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Acute and Chronic Pain: Assessment and Management: Presented by
Acute and Chronic Pain: Assessment and Management: Presented by
Presented by:
Acknowledgements ____________________________________________________________ 4 Purpose & Objectives __________________________________________________________ 5 Defining Pain__________________________________________________________________ 6 Categorizing Pain Types ________________________________________________________ 6 Nocioceptive Pain______________________________________________________________ 6 Neuropathic Pain ______________________________________________________________ 7 Acute Pain versus Chronic Pain __________________________________________________ 7 Summary of Pain Types_________________________________________________________ 7 Barriers to Effective Pain Assessments and Management ____________________________ 8 Patient Barriers________________________________________________________________ 8 Healthcare Professional Barriers _________________________________________________ 8 Health System Barriers _________________________________________________________ 8 Addressing Barriers to Pain Relief ________________________________________________ 9 Minimizing Barriers ____________________________________________________________ 9 Fears about Addiction __________________________________________________________ 9 Fears about Opioid Tolerance and Physical Dependence ____________________________ 10 Exaggerating Fears Related to Respiratory Depression _____________________________ 10 Principle of Double Effect ______________________________________________________ 10 Misconception that the Doctor or Nurse Knows Best _______________________________ 11 Impact of the Nursing Shortage on Pain Management_______________________________ 11 JCAHO Standards ____________________________________________________________ 11 Pain Assessment _____________________________________________________________ 12 Provocation or Palliative Symptoms _____________________________________________ 12 Quality ______________________________________________________________________ 12 Radiation ____________________________________________________________________ 13 Severity _____________________________________________________________________ 13 Timing ______________________________________________________________________ 13 Physical Examination: Inspection _______________________________________________ 13 Physical Examination: Auscultation _____________________________________________ 14 Physical Examination: Palpation and percussion __________________________________ 14 Summary of Assessment Findings ______________________________________________ 14 Communicating Assessment Findings ___________________________________________ 14 Case Discussion______________________________________________________________ 16 Pain Management _____________________________________________________________ 18 Understanding Opioids ________________________________________________________ 18 2
Non-Opioid Analgesia: Acetaminophen and NSAIDs ________________________________ 24 COX-2 Inhibitors ______________________________________________________________ 26 Adjuvant Analgesia ___________________________________________________________ 26 Non-pharmacological Therapies_________________________________________________ 27 The WHO Ladder to Manage Chronic Malignant Pain _______________________________ 28 Special Populations ___________________________________________________________ 29 Infants & Children_____________________________________________________________ 29 The Elderly __________________________________________________________________ 31 The Cognitively Impaired_______________________________________________________ 31 The Critically Ill _______________________________________________________________ 32 Culture Issues________________________________________________________________ 32 Patients with Prior History of Substance Abuse____________________________________ 32 Conclusion __________________________________________________________________ 33 Appendix A __________________________________________________________________ 34 Appendix B __________________________________________________________________ 35 References __________________________________________________________________ 37 Post Test Viewing Instructions __________________________________________________ 39
Acknowledgements
RN.com acknowledges the valuable contributions of ...Lori Constantine, MSN, RN-BC, author of this continuing nursing education course. Lori is a nurse with 12 years medical surgical experience. She has worked as a staff nurse, charge nurse and nurse preceptor on many different medical-surgical units including, vascular, neurology, neurosurgery, urology, gynecology, ENT, general medicine, geriatrics, oncology and blood and marrow transplantation. She received her Bachelors in Nursing in 1994 and a Masters degree in Nursing in 1998, both from West Virginia University. In 1998, Lori was certified as a Family Nurse Practitioner, and in 2005 became board certified in medical surgical nursing through the American Nurses Credentialing Center. She has held positions at West Virginia University School of Nursing, and is currently an adjunct faculty member for Waynesburg School of Nursing in Pennsylvania and a staff nurse on a surgical-trauma unit at West Virginia University Hospitals.
Robin Varela, RN, BSN, for updating and editing the revised version of this continuing nursing education course. Robin has over 20 years experience in critical care and emergency department nursing. During her years as a staff nurse and nurse preceptor she has been certified as CCRN, TNCC, BLS, ACLS, ACLS Instructor, PALS and MICN. As an emergency department Clinical Nurse Manager, Varela took an active role in numerous multi-disciplinary committees and partnered with local EMS to co-ordinate emergency preparedness within the community. She has worked for American Mobile Healthcare as a Clinical Services Clinical Liaison RN and works per diem as a critical care transport nurse. Varela completed her BSN in 2003 and plans to begin graduate school the summer of 2007.
