Pain Management Overview

Overview

This lecture covers the assessment and management of acute and chronic pain in patients, including pharmacological and non-pharmacological approaches, barriers to pain management, and special considerations for different patient populations.

Pain Assessment and Principles

• Pain is the fifth vital sign and must always be assessed with other vitals.
• The patient’s self-report is the most reliable measure of pain.
• Nurses must respect patient values and cultural differences regarding pain management.
• The Joint Commission has standards requiring pain assessment and management.

At-Risk Populations

• Older adults, especially with dementia or communication difficulties, are at risk for inadequate pain management.
• Substance abusers and non-English speakers are at higher risk for poor pain control.

Types of Pain

• Acute pain: short-term, well-defined, reversible, associated with anxiety and increased vital signs.
• Chronic pain: lasts >3 months, not always linked to a clear cause, often irreversible, can cause depression and fatigue.
• Pain sources: somatic (musculoskeletal), visceral (organs), neuropathic (nerve damage).

Pain Theories and Barriers

• Gate control theory: pain impulses can be blocked centrally by endorphins or certain medications.
• Barriers include provider knowledge, cultural beliefs, patient misconceptions, and fear of addiction.

Pain-Related Definitions

• Tolerance: need for increased medication to achieve same effect.
• Physical dependence: withdrawal symptoms if the drug is stopped.
• Pseudo-addiction: behaviors from under-treatment, not actual addiction.
• Addiction: compulsive drug-seeking behavior regardless of pain.

Pain Assessment Methods

• Use PQRST or OLD CARTS mnemonics to assess pain characteristics.

Pharmacological Management (WHO Ladder)

• Step 1: Non-opioid analgesics (acetaminophen, NSAIDs, COX-2 inhibitors).
• Step 2: Weak opioids (codeine, hydrocodone with acetaminophen).
• Step 3: Strong opioids (oxycodone, morphine, hydromorphone, fentanyl, methadone, tramadol).
• Adjuvant medications include antidepressants, anticonvulsants, anxiolytics, steroids, and topical agents.
• You're on the right track! Here's a clearer breakdown of the **WHO pain ladder** steps and the types of medications used at each level: ### WHO Pain Ladder Overview | Step | Pain Level | Medications Used | |-------|---------------------|----------------------------------------------| | **Step 1** | Mild pain (0-3) | Non-opioid analgesics:
  - Acetaminophen (Tylenol)
  - NSAIDs (ibuprofen, naproxen)
  - COX-2 inhibitors (e.g., Celebrex) | | **Step 2** | Moderate pain (4-6) | Weak opioids ± non-opioids:
  - Codeine
  - Hydrocodone with acetaminophen (Vicodin, Norco)
  - Oxycodone (short-acting) sometimes combined with acetaminophen (Percocet) | | **Step 3** | Severe pain (7-10) | Strong opioids:
  - Morphine (gold standard)
  - Hydromorphone (Dilaudid)
  - Fentanyl (patch or IV)
  - Methadone
  - Sometimes tramadol (atypical opioid) | ### Additional Notes: - **Step 1** medications are for mild pain and work peripherally. - **Step 2** adds weak opioids for moderate pain, often combined with non-opioids. - **Step 3** uses strong opioids for severe pain, working centrally. - Adjuvant medications (like anticonvulsants or antidepressants) can be added at any step depending on pain type (especially neuropathic pain). So, **acetaminophen and COX-2 inhibitors like Celebrex** are typically Step 1 (mild pain). For moderate pain (Step 2), weak opioids like codeine or hydrocodone combinations are used. For severe pain (Step 3), strong opioids like morphine or fentanyl are used. If you want, I can help you summarize this into a quick reference chart!

Opioid Side Effects and Monitoring

• Common side effects: constipation, nausea, sedation, confusion, respiratory depression, pruritus.
• Initiate bowel regimens and monitor for sedation and respiratory status.
• Naloxone (Narcan) reverses opioid overdose and requires immediate medical attention.

PCA and Other Anesthesia Routes

• PCA pumps: only the patient should press the button; lockout intervals prevent overdose.
• PCA order sets specify monitoring frequency, oxygen, and naloxone use.
• Epidurals/intrathecal anesthesia require monitoring for lower extremity weakness and fall risk.

Non-Pharmacological and Complementary Therapies

• Heat, ice, massage, TENS, relaxation, distraction, cognitive behavioral therapy, and imagery are useful.
• Complementary therapies include supplements, meditation, acupuncture, and energy therapies.
• Nurses should ask about and document patient use of alternative therapies.

Pain in Pediatrics

• Children may show pain through behavior changes; use observation and the faces scale.
• Utilize both non-pharmacological and weight-based pharmacological approaches.

Key Terms & Definitions

• Tolerance — Need for higher doses for the same effect after repeated use.
• Physical Dependence — Withdrawal symptoms after stopping opioids.
• Pseudo-addiction — Drug-seeking due to inadequate pain relief.
• Addiction — Compulsive use and unlawful obtaining of drugs despite harm.
• WHO Ladder — Stepwise guideline for escalating pain management.
• PCA (Patient-Controlled Analgesia) — Pump allowing patient to self-administer pain medication within programmed limits.
• Adjuvant Analgesic — Medication given to enhance pain relief, not primarily designed as an analgesic.

Action Items / Next Steps

• Review the acute and chronic pain PowerPoint and WHO ladder document.
• Practice pain assessment using PQRST or OLD CARTS.
• Familiarize yourself with your facility’s PCA and opioid protocols.
• Complete assignments and be prepared for in-class application of these concepts.