CHAPTER 15 Pain ManagementMARY L. HEYEKATHLEEN A. REEVESObjectives

After reading and studying this chapter, you should be able to:

1. Define pain. 2. Explain the physiologic basis for pain. 3. Identify situations in which patients are likely to experience pain. 4. Explain the relationships between past pain experiences, anticipation, culture, anxiety,

or activity and a patient's response to pain. 5. Identify differences in the duration of pain and patient responses to acute and chronic

pain. 6. Explain the special needs of the older adult patient with pain. 7. List the data to be collected in assessing pain. 8. Describe interventions used in the management of pain. 9. Describe the nursing care of patients receiving opioid and nonopioid analgesics for

pain. 10. List the factors that should be considered when pain is not relieved with analgesic

medications.

Key Termsacute pain(p. 205)addiction(p. 217)

analgesia( , p. 204)

analgesic( , p. 202)

anesthesia( , p. 204)chronic pain(p. 205)

nociceptor( , p. 203)pain(p. 202)pain threshold(p. 204)pain tolerance(p. 204)physical dependence(p. 217)tolerance(p. 217)Pain is one of the most complex experiences to understand and treat. It is also the most common problem that nurses encounter. Research about pain, analgesics (drugs that relieve pain), and the mind-body influence is just beginning to filter down to nursing practice. Still, many questions about pain remain unanswered.

Pain is influenced by many variables: the individual experiencing it, the cause of the pain, and the environment. Pain may arise from a new source, from an old injury, or from nerve injury.

Sometimes the cause is unknown. Pain relief rests primarily with the nurse, who must assess the patient and implement appropriate interventions.

Nurses have many categories of pain-relieving interventions to choose from, yet they frequently administer only analgesics. Most nurses believe that pain is easily managed with analgesic drugs. Patients, however, often report that pain remains moderate to severe despite these medications. Research indicates that nurses fail to assess pain, tend to undermedicate for pain, and have inadequate knowledge of pain relief measures. Because of these findings, the Joint Commission on Accreditation of Healthcare Organizations published standards for the management of pain for all patients. Health care facilities are expected to comply with these standards. These include (1) recognizing the right of patients to appropriate assessment and management of pain, (2) performing pain assessments, (3) recording results of assessment and follow-up, (4) teaching patients about effective pain management, and (5) addressing needs for pain and symptom management at discharge.

The purpose of this chapter is to enable the nurse to understand pain and provide the most effective interventions for pain relief.

DEFINITION OF PAIN

Pain is defined in many ways. The International Association for the Study of Pain defines it as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. McCaffery, a nurse and leader in the pain management field, has a more useful definition for nurses. She says, “Pain is whatever the person experiencing it says it is and exists whenever he says it does.”

PHYSIOLOGY OF PAIN

Pain consists of various sensory experiences such as experiences of time and space, emotions, and cognition. The perception of pain involves afferent pathways, the central nervous system, and efferent pathways. Afferent pathways are nerves that carry messages to the brain for interpretation. Efferent (or descending) pathways are nerves that carry messages away from the brain to the rest of the body via the spinal cord.

Afferent pathways are activated by pain receptors called nociceptors. These pain receptors are unevenly distributed in muscles, tendons, subcutaneous tissue, and the skin. This may explain why parts of the body are more sensitive to pain than other parts. Pain receptors are sensitive to chemical changes, temperature, mechanical stimuli, and tissue damage. Some receptors are sensitive to more than one type of stimulus. Pain receptors are unable to adapt to repeated stimuli and thus continue to react until the stimuli are removed.

When pain receptors are stimulated, impulses are transmitted to the spinal cord. The impulses then travel up the spinal cord to the brain. In the brain, the cortex interprets the impulses as pain and identifies the location and qualities of the pain. Other structures involved in the interpretation of pain signals activate the stress response and produce the unpleasant qualities associated with pain, such as fear. Once pain is transmitted to the spinal cord and brain, the

descending pathway is activated and several substances like endorphins, serotonin, norepinephrine, gamma-amino butyric acid (GABA), and enkephalins are released that can inhibit pain transmission to the spinal cord.

Endorphins and enkephalins are the body's natural opioid-like substances that block the transmission of painful impulses to the brain. Differences in the amount of endorphins in individuals may explain why some people seem to experience more pain than others. Research suggests that prolonged stress and pain, as well as the prolonged use of morphine and alcohol, decrease endorphin levels. Factors that increase endorphin levels include brief stress and pain, laughter, exercise, acupuncture, transcutaneous electrical nerve stimulation (TENS), massive trauma, and sexual activity.

GATE-CONTROL THEORY

Although many theories have been proposed to explain pain, none fully describe the pain experience. One of the best known theories is Melzack and Wall's gate-control theory. It assumes that the pain experience reflects both physical and psychosocial factors. Painful impulses are transmitted to the spinal cord through small-diameter nerve fibers in the afferent pathway. When these small-diameter fibers are stimulated, the gating mechanism opens in the spinal cord, which permits the transmission of impulses from the spinal cord to the brain. Consequently the patient perceives pain. Factors that cause the gate to open include tissue damage, a monotonous environment, and fear of pain. These small-diameter fibers end in the spinal cord along with large-diameter fibers. The stimulation of large-diameter fibers can close the gate and interfere with impulse transmission between the spinal cord and the brain. This causes diminished pain perception. Large-diameter nerve fibers are stimulated by cutaneous (skin) stimulation through massage, position change, and heat or cold applications. Sensory input such as distraction, guided imagery, and preparatory information also may close the gate. Figure 15-1 shows the structures and mechanisms associated with the gate-control theory.

FACTORS INFLUENCING RESPONSE TO PAIN

Consider the following example: Miss Smith and Mrs. Johnson are roommates in Room 200. Miss Smith, age 19, underwent a cholecystectomy the previous day, as did Mrs. Johnson, age 67. The nurses discussed the difference in behavior of each patient: “Miss Smith constantly wants more pain medication. She moans and groans all the time. She won't even turn, cough, or breathe deeply for more than 10 seconds. She always rates her pain a 9 or a 10 on the pain scale. On the other hand, look at Mrs. Johnson. She's already ambulating. She rarely rates her pain as more than a 5 or a 6 on the pain scale. She usually just complains of aching, and she sure doesn't ask for as much pain medication as Miss Smith. You'd never guess they had undergone the same procedure.”

FIGURE 15-1 The gate-control theory of pain.

This example illustrates that although people may have the same injury or insult (in this case, surgery), they may respond differently. This is because many physical and psychosocial factors

affect the response to pain. It is important for health professionals to be nonjudgmental and to avoid comparing one individual in pain with another individual in pain.

PHYSICAL FACTORS

Many physical factors influence the pain experience, including the individual's pain threshold, pain tolerance, age, physical activity, nervous system integrity, and, in cases of surgery, the type of surgery performed and the type of anesthesia used.

Pain Threshold

The pain threshold is the point at which a stimulus causes the sensation of pain. Anger, fatigue, anxiety, insomnia, depression, and uncontrolled pain all lower the pain threshold. With a lower threshold, the person experiences pain more readily with less stimuli. During hospitalization or illness, a patient may experience anxiety, fatigue, or loss of sleep, all of which can lower the pain threshold or cause the patient to experience pain more easily.

Pain Tolerance

Pain tolerance refers to the intensity of pain that a person will endure. It is another factor influencing response to pain. Pain tolerance varies among patients and varies for an individual patient, depending on the situation. Increasing or prolonged pain may lower the pain tolerance because the patient fears the pain will not be relieved. Low pain tolerance or high pain tolerance must be respected and must not interfere with adequate pain management.

Age

Age may also influence response to pain. At times, older patients do not report their pain or they report that their pain is much less severe than it really is. Some do not report pain because they are stoic or they have been told incorrectly that pain is a normal part of aging. Some older patients may not want to bother the nurse, or they may fear rejection from the caregiver. Pain is not a normal part of aging, although older adults often suffer from chronic conditions such as arthritis, cancer, and bone fractures that are associated with pain.

Physical Activity and Nervous System Integrity

Physical activity and the integrity of the nervous system also can influence the reaction to pain. Physical activity may aggravate or precipitate pain. However, with some patients, physical activity may be used to relieve pain. Because pain is perceived and interpreted within the nervous system, the integrity of the system affects the response to pain. For example, patients with diabetic neuropathy may lose sensation in the extremities and may not feel pain there.

Surgery and Anesthesia

In surgical patients, the type of surgery performed and the type of anesthesia used can influence the response to pain. Surgery on the upper abdominal region of the body is thought to be the

most painful type because of the numerous tissues traumatized during the procedure. Within this group are cardiac, pulmonary, gastric, and gallbladder procedures. The type of anesthetic agent used can influence postoperative pain. For example, ketamine has analgesic properties. Some anesthetic agents injected at the operative site may prolong analgesia for 12 to 24 hours after surgery. When these types of agents are used, patients may experience much less pain after surgery than those who do not receive these anesthetic agents.

