain and sedation. To minimize the effects of orthostatic hypotension and sedation, recommend that clients take the medication at bedtime. Additional instructions for clients experiencing adverse effects while taking TCAs include the following:
· Avoid sudden changes in position and sit or lie down if feeling dizzy
· Increase fluid intake and sip fluids throughout the day
· Increase fiber intake
· Increase physical activity
· Take a stimulant laxative and a stool softener as needed
Antihistamines block histamine receptors in the body. They are also referred to as histamine antagonists. Hydroxyzine potentiates the effects of opioid analgesics, reduces anxiety and promotes sedation.
Glucocorticoids reduce pain by decreasing inflammation,: therefore, they are useful in treating painful inflammatory conditions such as rheumatoid arthritis and gout. Because long-term use can cause adrenal insufficiency, hyperglycemia and other adverse effects, these medications are tapered downward as soon as possible.
Bisphosphonates: alendronate, ibandronate
Bisphosphonates are used for the prevention and treatment of osteoporosis. They are also useful in the treatment of cancer-related bone pain. Instructions for clients who take bisphosphonates include the following:
· Take first thing in the morning with a full glass of water while sitting or standing
· Remain sitting or standing for at least 30 min after taking the medication (60 minutes for ibandronate)
· Do not eat or drink anything for at least 30 min after taking the medication (60 minutes for ibandronate)
Calcitonin is used to treat bone conditions such as osteoporosis and Paget’s disease. It works by decreasing bone resorption and promotes the renal excretion of calcium.
Patient‑controlled analgesia (PCA) is a medication delivery system that allows clients to self‑administer safe doses of opioids.
Other Strategies for Effective Pain Management
Chronic Pain Relief Strategies
Strategies specific for relieving chronic pain include the above interventions, plus the following:
Complications and Nursing Implications
Under treatment 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. To reduce the risk of overdose when administering opioids, take the following actions:
1. American Academy of Pain Management: Facts on Pain: Facts and Figures on Pain (2012) Retrieved November 21,, 2017 from www.painmed.org/PatientCenter/Facts_ on_Pain.aspx
2. Burchum, J., Rosenthal, L., (2016). Lehne’s Pharmacology for nursing care (9th ed.)St. Louis, MO: .Elsevier, Saunders.
3. Berman, A., Snyder, S., & Frandsen, G., (2016). Kozier & Erb’s fundamentals of nursing: Concepts, processes and practice (10th ed.) .New York, NY: Pearson Education.
4. Centers for Disease Control and Prevention (2017) What Everyone Should Know About Shingles Vaccine Retrieved November 21, 2017 from https://www.cdc.gov/vaccines/vpd/shingles/public/index.html
5. Centers for Disease Control and Prevention (2017) CDC Guideline for Prescribing Opioids for Chronic Pain Retrieved November 21, 2017 from https://www.cdc.gov/drugoverdose/prescribing/guideline.html
6. Centers for Disease Control and Prevention (2017) Understanding the Epidemic Retrieved November 21, 2017 from https://www.cdc.gov/drugoverdose/epidemic/index.html
7. deWit, S., Dalred, C., Stromberg, H., Medical Surgical Nursing: Concepts and Practice (3rd ed.). St. Louis, MO. Elsevier.
8. Federal Drug Administration (2014) Living With Fibromyalgia, Drugs Approved to Manage Pain Retrieved October 23, 2017 from https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm107802.htm
9. Federal Drug Administration: Department of Human Services, Nonsteroidal Anti-inflammatory Drugs Retrieved November 21, 2017 from https://www.hhs.gov/sites/default/files/2017-opioids-infographics.pdf
10. Federal Drug Administration (2017) FDA Opioids Action Plan Retrieved November 21, 2017 from https://www.fda.gov/drugs/drugsafety/informationbydrugclass/ucm484714.htm
11. The Fentanyl Patch Retrieved October 30, 2017 from https://www.drugs.com/cdi/fentanyl-transdermal-patch.html
12. Ignatavicius, D. & Workman, L. (2016). Medical-surgical nursing: Patient centered collaborative care (10th ed.). Philadelphia: Saunders.
13. Lilley. L., Collins, S., Snyder, J. (2014) Pharmacology and the Nursing Process (7th ed.) St. Louis, MO; Elsevier.
14. Mezack, R., Wall,P, (2012) The Gate Control Theory Retrieved November 21, 2017 from http://currentnursing.com/nursing_theory/Gate_control_theory.html
15. The Pasero Opioid-Induced Sedation Scale Retrieved November 21, 2017 from http://www.mghpcs.org/eed_portal/Documents/Pain/POSS-Pasero_Opioid-induced_Sedation_Scale.pdf
16. Potter, P., Perry, A., Stockert, P., Hall, A., Fundamentals of Nursing (9th ed.) St. Louis, MO. Elsevier.
17. Top Ten Safety List for Fentanyl Patches Retrieved November 21,, 2017 from http://www.ismp.org/Tools/highalertmedications/fentanyl.pdf
18. United States Department of Health and Human Services (2017) About the Epidemic Retrieved November 21, 20917 from https://www.hhs.gov/opioids/about-the-epidemic/index.html
19. Vallerand, A., Sanoski, C. (2017). Davis’s Drug Guide for Nurses (15th ed.) Philadelphia: F. A. Davis Company