After successful completion of this course, the participant will be able to: 1. 2. 3. 4. 5. 6. Define pain and describe various pain types. Describe patient, provider, and health system barriers associated with poor pain control. Identify patient and provider misconceptions regarding pain management. Describe how pain is assessed based upon the patients self-report. Identify pharmacological and non-pharmacological strategies associated with achieving pain control particularly in the acute post-surgical patient and chronic pain suffers. Identify special groups that are at risk for under-treatment of pain.
Disclaimer
RN.com strives to keep its content fair and unbiased. The author(s), planning committee, and reviewers have no conflicts of interest in relation to this course. There is no commercial support being used for this course. There is no "off label" usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients.
Defining Pain
Pain is a universal affliction that can affect all of us at some point in our lives. Practically all hospitalized patients experience pain at some point in their stay. The presence of pain negatively affects the patient and family and has significant clinical effect on recovery, morality and quality of life (Jacox et al., 1992). Despite the fact that satisfactory pain relief can occur in approximately 90% of pain suffers, it is still not regularly occurring (Stjernsward & Teoch, 1992). The International Association for the study of pain (IASP) and the American Pain Society adopted the following definition of pain: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms such as damage (APS, 1992; Mersky & Bogduk 1994). When it comes down to assessing for pain, healthcare professionals cannot always determine the source of the patients pain or identify any source or damage that could be responsible for a report of pain. Yet, the person is experiencing pain. This does not infer that the pain is not real. McCaffery addresses this perceived incongruence by explaining that, Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does (1979). In other words, pain is personal. Only the individual experiencing the pain can fully describe it. Pain may also be induced by the psychic perception of real, threatened, or fantasized injury (Engel, 1970). Therefore, the patients meaning of pain may play a significant role in how that person experiences it.
is
Nocioceptive Pain
Nocioceptive pain results from real or impending tissue damage, either to the viscera or the soma. Nocioceptive, somatic pain usually occurs due to real or impending damage to bone, muscle, skin, or connective tissue. Somatic pain is most commonly described as localized, aching, or throbbing. Nocioceptive visceral pain usually occurs due to real or impending damage to the thoracic, abdominal, or pelvic organs such as the heart, liver, or bowel. Visceral pain is often described as deep, cramping, referred, aching, or gnawing (Griffie, McKinnon, & Heidrich, 2002).
Neuropathic Pain
Neurophathic pain occurs from damage to peripheral or central nervous tissue or from distorted processing of pain. Examples of neuropathic pain include: peripheral neuropathies, neuralgias, phantom limb pain, and spinal cord injuries. It is often described as burning, piercing, lacerating, and pricking (Griffie, McKinnon, Berry, & Hedrich, 2002). Nocioceptive Pain Somatic Localized, aching, throbbing Visceral Deep, cramping, aching, referred, gnawing Neuropathic Pain Central Burning, piercing, lacerating, pricking Peripheral Burning, piercing, lacerating, pricking
Referred Pain
Referred pain is often nocioceptive in origin and involves visceral organs. It is not well organized. For example, the pain of the gall bladder disease is often referred to the right shoulder and cardiac pain may be felt in the neck, back, jaw or arms. Diaphragmatic and pulmonary pain may also be felt in the neck. Kidney pain is often felt in the associated flank as well as the lateral thigh. Pancreatic pain may be experienced in the back. The exact mechanism of referred pain is not fully understood. It is known, however, that the site of referred pain is linked to the involved nerve root. Critical Thinking Tip: Acute pain diminishes as healing occurs. Chronic pain may be exacerbated by acute pain. Referred pain is not well localized and usually visceral in origin.
Types of Pain Include: Somatic Visceral Referred Acute Neuropathic Chronic Break-through
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JCAHO Standards
The Joint Commission (JCAHO) standards clearly outline how healthcare institutions should manage pain. These standards focus on making pain management more of a priority, the critical 5th vital sign. Click on this link to review JCAHO pain standards: www.JointCommission.org
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Pain Assessment
P Q R S T
Provocative or Palliative: What makes the pain better or worse? Quality: Describe the pain. Is it burning, shooting, aching, stabbing, crushing, etc.? Radiation: Does the pain radiate to another body part? Severity: On a scale of 0 -10, (10 being the worst) how bas is your pain? (may use other scales also). Timing: Does it occur in association with something else? (e.g. eating, exertion, movement)
Quality
Pain descriptors such as; aching, throbbing, burning, piercing, shooting, tearing, or crushing can also give clues to the origins of pain. Remember, somatic pain is most commonly described as localized, aching, and throbbing. Visceral pain is often described as deep, cramping, referred, aching, or gnawing. Neuropathic pain is often described as burning, piercing, lacerating, and pricking. Qualifying the patients pain allows you and your team to determine the appropriate analgesic or adjuvant treatment.