Surgery or invasive procedures may be performed to relieve pain that is severely debilitating. Rhizotomy and cordotomy are surgical procedures that cut or destroy selected nerve tissue to interrupt the pain pathway. These operations intentionally leave the patient with some neurologic deficit, which may pose a risk for injury. The patient may be unaware that a body area is painful and may not protect that area from harm. Pain relief from these procedures may not be permanent because nerve tissue regenerates. Nerve blocks are procedures that involve destruction or anesthesia of a nerve root with injection of a chemical to achieve pain relief in a specific body area. Drugs are injected to block the transmission of pain signals. For example, intercostal (between the ribs) anesthetic nerve blocks may be performed with cardiac operations to reduce postoperative pain in the thoracic area. Acupuncture is another invasive technique that produces anesthesia or analgesia. It is an ancient Chinese practice in which tiny needles are inserted into the skin or subcutaneous tissues at specific points on the body. This technique may be used to relieve acute and chronic pain such as headache, menstrual cramps, and low back pain.

PSYCHOLOGICAL FACTORS

Along with physical factors, several psychological factors can influence the response to pain, including culture, religion, past experiences with pain, anxiety, and situational factors.

Culture and Ethnicity

Although studies have been conducted to determine the effect of culture and ethnicity on people's reaction to pain, it is critical to avoid making judgments based on how you think a person should react or behave. Some persons may deny pain, remain calm and unemotional, or withdraw. Other persons may cry, moan and groan, and involve their families in the painful experience. Be aware of the different ways of expressing pain, and respect individual variations in the response to pain.

Religious Beliefs

Religious beliefs also may have an impact on reaction to pain. Some patients may pray and believe that divine intervention will help them endure the pain. Others may view pain as a punishment for sins. Some individuals believe that suffering is required before pain relief can be obtained.

Past Experiences and Anxiety

Past experiences and anxiety may affect a person's response to current pain. A person may have developed positive coping strategies to deal with previous painful experiences. If, however,

previous coping strategies were unsuccessful, the patient may be very anxious and overwhelmed by another painful experience.

Situational Factors

Finally, situational factors may influence response to pain. If the pain is associated with a serious illness such as cancer, the pain may have a greater impact on mood and activity than if the pain were associated with a less serious condition. The pain associated with childbirth is relatively short-lived and usually results in a beautiful outcome, whereas cancer pain may be chronic and increasing and may be associated with progression of the disease and death.

What Does Culture Have to Do with Pain?

The way a person behaves in response to pain is, in part, determined by cultural norms. Therefore people from some cultures quietly endure pain, whereas people from other cultures loudly express their pain. As nurses, we must accept each response and assess and intervene to promote maximum comfort.

RESPONSES TO PAINAUTONOMIC NERVOUS SYSTEM

The pain signal is interpreted by the brain as a stressor. The autonomic nervous system activates the fight-or-flight response, and certain physiologic responses are initiated. Box 15-1 indicates some of the responses that occur and the associated effects. The patient in pain may exhibit these physiologic responses, along with behaviors such as grimacing, moaning, and verbalizing pain, or withdrawing. The nervous system responses are measured by an increased heart rate, respiratory rate, and blood pressure. These are predictable responses to acute pain; however, the pain behavior will vary from individual to individual. Acute pain and chronic pain elicit different kinds of responses. Table 15-1 lists some differences between acute pain and chronic pain.

Box 15-1 Autonomic Nervous System Responses to PainSympathetic Nervous System Responses↑ Blood pressure↑ Pulse rate↑ Respiratory rateDilated pupilsPerspirationPallorParasympathetic Nervous System ResponsesConstipationUrinary retentionACUTE PAIN

Most pain experienced in the hospital is acute pain. Acute pain follows the normal pathway for pain from nociceptor activation to the brain and may be called nociceptive pain. Examples are postoperative pain from incisions, renal colic pain from kidney stones, bone fractures, and pain

in childbirth. Acute pain is temporary, and its cause is known and treatable. It serves as a warning of tissue damage and subsides when healing takes place. Nurses observe behavioral and physiologic signs of acute pain when the patient guards or rubs a body part, wrinkles the brow, bites the lip, and has changes in the heart rate, blood pressure, and respiratory rate. These responses may be absent or lessened in chronic pain.

CHRONIC PAIN

Chronic pain is usually defined as pain that persists or recurs for more than 3 to 6 months; it may last a lifetime. Chronic pain may also be nociceptive; however, most chronic pain is called neuropathic pain because it follows an abnormal pathway for pain. This is a new term that encompasses some puzzling and challenging pain syndromes classified as chronic pain. Neuropathic pain results from nerve damage resulting from a wide variety of anatomic and physiologic conditions and underlying diseases. It includes unusual sensations such as burning, shooting pain, and abnormal sensations that occur when there is no painful stimulus present.

The cause of the pain may be unknown. Treatment may or may not be helpful in relieving the pain. There are several types of chronic pain. Some classes of chronic pain and examples are shown in Table 15-2. Chronic pain is associated with a variety of diagnoses, including cancer, arthritis, peripheral vascular diseases, and traumatic injuries.

Table 15-1 Differences in Acute Pain and Chronic PainCHARACTERISTIC ACUTE CHRONICTime Limited, short duration Lasts 3-6 months, longer durationPurpose Sign of tissue injury No purposeVerbal Reports pain, focuses on pain No report of pain unless questioned

BehavioralRestless, thrashing, rubbing body part, pacing, grimacing, and other facial expressions of pain

Tired-looking, minimal facial expression, quiet, sleeps, rests, attention on other things

PhysiologicIncreased heart rate, blood pressure, respiratory rate

Normal heart rate, blood pressure, respiratory rate

Interventions

Responds to analgesics Less responsive to analgesicsStandard doses effective Higher doses needed for pain reliefParenteral or oral route used Oral route preferredAdditional drugs (adjuvant) seldom needed to manage pain

Additional drugs often needed to manage pain

Table 15-2 Chronic PainCLASS EXAMPLES

Acute pain: recurrent episodesNeuralgia (herpes zoster)Migraine headachesSickle cell crisis

Chronic malignant Cancer pain syndromesChronic nonmalignant or benign Low back pain

CLASS EXAMPLESRheumatoid arthritisPhantom limb pain

Chronic nonmalignant or benign pain is pain that cannot be explained or that persists after healing has taken place. It usually occurs daily and is not life-threatening. Treatments may or may not be successful in relieving the pain. Intractable pain is another term used to describe pain that cannot be relieved and has no known effective treatment.

Many conditions common in older adults may be associated with chronic pain. Phantom limb pain, in which the patient still feels sensations and pain in the amputated limb, is an example of chronic benign pain and neuropathic pain. It can be extremely debilitating if it is not recognized and treated early. It may occur in any related body part that has been amputated or traumatized, for example, amputation of the breast or leg. A number of therapies may be used to reduce this type of pain (e.g., analgesic opioids, antidepressants, nerve block, surgical revision, and physical therapy).

Chronic malignant pain or cancer-related pain may be considered acute and chronic pain. Cancer pain may be chronic pain if it lasts longer than 3 to 6 months. Cancer may also cause the development of new pain when the cancer causes pressure or damage to tissue or nerves. This would be acute pain. Pain related to cancer can be very complex because it may include a variety of pain problems that can be nociceptive and/or neuropathic in nature.

Chronic pain is poorly understood, and new and challenging pain syndromes are currently being identified and classified. Among the treatments that are being tried for chronic pain are surgically implanted stimulators in the spinal cord or brain that can block pain impulses.

COMPARISON OF ACUTE PAIN AND CHRONIC PAIN

In contrast to acute pain, which warns of tissue damage and trauma, chronic pain serves no useful purpose. It can have a debilitating and destructive effect on a person's life. Chronic pain can lead to depression, marital difficulties, loss of self-esteem, immobility, and isolation. The patient in chronic pain often does not report pain and shows little facial expression or few physical signs of pain. When pain is chronic, adaptation may occur. The sympathetic nervous system adapts. The heart rate, blood pressure, and respiratory rate may not be elevated, and the patient may rest, sleep, or turn attention to other activities despite severe pain.

The nurse may underestimate the severity of the pain or undermedicate a patient with chronic pain. Nursing assessment of pain is essential to identify (1) the type and amount of pain, (2) whether the pain is chronic or acute, and (3) whether the patient has both acute pain and chronic pain at the same time. When the patient reports pain but shows no physical symptoms, this does not mean there is no pain. It may simply mean that the patient has learned other ways to deal with the pain or that the patient may be taking medications that block the response of the sympathetic nervous system to pain.

NURSING CARE of the Patient in Pain

Pain management continues to be a challenge for every nurse. Every individual experiences pain differently and reacts to pain with a variety of physiologic and behavioral responses. Based on an accurate assessment of pain, the physician prescribes treatment and the nurse provides nonpharmacologic and pharmacologic measures together to provide pain relief. The nurse plays a key role by assessing, intervening, and evaluating the patient in pain. Figure 15-2 shows the variety of interventions you can use to relieve pain.

Assessment

Assessment is the first step in pain management. Assessment of pain should be done on admission and on a regular basis. Anticipate pain as a result of procedures, surgery, or progression of a disease. A pain assessment done with vital signs is called the fifth vital sign. Accurately record the data, and compare with previous information. This permits evaluation of the pattern of pain or the effectiveness of an intervention.

It can be difficult to assess pain in some patients, especially older adults. Visual, speech, hearing, and motor impairments may limit the ability of older patients to communicate pain or to use scales to rate pain. Patients with cognitive impairment may be unable to report pain or recall pain sensations. Pain can also cause confusion, irritation, and depression in older adults. Consider these aspects when assessing the older adult.

When the patient cannot communicate verbally, he or she may be able to point to or direct your attention to a location on a body chart or pain intensity scale. You may also have to use family observations and patient behaviors to assess pain and pain relief in this type of situation. When the patient cannot report pain, the nurse may have to perform a different assessment that includes observing for usual or unusual behaviors that may indicate pain. These behaviors are not specific to pain, so other causes of discomfort should be assessed, too, such as impaction or bladder infection.

FIGURE 15-2 Nursing management of pain.

The six steps in pain assessment are listed in Box 15-2 and are discussed in the following sections.

Accept the Patient's Report

The first step in pain assessment is to establish rapport with the patient and accept what the patient says about the pain. When possible, all information about pain should be obtained directly from the patient. The person in pain is the only authority on the pain; no one else can really know what the pain feels like. Accept the report in a nonjudgmental and caring manner. Obtain specific details about the pain, and respond positively that action will be taken to relieve the pain.

Box 15-2 Six Steps in Pain Assessment

After reading and studying this chapter, you should be able to:

1. Accept the patient's report 2. Determine the status of the pain 3. Describe the pain:

o a.Locationo b.Qualityo c.Intensityo d.Aggravating and alleviating factors

4. Examine the site 5. Identify coping methods 6. Record assessment, interventions, and evaluation of interventions

The assessment of pain requires excellent therapeutic communication skills. Important attitudes are conveyed through verbal and nonverbal behaviors. Listen patiently without interruption, use eye contact, touch the patient, and repeat and clarify information in an unhurried manner to establish trust and obtain information. Do not compare one patient's report of pain with another's report, because pain is an individual experience.

Determine the Status of the Pain

The second step in pain assessment is to determine whether the pain is a new occurrence or has been experienced before. Ask the patient if he or she has had this pain before and whether it was diagnosed by a physician. On the basis of the patient's responses and history, decide whether the pain is chronic in nature or acute pain that needs immediate treatment. For example, a patient who is recovering from a prostatectomy may suddenly have chest pain. The patient identifies this discomfort as the typical angina pain for which he has taken medication in the past. A similar patient with chest pain and no previous cardiac history should be seen by a physician immediately because this is a new pain that the patient has not had before. Although both patients need to be evaluated by a physician, an accurate nursing assessment is essential to determine the difference between these two types of pain and consequently the action to be taken.

Describe the Pain

The third step in pain assessment is to describe the pain in terms of its location, quality, intensity, and aggravating and alleviating factors.

Location.

Have the patient describe where the pain is and point to the exact location with one finger. If there is more than one location of pain, use a body chart, as shown in Figure 15-3. Have the patient shade in or mark an X at the locations of pain. Then number the various locations on the body chart so that you can refer to the number rather than writing the exact location each time. Also determine whether the pain is confined to one area or whether it starts at one place and moves to another.

The location identified as painful does not always correspond with the disease or operative site. For example, patients may experience back and neck spasm after surgical procedures. Another example is referred pain. Referred pain is often experienced in a location different from its source (Fig. 15-4). To illustrate, pain from appendicitis is usually felt around the umbilicus and is of the aching, cramping type. The pain impulses come from an inflamed appendix in the right lower quadrant of the abdomen, where there may also be sharp pain. Anginal pain is another type of referred pain. It is caused by lack of blood flow to the heart muscle and may be experienced as pain in the jaw, arm, and neck as well as in the chest.

FIGURE 15-3 Body chart.

Quality

Ask the patient, “What words do you use to describe your pain?” or “What would you do to me to have me feel the pain you have?” If the patient has difficulty describing the pain, suggest words. Commonly used words are sharp, dull, cramping, aching, gnawing, burning, heavy, tender, and throbbing. However, it is best to allow the patient to use his or her own words, and record these in the chart.

Intensity.

Because pain is a subjective experience, nurses must have some way to measure the severity of pain. The purpose of asking about intensity is to put the patient's description into an objective

term or number. To determine intensity, use one of the scales shown in Figure 15-5. A simple descriptive scale uses words of varying intensity—for example, mild, moderate, or severe. Some patients have difficulty with these words, and it may be better to use a scale with words such as “a little pain,” “a lot of pain,” or “too much pain.” A numeric scale can be 0 to 10 or 0 to 5, with 0 meaning “no pain” and the highest number meaning “the worst pain experienced.” A visual analog scale (or VAS) allows the patient to mark an X anywhere on a line that shows intensity of pain at one end as “no pain” and at the other end as “pain as bad as it could possibly be.”

Explain the scale to the patient and ask, “Where would you rate your pain right now?” The scale used should make sense to the patient, be easy to use, and be consistently used with the same words or numbers. Remember to explain the scale to the patient each time pain intensity is assessed. The advantage of using a scale is that it provides a personal measure of the patient's pain and allows evaluation of pain relief using a consistent measure. A scale that is meaningful to the patient and that can be used repeatedly requires less effort for the patient in pain.

FIGURE 15-4 Anterior and posterior referred pain sites.

For example, a 42-year-old man with multiple fractures in the right arm used the numeric scale from 0 to 10 for rating pain. The patient complained of throbbing in his right arm and a backache. He rated the intensity of both pains at 7 on the scale at 8 pm. The nurse applied heat to the lower back as ordered, massaged his back, and administered 10 mg of morphine intramuscularly. At 9 pm, the patient rated the intensity of both pains at 2 and stated that the pain was slowly going away. The nurse recorded this information and identified that the interventions were effective in relieving the pain because the pain intensity had decreased from 7 to 2 on the 0-to-10 scale. The nurse also noted that she would reassess the patient's pain every 2 hours. Some hospital policies set a number or “comfort goal” that automatically triggers pain intervention. For example, any pain rating 4 or above on the pain scale requires a nursing intervention for pain relief because research has shown that a pain rating of 4 or above interferes with function and recovery.

Aggravating and Alleviating Factors.

Ask if any event or activity causes the pain or makes it better or worse. Ask, “What were you doing when the pain occurred?” Aggravating factors are those that make the pain worse. Certain positions, temperatures, or times of day or night may cause the pain to be more severe. Similarly, alleviating factors might include specific positions, application of heat, cold, or menthol, or physical activities that reduce pain in specific areas.

Patients can usually identify factors that aggravate or reduce pain and what specific pain relief methods have worked in the past. For example, four patients having abdominal surgery may have arthritic shoulder pain and have four different methods of reducing the pain. The first patient obtained relief with elevation and rest of the right arm. The second applied an analgesic balm, a menthol ointment. The third patient used a heating pad on the area, and the fourth increased the anti-inflammatory drug dose as prescribed by the physician.

Examine the Site of the Pain

The fourth step in the assessment of pain is to examine the location that the patient states is painful. Assess the area for heat, redness, swelling, tenderness, abnormal position, or other factors that may be causing local irritation.

Patients may identify a location of pain that is not expected as part of their medical problem. This pain location may be due to a complication or an injury that was sustained during a procedure or hospitalization. For example, one patient who had undergone orthopedic surgery on the ankle had also sustained a large burn on his back at some time during the procedure. When the nurse examined the pain location, the burn was discovered.

FIGURE 15-5 Examples of pain intensity scales. A, Simple descriptive pain intensity scale. B, 0-10 numeric pain intensity scale. C, Visual analog scale (VAS).

Another example is a patient who had undergone abdominal surgery and complained of pain in the right calf. Examination of the right calf revealed a red, firm, tender area that was reported to the physician and diagnosed as thrombophlebitis. When the exact location of the pain was examined, the correct cause of the pain could be identified.

Identify Coping Methods

The fifth step in pain assessment is to identify the patient's coping methods. People develop coping methods to increase control over pain or to relieve pain. Nurses should become aware of the methods patients use to cope with pain and should support the coping method. Some patients actively deal with pain. For example, they may complain and get up and move around or do some other activity. Some patients cope by staying quiet, praying, sleeping, or withdrawing.

Nurses must emphasize to patients and their families that their cooperation and information are critical to achieving pain relief. Some patients expect nurses to know that they are experiencing pain and to know what to do about it. Confirm how the patient copes with pain by discussing observations of the patient's behavior with him or her. You can also suggest other coping methods that could be used to relieve pain (e.g., changing positions, imagery, distraction). Pain in older adults, especially those with cognitive deficits, can be difficult to evaluate. Boxes 15-3 and 15-4 offer guidelines for evaluating pain in cognitively impaired older adults and list common pain behaviors that are likely to be observed in such patients.

Box 15-3 Evaluating Pain in Cognitively Impaired Older Adults and Observing Pain Behaviors

• Ask the patient about pain first. Many patients who appear cognitively impaired may be able to answer yes/no questions about pain or complete a simple descriptive or numeric pain intensity scale.

• Ask family members and caregivers what particular behaviors indicate pain for the patient.

• Review the medical record to identify a past history of pain or diagnoses that are associated with pain.

• Examine the patient physically to identify potential sources of pain or common problems causing pain.

• Observe behaviors that may indicate pain for the patient. Observe the behaviors at rest and with activity. Note if the behaviors change or improve when pain medication is administered. Assess, intervene, and evaluate behaviors again after intervention.

Document Assessment Findings and Evaluate Interventions

The sixth and last step in the pain assessment is to record the information in the patient's chart so that this information can be conveyed to nurses on other shifts and to other health professionals. Record the location, quality, and intensity of the pain, related factors, and how the patient copes with pain. Document the interventions provided and their effectiveness. Include the intensity of the pain after the intervention. If the nursing intervention was not effective in relieving the pain or reducing pain to an acceptable comfort goal, record what was done about the pain.

Box 15-4 Common Pain Behaviors in Cognitively Impaired Older AdultsFacial Expression

Frown, grimace, rapid blinking, wince, clenched teeth, narrowed eyes

Sounds

Sighing, moaning, groaning, calling out, noisy breathing, cursing during movement

Body Movement

Rigid, tense body posture, fidgeting, pacing, gait changes, rocking, rubbing affected area

Changes in Interactions with Others

Aggressive, striking out, resisting care, withdrawn, decreased social interactions

Changes in Activity Patterns or Routines

Refusing food, appetite changes, sleep or rest pattern changes, increased wandering

Mental Status Changes

Crying, increased confusion, irritability, or distress

You may also use the following diagnoses to identify other problems that often accompany pain:

•Activity Intolerance •Anxiety

•Disturbed Sleep Pattern •Fatigue •Self-Care Deficit

Put on Your Thinking Cap!

Think of one of your patients who had pain. Discuss with your classmates how you knew that the patient had pain. Compare and contrast how different patients expressed pain, the interventions that were being used for pain control, and the effectiveness of the interventions.

Nursing Diagnoses, Goals, and Outcome Criteria: Patients in PainNursing Diagnoses Goals and Outcome Criteria

Potential or actual Acute Pain related to surgery

Pain relief: Patient states pain is relieved, has relaxed manner

Chronic Pain related to arthritic joint inflammation

Pain reduction or relief: Patient states pain is lessened or relieved, has relaxed manner

Table 15-3 Nonpharmacologic InterventionsINTERVENTION COMMENTS

PHYSICAL

Heat, cold, massage, transcutaneous electrical nerve stimulation (TENS)

Increase pain threshold, reduce muscle spasm, and decrease congestion in injured area. Effective in reducing pain and improving physical function. Techniques require skilled personnel and special equipment. May be useful as adjuncts to drug therapy.

PSYCHOLOGICAL Relaxation Jaw relaxation Effective in reducing mild to moderate pain and as an adjunct to

analgesic drugs for severe pain.Progressive muscle relaxation

Simple imageryUse when patients express an interest in relaxation. Requires 3-5 minutes of staff time for instructions.

MusicBoth patient-preferred and “easy listening” music are effective in reducing mild to moderate pain.

ImageryEffective for reduction of mild to moderate pain. Requires skilled personnel.

Educational Instruction Effective for reduction of pain. Should include sensory and procedural information and be aimed at reducing activity-related pain. Requires 5-15 minutes of staff time.

Interventions Nonpharmacologic Interventions

Nonpharmacologic interventions are those that do not employ drugs. They include a wide range of physical and psychological interventions for pain relief (Table 15-3). Physical interventions usually involve comfort measures, adjusting the patient's environment, and cutaneous application techniques such as heat or cold. Psychological interventions include unconditionally accepting the patient's pain report and providing information about pain, analgesics, and procedures or

psychological strategies such as relaxation and imagery. These types of interventions should be used along with analgesics to obtain optimal pain relief.

Physical InterventionsPhysical Comfort Measures.

These nursing interventions focus on the patient and the environment. Comfort may increase pain tolerance and the patient may experience less pain. Because adequate air, food and fluid, elimination, mobility, hygiene, temperature, and rest and sleep are essential to comfort, monitor these areas for potential problems. For example, patients who are sleep deprived or fatigued may have increased pain. Therefore providing for uninterrupted sleep and periods of rest can enhance pain relief.

For some patients in pain, progressive exercise or immobility may be prescribed as a treatment for pain. The patient with an injury or incision should be moved carefully so that further trauma is avoided. Turning the patient carefully from side to side or supporting an affected extremity during activity can reduce pain. Usually the patient can describe which movements or positions increase or decrease the pain.

Administer analgesic medications before painful experiences to reduce the pain intensity and anxiety associated with the event. Aggressively treat pain, nausea, vomiting, appetite suppression, constipation, and other problems. Assist and teach patients how to splint abdominal and thoracic wounds to minimize pain when deep breathing, coughing, and ambulating. A change of bed linen and sheets free of wrinkles can be refreshing and reduce irritation of the skin. Apply ointment to cracked lips, and provide ice chips for a dry mouth. Any tubes or equipment attached to the patient should be secure but should not produce tension on the skin. Correct body alignment and frequent changes of position will relieve monotony, increase circulation, and prevent muscle contractures and spasms, which aggravate pain.

Pharmacology Capsule

Analgesics should be administered before painful activities to reduce the pain and anxiety associated with these events.

Environmental Control.

Each patient has individual preferences that affect comfort. Some patients prefer an active environment in which they can be distracted from pain. Listening to tapes or music, watching television, working with the hands, walking around, or visiting with others allows a person to focus attention on stimuli other than the pain sensation. On the other hand, lights, noise, and constant activity of the hospital environment often cause sensory overload for the patient in pain. This can increase pain. When this occurs, coordinate with staff to promote a quiet environment with nonglaring lights and scheduled rest and activity periods that meet the patient's needs.

Stimulation Techniques.

Stimulation of the skin and underlying tissues relieves pain. Various types of skin or cutaneous stimulation can be applied, and each has variable effects. These techniques are not curative; rather, they can decrease the intensity of pain or change the sensation so that it is more acceptable. The exact mechanism for pain relief is unknown, but it is thought that superficial stimulation may block the transmission of pain impulses to the brain. Applications of heat, cold, massage, and TENS are examples of cutaneous stimulation. These interventions tend to be most effective for mild to moderate pain, well-localized pain, and acute and chronic pain. The effects of these therapies last as long as or slightly longer than the application.

The physician may prescribe the application of heat or cold for pain. Heat or cold is used to reduce muscle spasm and decrease congestion or swelling in an injured area. Either therapy may be applied to the painful site, at a location beyond the site, between the site and the brain, or on the opposite side of the body. These therapies should be applied intermittently, not continuously. Heat and cold may be alternated. Both therapies should be applied at a temperature that is comfortable for the patient, and the patient's skin and circulation should be monitored frequently.

Cold may be applied with ice packs or cooling pads to decrease initial tissue injury and swelling (e.g., with musculoskeletal sprains or orthopedic procedures). Cold is contraindicated for patients with peripheral vascular disease or heart disease because it may cause further vasoconstriction of blood vessels and thus decrease circulation. Cold application should be limited to 15 minutes per session to avoid tissue injury or frostbite.

Moist or dry heat can be applied with heating pads, hot-water bottles, towels, gel packs, or warm tub baths or showers. Superficial heat has been shown to be effective for gastrointestinal cramps and muscle and joint pain. Treatment should be limited to 30 minutes to avoid tissue injury. Heat should not be applied to a site of malignancy, to areas of decreased sensation or circulation, or to patients who cannot communicate their discomfort.

Massage involves rubbing, kneading, manipulating, and applying pressure and friction to the body. Rubbing or massaging an area is a natural response when one has an injury or ache. Massage may be used to promote relaxation and relieve muscle cramps. Massage is commonly applied to the back, neck, and large leg muscles; however, massage of the hands and feet is more easily performed and perhaps more effective. Massage should not be applied to areas with injury, phlebitis, or skin lesions or to patients with bleeding problems.

Cold, heat, and massage are easy to apply, inexpensive, effective, and simple for the patient or family to learn. For each therapy, the nurse should evaluate whether the method or location of application is effective, and monitor for any side effects.

Compared with the therapies just mentioned, TENS is much more expensive and less widely available. It requires a physician's order, and often the physical therapy department handles the equipment. The therapy involves external electrical stimulation of the skin and underlying tissues through electrodes attached to a small unit that the patient can carry around. The electrodes are placed over, above, or below painful sites and attached to a battery-operated device that delivers low-voltage electrical currents. The electrical current is adjusted through a dial on the unit. The

patient should feel a mild tingling or vibrating or prickly sensation over the area of application. Nursing responsibilities with TENS include the following:

1.Apply electrodes in the correct locations and with good contact with the skin. 2.Check that all connections are secure, from skin electrodes to unit. 3.Adjust the current to the prescribed level and/or the patient's level of comfort. 4.Document and evaluate pain relief.

The major disadvantage of TENS is irritation of the skin under the electrodes. The electrodes should be changed daily, the sites rotated, and the skin inspected. Figure 15-6 shows the application of electrodes and a TENS unit.

Psychological InterventionsAnxiety Reduction.

Anxiety, fear of the unknown, and feelings of loss of control may be directly related to the level of pain experienced. The patient who is anxious and uncertain will tend to rate pain high. If the nurse can increase the predictability and control of painful stimuli, pain may be reduced. An important aspect of relieving anxiety associated with pain is the relationship between the nurse and the patient. The nurse can be with the patient, assure the patient that everything possible is being done, and provide timely and appropriate interventions for pain relief.

Several strategies are used to decrease anxiety and increase control. Telling the patient about events and providing descriptions of the sensations or feelings that may accompany the event can reduce anxiety. However, some patients may prefer not to know this information, and their wishes should be respected. Allowing the patient to choose physical comfort measures and the time for treatments or to rearrange items in the room also provides control.

FIGURE 15-6 Application of a TENS unit.

Preoperative teaching should include skills to help patients cope with their pain, such as breathing, relaxation, or imagery techniques. Providing strategies to help the patient cope with pain and anxiety also provides the patient with a sense of control. The Health Promotion Considerations box on p. 214 describes a sample relaxation exercise, one of the psychological interventions used for pain relief.

Distraction.

Distraction refers to focusing on stimuli other than pain. Distraction may help the patient gain a sense of control as well as increase pain tolerance, decrease pain intensity, and alter the quality of pain, but it does not eliminate pain. Because the pain is not eliminated, the patient will usually need analgesics and other methods of pain relief. A patient using distraction may not appear or behave as if in pain, which may cause other people to doubt that the pain exists. After a patient

has used a distraction technique, he or she may once again focus on the pain and experience a heightened awareness of pain.

Distraction techniques are often most helpful with mild to moderate pain or during brief periods of pain associated with painful procedures such as dressing changes, intramuscular injections, and venipunctures. Examples of distraction methods include rhythmic breathing, listening to music, laughing, counting, watching television, reading, exercising, resting, talking on the phone, and visiting with others. Older adults may find reminiscing (relating past experiences) to be an effective distraction technique. It is helpful to include several distraction techniques in the plan of care so that the patient can choose the methods most effective for his or her individual pain relief.

Relaxation.

Patients should be aware that relaxation is one of the options for pain relief. Patients may already know this technique or may be taught relaxation techniques. Be aware that the patient is using relaxation, know the rationale for using relaxation, and know the effects of relaxation.

Relaxation is a cognitive approach to pain management. It is a self-hypnotic technique that may, but does not always, produce the relaxation response. The relaxation response counteracts the stress response. It is characterized by decreased muscle tension, a decreased heart rate, decreased respiratory rate, and normal or decreased blood pressure. Relaxation decreases mental stress and physical tension; this is helpful because pain is often accompanied by increased anxiety and muscle tension. Relaxation is more effective for mild to moderate pain than for severe pain.

Rhythmic breathing is a relaxation technique that focuses on just breathing, as described in the Health Promotion Considerations box above. Relaxation techniques that focus on total body relaxation require the patient's active participation. Each part of the body is deliberately relaxed, usually in an orderly sequence such as head to toe or vice versa. Relaxation often involves breathing exercises combined with other methods to promote freedom from anxiety and muscle tension. Methods may include yoga, meditation, and music.

Health Promotion ConsiderationsSample Relaxation Exercise: Slow, Rhythmic Breathing

1. Breathe in slowly and deeply. 2. As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving

your body. 3. Now breathe in and out slowly and regularly at whatever rate is comfortable for you.

You may wish to try abdominal breathing. If you do not know how to do abdominal breathing, ask your nurse for help.

4. To help you focus on your breathing and to breathe slowly and rhythmically, do the following:

o a.Breathe in as you say silently to yourself, “in, two, three.”o b.Breathe out as you say silently to yourself, “out, two, three.”

o c.Each time you breathe out, say silently to yourself a word such as “peace” or “relax.”

5. You may imagine that you are doing this in a position and a place you have found very calming and relaxing, such as lying on a beach in the sun.

6. Do steps 1 through 4 only once, or repeat steps 3 and 4 for up to 20 minutes. 7. End with a slow, deep breath. As you breathe out, say to yourself, “I feel alert and

relaxed.”

Additional Points

If you intend to do this for more than a few seconds, try to get into a comfortable position in a quite environment. You may close your eyes or focus on an object. This technique has the advantage of being very adaptable in that it may be used for only a few seconds or for up to 20 minutes.

The patient may be taught relaxation through coaching by the nurse, the use of a script, or an audiotaped relaxation exercise. Emphasize to patients that the use of relaxation does not indicate that the pain is thought to be psychological or that the patient must substitute relaxation for analgesics. Relaxation is a technique to be used in addition to analgesics to enhance pain control and reduce anxiety that contributes to pain.

Imagery.

Imagery is another cognitive approach to pain control that encourages physical and mental relaxation. Imagery uses a person's imagination to help control pain. Besides promoting relaxation, imagery may be used for distraction or may help the patient imagine pain relief.

Patients are asked to describe the quality of pain they are experiencing. On the basis of this description, imagery can be used to modify the patient's experience. For example, if the pain is described as “burning,” an image of something cool may help reduce pain intensity. As with relaxation, the use of imagery does not mean that medical personnel view the pain as imaginary. In both relaxation and imagery, a script or a prerecorded tape may be used to guide the patient through the experiences. Encourage the patient to practice relaxation or imagery, or both, to evaluate their potential effectiveness.

Consider the Alternative

Massage and relaxation with music or imagery are examples of complementary therapies that can be used with analgesics to obtain optimal pain relief.

Pharmacologic Interventions

Drug therapy continues to be the mainstay of pain management. Although the physician orders specific analgesics, it is the nurse's responsibility to assess the pain, to decide which analgesic and how much to administer, and to evaluate the drug's effectiveness.

When administering analgesics, keep in mind that it is critical to use a preventive approach to pain management. When pain is predictable, such as with postoperative pain and cancer pain, analgesics are more effective when given around the clock (ATC) rather than as needed (PRN). An ATC schedule maintains therapeutic blood levels of the analgesics. With a PRN schedule, the patient may have frequent periods of unrelieved pain and may also have more significant and frequent side effects such as sedation. Even when a physician orders analgesics PRN, the analgesics can be given on an ATC schedule. The ATC schedule is usually based on how long the drug lasts; thus when the order reads every 3 to 4 hours, the analgesic should be administered every 3 to 4 hours to maintain pain relief. Of course, you should assess the patient's pain before the analgesic is administered. The duration of analgesic effect varies among patients.

When pain is unpredictable, it may be appropriate to administer analgesics on a PRN basis. In these situations, instruct the patient to request medication as soon as the pain begins rather than waiting for the pain to become more severe. Patients often report that they wait to call for analgesics, thinking that the pain will decrease with time. Unfortunately, waiting often results in pain reaching an intensity level that is difficult to control.

The three categories of drugs that are used to relieve pain are (1) nonopioid analgesics, (2) opioid analgesics, and (3) adjuvant drugs. Figure 15-7 shows how these categories of drugs are used by themselves or in combination to relieve mild, moderate, and severe pain.

FIGURE 15-7 The World Health Organization three-step analgesic ladder.

Nonopioid Analgesics.

Nonopioid analgesics include aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. The nonopioids are generally the initial treatment choice for mild pain. These analgesics may also be combined with opioids to control moderate to severe pain.

Nonopioid analgesics act mostly on the peripheral nervous system and are used for pains such as arthritic pain, backache, headache, dysmenorrhea, postoperative pain, cancer pain, and bone pain. Nonopioids may have antipyretic (fever-reducing), analgesic (pain-reducing), and/or anti-inflammatory (inflammation-reducing) properties. This range of actions makes them especially useful for many conditions.

Most of the nonopioids are oral preparations, but a few are available for rectal administration. A parenteral NSAID, ketorolac (Toradol), also is available. It is generally used for the short-term management of postoperative pain. Approximately 30 mg of ketorolac given intramuscularly provides the same amount of pain relief as 12 mg of morphine or 100 mg of meperidine (Demerol) given intramuscularly. Ketorolac has a longer duration of action than many of the opioid analgesics and, like other NSAIDs, can cause nausea and possibly bleeding.

The nonopioids, unlike the opioids, have a ceiling effect on analgesia. This means that, beyond a certain dosage, improved analgesia will not occur. However, these drugs do have side effects, including stomach irritation, fluid retention, and an increased bleeding time. Therefore they are usually not recommended for patients with liver or kidney disorders, thrombocytopenia, or

neutropenia. (Thrombocytopenia is a deficiency of platelets in the blood. Neutropenia is a decreased percentage of neutrophils, the white blood cells that respond to inflammation.) Some nonopioids should be used cautiously in patients with congestive heart failure or hypertension because they cause fluid retention, which may aggravate these conditions. Because nonopioids have many side effects, you should assess the patient's history and present condition before administering prescribed analgesics. Some patients have better pain relief with certain types of nonopioids compared with others. It is important to ask which nonopioids work best to relieve their pain.

Table 15-4 identifies commonly used NSAIDs and some considerations to keep in mind when administering these drugs. Older adults may be more sensitive to NSAIDs and may experience more side effects. Carefully monitor each patient's reaction to the analgesic. Older adults especially should be monitored for signs of increased bleeding time, gastrointestinal irritation, and unusual drug reactions such as confusion, constipation, and headaches. Experts agree that some drugs should be avoided in older adults because of the high risk of side effects—for example, propoxyphene, meperidine, indomethacin, ketorolac, and promethazine.

Many nurses forget to administer nonopioids because they fail to recognize the importance of using these drugs for the types of mild to moderate pain mentioned previously. The nonopioids can be administered along with opioids and may be as effective as lower doses of opioids. For instance, 650 mg of aspirin or acetaminophen taken orally provides the same amount of analgesia as 32 mg of codeine or 50 mg of meperidine taken orally. Nonopioids tend to block pain transmission peripherally, whereas opioids block pain transmission in the central nervous system. It is advantageous to administer both for pain relief.

Table 15-4 Nonopioid Analgesics: Commonly Used NSAIDsDRUGS COMMENTS

ORAL NSAIDs Acetaminophen Lacks the peripheral anti-inflammatory activity of other NSAIDs

Aspirin* The standard against which other NSAIDs are compared. Inhibits platelet aggregation; may cause postoperative bleeding

Choline magnesium (Trilisate) May have minimal antiplatelet activity; also available as trisalicylate oral

liquidFenoprofen calcium (Nalfon)Ibuprofen (Motrin, others) Available in several brand-name formulations and as a generic product;

also available as oral suspensionKetoprofen (Orudis)Magnesium salicylate Many brands and generic forms availableNaproxen (Naprosyn)

Also available as oral liquidNaproxen sodium (Anaprox)Salsalate (Disalcid, others)

May have minimal antiplatelet activity

DRUGS COMMENTSSodium salicylate Available in generic form from several distributorsPARENTERAL NSAIDs Ketorolac IM administration not to exceed 5 days* Pharmacology Capsule

The adverse effects of nonopioid analgesics include stomach irritation, fluid retention, and increased bleeding time.

Opioid Analgesics.

Opioid analgesics are generally used for moderate to severe acute pain, chronic cancer pain, and some other types of pain. The opioids vary in potency and duration of action.

There are currently two types of opioid analgesics:

•Opioid agonists. Examples include codeine, methadone (Dolophine), hydromorphone (Dilaudid), meperidine (Demerol), morphine, and fentanyl.

•Opioid agonist-antagonists. Examples include buprenorphine (Buprenex), nalbuphine (Nubain), butorphanol (Stadol), and pentazocine (Talwin).

Both types of opioids relieve pain at the level of the central nervous system. Agonist drugs fit into receptor sites on the cell to “turn on” the site and produce the drug effect. Antagonists are drugs that block drug effects at the receptor sites. Opioid agonists bind to opioid receptors to produce analgesia, but they also bind to other receptors to produce unwanted side effects such as decreased respiration, drowsiness, and nausea. Opioid agonist-antagonists are drugs designed to produce analgesia and also to block certain side effects. The agonist-antagonists block some of the effects of the pure opioid agonists in much the same way that naloxone (Narcan) acts to block or reverse the effects of opioids. Drugs classified as agonist-antagonists (e.g., pentazocine, nalbuphine, buprenorphine) produce analgesia, but they can also block the effects of opioids such as morphine or meperidine if the patient has been receiving these drugs. Thus a patient receiving pure opioid agonists for pain relief should not be given opioid agonist-antagonists because they may block analgesia, precipitate withdrawal symptoms, and increase pain. For example, if a patient has been receiving morphine intramuscularly for several days, it would not be advisable to administer nalbuphine (Nubain) because it may block some of the analgesic effects of morphine.

Older adults are generally more sensitive to the analgesic effects of opioids because of delayed excretion and slower metabolism. Also, side effects may be more pronounced in older adults. Thus the recommended adult dose should be reduced 25% to 50% initially and then titrated (adjusted) for optimum pain control with minimal side effects. Some older adults are small and thin and weigh less than 100 pounds. In this case, charts with recommended opioid doses for adults and children weighing less than 50 kg or less than 110 pounds are available. Table 15-5 provides guidelines for dosing opioids.

It is important to refer to an equianalgesic (approximately equal analgesia) table when changing to a new opioid or a different route. Table 15-5 is such a table, showing approximately equianalgesic oral and parenteral doses. The information in the table helps estimate the new dose, which should then be modified based on the specific patient reaction and drug. An equianalgesic table shows that oral doses are two to six times larger than parenteral doses of the same drug to achieve the same effect. This is because oral opioids must pass through the liver after absorption, which reduces the amount of medication absorbed. Therefore larger doses of oral opioids must be ordered to provide the same amount of analgesia as parenteral opioids. For example, a patient receives 10 mg of morphine intramuscularly for pain relief and the order is changed to oral morphine. To receive an equianalgesic dose of morphine, the patient should be given 30 mg of morphine orally.

Table 15-5 Opioid Analgesics: Starting Oral Dose Commonly Used for Severe PainEQUIANALGESIC DOSE (MG)

NAME ORAL PARENTERAL* STARTING ORAL DOSE ADULTS (mg)

Morphine 30 10 15-30Hydromorphone (Dilaudid) 7.5 1.5 4-8Fentanyl — 0.1 —Methadone (Dolophine) 10 5 5-10From American Pain Society. (2003). Principles of analgesic use in the treatment of acute pain and cancer pain. (5th ed., p. 14). Glenview, IL, The Society.*

These are standard intramuscular doses for acute pain in adults. Equianalgesic doses should be based on the opioid characteristics, and patient characteristics such as age, weight, liver and renal function, and reaction to the drug.

Meperidine or Demerol continues to be used for moderate to severe pain. Clinical practice guidelines state that meperidine may cause central nervous system toxicity. You should be aware that one of the products of meperidine metabolism is normeperidine, which is a central nervous system stimulant. When this metabolite accumulates in the body, the patient may exhibit anxiety, twitching, tremors, muscle jerking, and generalized seizures. This opioid is contraindicated for long-term administration, specifically over 48 hours, and for diminished renal function. Because many older adults have decreased renal function, meperidine should be avoided.

Pharmacology Capsule

Older adults are more sensitive to opioid analgesics and should be monitored frequently for side effects.

Misconceptions About Opioid Analgesics.

When discussing opioid analgesics, it is critical to review a few terms that are often misunderstood, resulting in undertreatment of pain. Patients, families, nurses, and physicians

have misconceptions about addiction; therefore the term must be defined and differentiated from the terms tolerance and physical dependence. Box 15-5 contains information about these terms. When patients take opioids over a period of time for pain, tolerance and physical dependency may occur. The patient who is tolerant requires higher doses of a drug to achieve an analgesic effect. The patient who is physically dependent on an opioid will experience unpleasant withdrawal symptoms when the opioid is stopped. Both tolerance and physical dependence are normal responses to continued opioid administration for pain relief; they do not lead to a craving for the drug for its mind-altering effects. Fear of addiction is greatly exaggerated, and addiction rarely occurs (1%) in patients taking opioids for pain relief. Remind patients that pain relief is an important goal and they should not worry about addiction. Most patients simply stop taking opioids when the pain stops.

Routes of Administration.

The opioids can be administered through various routes, depending on the needs of the patient. If tolerated, the oral route is preferred, especially for patients with chronic pain. Oral opioids can control severe pain when given in adequate dosages.

The intramuscular route may be used to administer opioids for breakthrough pain, that is, pain that occurs between regularly scheduled doses of pain medication. Breakthrough pain would require immediate-acting or short-acting analgesic medication such as morphine. Consider the drug being administered when selecting appropriate needle-gauge size and administration site for intramuscular medication. For example, to administer 10 mg of morphine intramuscularly, use at least a 1.5- to 2.5-inch needle to reach the muscle, depending on the patient's size. Some drugs such as Demerol are more irritating to muscle tissue and should be administered deep into the muscle with the Z-track method. You can use the ventrogluteal, dorsogluteal, and vastus lateralis muscles. The intramuscular route is impractical for repeated injections. Absorption is often unpredictable with intramuscular injections, particularly in older adults, who have reduced muscle mass. This route is also painful. An accessible and appropriate site for the intramuscular injection of analgesics is the ventral gluteal muscle, especially in older adults.

Box 15-5 Characteristics of Tolerance, Physical Dependence, and AddictionTolerance

Physiologic changes that occur from repeated doses of opioids.

Result: Higher doses are needed to achieve pain relief.

Physical Dependence

Physiologic changes that occur from repeated doses of opioids.

Result: Withdrawal symptoms (e.g., irritability, chills, sweating, nausea) may occur if the opioid is stopped abruptly.

Addiction

Psychological dependence characterized by continued craving for opioid for other than pain relief.

Result: Compulsive and continued use for psychic effects despite harm.

MNSC9 Risk of addiction is not a concern in treating acute or cancer pain.

A limited number of opioids, such as morphine, hydromorphone, and oxymorphone, may be administered rectally. This route is useful when the patient is nauseated or has difficulty swallowing.

Opioids may also be administered sublingually (under the tongue). Intermittent bolus injections, continuous infusions, or patient-controlled analgesia (PCA) are methods of administering medications subcutaneously. These methods may be used in patients in whom the oral and rectal routes cannot be used and who also have poor intravenous access.

The intravenous route is another method of administering opioids. Intravenous PCA is commonly used postoperatively. With PCA, the patient is able to self-administer doses of analgesics to control pain. Opioids, when administered intravenously, have a rapid onset but shorter duration of action than when given by any other route. Although the registered nurse is usually responsible for the PCA, the practical nurse may be responsible for monitoring the patient's response and the effectiveness of the medication. Side effects should be reported to the registered nurse.

Opioids can be administered also via the spinal route epidurally (in the epidural space) or intrathecally (in the subarachnoid space). The epidural or intrathecal route may be selected in patients with postoperative pain and chronic cancer pain. The practical nurse may participate in monitoring the patient. Side effects such as itching, hypotension, nausea, urinary retention, sedation, and respiratory depression may occur more frequently in patients receiving opioids epidurally or intrathecally than by other routes of administration. The older adult who has received a spinal opioid infusion is at increased risk for respiratory depression. If anesthetics such as bupivacaine are used with spinal opioids, the nurse must be alert for the side effects of sensory loss and motor weakness. Side effects, as well as any adverse effects, should be reported promptly. A sedation assessment scale should be used with patients receiving spinal opioid infusions. Sedation is usually seen before signs of respiratory depression.

Patient Teaching PlanPatient-Controlled Analgesia (PCA)

• Safety features: The pump has a delay feature and a lock-out interval that prevents the patient from receiving more than the prescribed amount of medication. Only the patient should push the PCA button.

• Patient instruction: Press the PCA button when pain begins to return; then put it down and wait 10-15 minutes to evaluate pain relief. If pain returns, push the PCA button again and repeat the process until the pain is relieved.

• If pain is not relieved: Notify the RN, who can recommend changes in the opioid, bolus amount, or lockout interval to the physician to achieve satisfactory pain relief.

Other routes of administration of opioids also are available. Liquid morphine may be administered sublingually. Duragesic or fentanyl transdermal patches are used to treat cancer and chronic pain by producing constant delivery of the opioids for 72 hours through the skin surface. Intranasal butorphanol is available and may be used preoperatively for sedation and postoperatively for analgesia. Package inserts should be reviewed for doses, precautions, and administration guidelines.

Side Effects.

Regardless of the route of administration, opioid analgesics have specific side effects. A common side effect is constipation. Tolerance for this side effect does not develop. Assess the patient for abdominal distention, cramping, and abdominal pain. Stool softeners and laxatives, along with increased fluid intake, exercise, and bulk-containing foods, may prevent this side effect.

Opioids may also cause nausea, with or without vomiting. Some patients develop a tolerance for nausea but may require antiemetic therapy until tolerance develops. At times, the order may need to be changed to a different opioid to relieve this problem.

Sedation is another side effect that may occur initially with opioids, but it usually subsides in a few days. In patients who have had unrelieved pain for some time and have been sleep deprived, the control of pain may allow the patient to rest, which may be misinterpreted as sedation. When sedation is noted, however, the dose of the opioid may need to be titrated to a level that does not cause sedation but does provide pain relief. Box 15-6 illustrates a sedation scale. Be aware that drugs such as promethazine (Phenergan), which are sometimes ordered to be given with opioids, may also contribute to sedation. Promethazine does not potentiate or increase the analgesic effects of opioids but does potentiate sedation, respiratory depression, and hypotension. If sedated, the patient may benefit from having separate orders for the opioid and for the promethazine. Work with the physician and ordered drug(s) to reduce sedation to a rating of 1-2 on the scale and achieve the most effective pain relief.

Respiratory depression can occur but does not occur as frequently as commonly thought. If a patient is easily arousable, it is highly unlikely that respiratory depression has occurred. If severe respiratory depression occurs (fewer than 6-8 respirations a minute) and stimulation does not awaken the patient, this is an emergency. Stay with the patient and call for help. The RN may administer naloxone (Narcan) intravenously if prescribed to reverse the opioid.

Other side effects may be noted with the use of opioid analgesics. These include confusion, hypotension (especially orthostatic), dizziness, itching, and urinary retention. Nonopioid analgesics given with opioids may allow a decrease in the opioid dose to one that maintains pain control with fewer opioid side effects.

Placebos.

Placebos are inactive substances (e.g., saline) used in research or clinical practice to determine the effects of a legitimate drug or treatment. Placebos are appropriately used in studies in which patients consent to participate in the study. Many professional health care organizations take the position that placebos should not be used to assess or manage pain. Nurses have an ethical obligation to ensure that patients are not deceived and that institutional policies related to placebos are followed.

Put on Your Thinking Cap!

Ask five people (patients, friends, strangers) what helps when they have pain. Compile a list with your classmates, and sort the treatment measures into pharmacologic and nonpharmacologic. Include home remedies and herbal remedies.

Pharmacology CapsuleOral analgesics are preferred for the treatment of chronic pain.Consider the AlternativePatients who have migraines may be taking feverfew, an herbal supplement, for headache prevention. There is no evidence of effectiveness in treating other conditions. Advise patients that feverfew can increase the risk of bleeding in patients taking aspirin, warfarin, or heparin.Box 15-6 Sedation ScaleS Sleeping but easy to arouse when called or stimulated1 Awake and alert2 Slightly drowsy but easily aroused3 Frequently drowsy, arousable but drifts off to sleep during conversation—alert the RN4 Somnolent, minimal or no response to physical stimulation—emergencyAdjuvant Analgesics and Medications.

Drugs that are not usually classified as analgesics may relieve pain in certain situations. For instance, a patient who has undergone back surgery may complain more about muscle spasms than incisional pain. A muscle relaxant may be more effective in relieving pain than an opioid alone. Specific pain syndromes, especially neuropathic pain syndromes, may be controlled with drugs other than the commonly known analgesics. Table 15-6 lists adjuvant drugs and the conditions they effectively treat.

Pharmacology Capsule

The adverse effects of opioid analgesics include constipation, nausea, sedation, respiratory depression, confusion, hypotension, dizziness, itching, and urinary retention.

Table 15-6 Adjuvant Analgesics and Medications

DRUG CLASSIFICATONTYPE OF PAIN OR PROBLEM

ASSOCIATED WITH PAINANTIDEPRESSANTS Neuropathic pain; dull, aching painAmitriptyline (Elavil) Pain associated with herpes zoster (shingles)Doxepin (Sinequan) Sleep disturbancesMUSCLE RELAXANTS Muscle spasms and anxiety

DRUG CLASSIFICATONTYPE OF PAIN OR PROBLEM

ASSOCIATED WITH PAINMethocarbamol (Robaxin)Cyclobenzaprine (Flexeril)BENZODIAZEPINES

Muscle spasms and anxietyAlprazolam (Xanax)Lorazepam (Ativan)ANTIHISTAMINES

Nausea, anxietyHydroxyzine (Vistaril, Atarax)CORTICOSTEROIDS

Spinal cord or nerve compression; bone painPrednisone (Deltasone)Dexamethasone (Decadron)ANTICONVULSANTS/ANTIEPILEPTICS Neuropathic pain, stabbing painCarbamazepine (Tegretol) Trigeminal neuralgiaPhenytoin (Dilantin) Pain associated with herpes zoster (shingles)Gabapentin (Neurontin) Other nerve painLOCAL ANESTHETICS/ANTIDYSRHYTHMICS Postherpetic neuralgia, diabetic neuropathy,

other chronic pain conditionsLidocaineMexiletineMISCELLANEOUS Pain from spinal cord injury, phantom limb

pain, peripheral nerve injuriesClonidinePSYCHOSTIMULANTS

Analgesic effect, cancer painDextroamphetamines (Dexedrine)Methylphenidate (Ritalin)

Problem Solving with Pain Medication.Nurses are often faced with patients whose prescribed analgesic drugs do not relieve pain. In these situations, use all of the information presented here. Ask questions about the analgesic drug and the “five rights” (right dose, right patient, right time, right route, right analgesic) to determine why the patient is not getting adequate pain relief. Box 15-7 provides a nursing plan of care checklist. Box 15-8 describes a method for problem solving when analgesic drugs do not provide effective pain relief.Box 15-7 Southwest Texas Methodist Hospital Nursing Plan of Care: PainNURSING DIAGNOSIS/PATIENT PROBLEM STANDARDS OF PRACTICE/GUIDELINES FOR CAREPain (Acute/Chronic) related to: __________ Accept patient's level/tolerance of pain

Date/Initials __________Assess pain characteristics to include location, intensity, duration, type, precipitating factors

__________ Disease processes/illness __________Provide the patient with prescribed medication as ordered

__________ Surgery __________Provide and teach alternative methods of pain relief based on individual needs and/or physician orders:

__________ Injury/trauma __________ Positioning__________ Diagnostic procedures __________ Back rub__________ ________________________________________ __________ Massage__________ ________________________________________ __________ Application of heatAs evidenced by:

__________ Diversion/distraction

__________ Application of cold__________ Verbalization of pain/discomfort __________ Relaxation/imagery__________ Verbalization of spasms (specify bladder, back, __________ Exercise/ambulation

NURSING DIAGNOSIS/PATIENT PROBLEM STANDARDS OF PRACTICE/GUIDELINES FOR CAREmuscle) ________________________________________

__________ Facial grimacing __________ Range of motion__________ Tense body posture __________ Other:

__________ Rubbing/guarding of body parts __________Consults: ________________________________________

__________ Inability to concentrate __________Teach patient and/or significant other pain management strategies:

__________ Increased vital signs __________ Use of PCA__________ Restlessness/difficulty sleeping __________ Medications__________ Crying, moaning __________ Explain procedures to decrease/relieve anxiety__________ Withdrawal __________ Validate patient's understanding/coping

__________ Change in appetite __________Evaluate effectiveness of interventions and reintervene as necessary

__________ Decreased activity__________ __________________________________________________ ________________________________________Standard of Care/Expected Outcome Patient will verbalize/demonstrate minimal discomfort or absence of pain AEB:

__________Statements of pain relief and effectiveness of pain medications and/or other interventions

__________ Decreased need for pain medication__________ Relaxed facial expression and body part

__________Increase in voluntary movement, ambulation, and ADL

__________ Increased ability to concentrate__________ Stable vital signs

__________Statements or demonstrations of coping behaviors and/or factors that reduce or eliminate discomfort or pain

__________ Able to sleep/rest__________ Increased appetite__________ ________________________________________

The administration of analgesics is simply one intervention in the nursing care of a patient in pain. Nurses should provide many interventions along with analgesics to relieve pain. The Management and Supervision box on p. 221 also includes the expected patient outcomes and guidelines for nursing care.

Box 15-8 Problem Solving with Pain Medication

When the analgesic medication prescribed for pain is not effective in relieving pain, the nurse should take the following steps to solve the problem:

1.Check the analgesic order. o a.Right dose: Is the dose prescribed a recommended starting dose for analgesia,

or is the dose prescribed less? If a dose range of medication is prescribed, has the maximum dose been administered? If the order states morphine 10-20 mg IM PRN for pain, and 10 mg morphine is ineffective for pain relief, has 20 mg been administered? Solution: Adjust the dose up as ordered until pain is relieved without serious side effects or minimal side effects.

o b.Right patient: Is the patient experiencing side effects of the analgesic at the present dose? Can the patient tolerate the increase in dose with few side effects?

o c.Right time: What is the onset, peak, and duration of the analgesic? Is the analgesic administered around-the-clock based on the duration or properties of the drug? Solution: Evaluate pain intensity periodically to see if correct timing of drug is more effective in relieving pain.

If the patient's pain is still not relieved, the following steps should be taken:

2. Consider an alternative prescription. o a.Right patient: What is the diagnosis or source of pain, and what analgesic is

most effective for this type of pain? What are patient characteristics to consider (e.g., age, liver or renal problems, NPO status)?

o b.Right route: Which route is most appropriate for the patient's condition, severity of pain, and medication prescribed (e.g., IV, IM, PO, or topical administration)?

o c.Right analgesic: Which analgesic or adjuvant drug is best for this type of pain? Which analgesic has proven effective for the patient in the past or in a similar condition? Can the opioid or nonopioid prescribed be switched to another drug in the class that may provide more effective pain relief? Have both opioids and nonopioids been prescribed to increase pain relief?

o d.Right dose: Has the dose of opioid been titrated up or adjusted to a higher dose to reduce the pain? Has the patient been receiving opioids over time and requires increased doses of opioids to control pain because of the development of tolerance? If switching opioid drugs, is the correct equianalgesic dose calculated to make sure you have the approximate same level of analgesia?

o e.Right time: What is the time interval at which the analgesic should be administered or evaluated given its duration of action and patient?

3. Collaborate with patient, other nurses, pharmacist, and family. o a.Collect information.o b.Establish credibility with facts about the patient, analgesics, and written

references (articles or drug guides).o c.Anticipate questions.o d.Be assertive and keep trying.o e.Always use other nursing interventions in addition to the analgesic to relieve

pain.

Management and SupervisionDelegation of Pain Assessment

Pain assessment is one of the most important responsibilities for which the nurse is accountable. According to the American Pain Society, half of all hospitalized patients experience moderate to severe pain during the last days of their lives. Of the 70% of cancer patients with significant pain, fewer than half receive adequate relief. Pain may also be caused by postoperative wounds, sickle cell disease, arthritis, and many other conditions.

Pain assessment cannot be delegated to an unlicensed person. However, it is essential that unlicensed personnel understand the importance of informing the nurse of any reports of pain

from the patient. Although a licensed practitioner with prescribing authority is ultimately responsible for adjusting dosages, both the LPN and the RN must be able to assess the patient's pain to implement range dose orders. Working within their scope of practice and adhering to applicable organizational policy, nurses must draw on their knowledge, skills, abilities, and experience to execute the pain management plan. They must be aware of the following:

•The medication to be administered •Dosage and route of administration •Potential interactions with other medications •Time to onset and peak effect •Duration of action •Potential side effects

If the patient experiences an unacceptable level of pain or has troublesome side effects, the nurse should document the finding and report it to the prescriber so that appropriate pharmacologic or nonpharmacologic interventions can be implemented. Ideally, the patient will take part in achieving safe, effective pain management. Good communication among all members of the health care team is essential to ensure the patient's optimal comfort and well-being.

Key Points

• Pain is the most common problem that nurses encounter. • “Pain is an unpleasant sensory and emotional experience associated with actual or

potential tissue damage” (International Association for the Study of Pain). • When pain receptors are stimulated, impulses are transmitted to the spinal cord and then

to the brain, where the cortex interprets the signals as pain. • Endorphins are natural opioid-like substances that block the transmission of painful

impulses to the brain. • According to the gate-control theory, stimulation of large-diameter fibers in the spinal

cord interferes with the transmission of painful impulses to the brain. • Physical factors that influence the pain experience are pain threshold, pain tolerance,

age, physical activity, nervous system integrity, and, in surgical patients, the type of surgery and anesthesia.

• Psychological factors that influence the pain experience include culture, religion, past experiences with pain, anxiety, and situational factors.

• Based on the duration and cause, pain is classified as acute, chronic, chronic benign (nonmalignant), and chronic malignant pain (cancer-related pain).

• Most chronic pain is neuropathic because of nerve damage. • Assessment is the first step in pain management. • Pain can be described in terms of location, quality, intensity, and aggravating and

alleviating factors. • It is essential to document assessment findings and the effects of pain interventions. • Nursing diagnoses for the patient in pain may include Acute Pain, Chronic Pain,

Activity Intolerance, Anxiety, Fatigue, Self-Care Deficit, and Disturbed Sleep Pattern. • Examples of nonpharmacologic interventions are comfort measures, control of

environmental factors, stimulation techniques, and measures to reduce anxiety.

• Predictable pain is best controlled by around-the-clock (ATC) analgesics rather than as-needed (PRN) medication.

• The categories of drugs used to relieve pain are nonopioid analgesics, opioid analgesics, and adjuvant drugs.

• Fear of addiction to opioids is greatly exaggerated. Addiction rarely occurs when opioids are taken for pain relief.

• Placebos are inactive substances such as saline that are used as a control to determine the effects of a legitimate drug or treatment.

• Most professional health care organizations take the position that placebos should not be used to assess or manage pain.

• Opioid side effects to monitor and treat include constipation, nausea, sedation, and respiratory depression.

REVIEW QUESTIONS Choose the best answer

1. Pain is best defined by the: o 1.Patiento 2.Nurseo 3.Physiciano 4.Physiologist

2. When you cut your finger, which of the following represents the steps involved in your experiencing pain?

o 1.Afferent pathways activate nociceptors, which transmit information to the spinal cord for interpretation.

o 2.Nociceptors are stimulated, and afferent pathways send impulses to the spinal cord and then to the brain.

o 3.Efferent pathways stimulate nociceptors, which transmit impulses to the brain.o 4.The brain stimulates nociceptors, which trigger efferent pathways to send

impulses to the spinal cord. 3. Mr. A. and Mr. B. both had back surgery yesterday. Mr. A. has used his PCA

regularly. He says that he is “pretty comfortable,” and he sleeps most of the time. Mr. B. has used the maximum analgesic permitted by his PCA and has required additional analgesic twice while continuing to complain of some discomfort. Of the following, which is the most likely explanation for the difference in the pain experience of these two patients?

o 1. Mr. B. is a complainer who is seeking attention. o 2. Mr. B. has higher pain tolerance than Mr. A. o 3. Mr. B. has a lower pain threshold than Mr. A. o 4. Mr. B. is more anxious, which has raised his pain threshold.

4. Autonomic nervous system responses to pain include the following: o 1.Decreased respiratory rateo 2.Flushingo 3.Urinary frequencyo 4.Constipation

5. A patient says she has pain whenever she bends over. Which aspect of the pain assessment is she describing?

o 1.Locationo 2.Alleviating factoro 3.Qualityo 4.Aggravating factor

6. A frail, older adult patient who is being cared for by her family at home says she finds a heating pad soothing to stiff joints. What patient/family teaching is needed for safe and effective heat therapy?

o 1. “It is more effective to use the heating pad continuously rather than intermittently.”

o 2. “Do not apply heat to any area that lacks normal sensation or circulation.” o 3. “Set the heating pad at the highest temperature that the patient can tolerate.” o 4. “Heat application is not a safe or effective strategy for pain management.”

7. Which statement correctly describes a nonpharmacologic approach to pain control? o 1.Imagery is the use of the patient's imagination to help control pain.o 2.Distraction is most effective in the management of chronic pain.o 3.Relaxation therapy requires that the nurse must be able to hypnotize the patient.o 4.Patient education is usually all that is needed to reduce anxiety.

8. Nonopioid analgesics must be used cautiously in patients with hypertension because they cause:

o 1.Peripheral vasoconstrictiono 2.Potassium losso 3.Sleep disturbanceso 4.Fluid retention

9. You should question an NSAID order for a patient who is also taking:

o 1. Antibiotics o 2. Decongestants o 3. Anticoagulants o 4. Hormone replacements

10. When patients take opioid analgesics, the nurse must assess for: o 1.Diarrheao 2.Deficient fluid volumeo 3.Respiratory depressiono 4.Urinary incontinence