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Radiation
Ask the patient where the pain on their body is. They can point, describe, or use an outline of a person to shade in areas that are painful. Pain is localized if the patient can point to exactly where it is hurting. If the patient can pinpoint where the pain is, it is often somatic in origin (bone, muscle, or connective tissue). Referred pain or pain that radiates is not well localized and can complicate understanding a persons pain if a thorough history is not explored. Some common pathologic processes that cause pain to radiate or be referred include acute coronary syndrome, gall bladder disease, appendicitis, and pancreatitis. Depression and anxiety also play key roles in pain processing and may exacerbate pain. When a patient describes their pain as being all over their body, chronic pain syndromes and psychological components of the pain should be explored.
Severity
Most patients are able to use a numerical pain rating scale to quantify their pain. When using a numerical scale, ask the patient to rate their pain on a scale from 0 to 10. Zero means no pain. Ten means the worst pain imaginable or that they have ever experienced.
Timing
When assessing the timing of pain, ask the patient how long the pain has lasted and how often it occurs. Chronic pain usually lasts for longer than six months. Acute pain is commonly related to a new disease process, bodily injury, post-surgery or post-procedure, or may be an exacerbation of chronic pain. Pain that is always present may be termed baseline pain. Baseline pain may be aggravated by acute increases in intensity throughout the day. This is known as breakthrough pain. Often patients with chronic disease and post-operative patients experience both baseline and breakthrough pain.
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Case Discussion
Describe the focus of your pain assessment with each patient and discuss how you would assess the pain. Diane: The focus of Dianes pain assessment should center on looking for complications from her blunt chest and abdominal trauma. Using the pneumonic, PQRST, you discover Dianes pain worsens with coughing or palpation of her upper abdomen. Her pain is a dull ache that is diffuse across her abdomen and chest. It does not radiate. It is a 7 on a numeric scale of 0-10. It has been present for the past few hours and is not worsening. She is alert and oriented x 3. Lungs are clear to auscultation bilaterally. Heart rate is regular S1 and S2 are heard. Abdomen is soft and slightly tender with hypoactive bowel sounds. Extremities are warm and pink. BP = 106/74, HR = 88, Respirations = 22 Temp = 37.5 C orally. Elizabeth: Elizabeths pain assessment is complicated due to her cognitive impairment. There is no family available to discuss her pain with you. Elizabeth can only nod her head yes when asked if she hurts. The responses to all other assessment questions are a blank stare. You notice that when Elizabeth coughs, she grimaces and pulls her right arm to midline. The focus of Elizabeths pain assessment should center on her non-verbal cues and physical exam findings. She continues to be febrile with a current temperature of 38.0 C orally. BP=148/90, HR = 92, Respirations = 24. Her lungs have crackles in the right lower and middle lobes and are diminished bilaterally. She has a frequent productive cough of yellow sputum. Heart rate is regular. S1 and S2 are normal. Abdomen is soft, non-tender with normal bowel sounds. Extremities are warm but, pale with a capillary refill of 5 seconds. Benjamin: Benjamins pain assessment should be appropriate for his age. The patient, if possible, is the best person to report the pain. In this case, Benjamins self report is especially important to elicit since his parents speak little English. His pain assessment should be focused on his abdominal region. When asked about provocative or palliative factors, Benjamin does not respond. He clings tightly to his mother. When asked about how his pain feels, he replies, like something poking me really hard. Benjamin points to the face that corresponds with the number 8 on the faces pain rating scale. There is no radiation of the pain. He is alert and oriented x 3. His breath sounds are clear to auscultation bilaterally. Heart rate is regular. S1 and S2 are normal. His abdomen is soft with hypoactive bowel sounds. BP= 90/64, HR = 90, Temperature = 38.2 C orally, Respirations = 24.
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How will a baseline pain assessment and physical exam will determine your care for each patient. Diane: A baseline pain assessment in Dianes case is imperative to monitor for signs and symptoms of complications of blunt chest and abdominal trauma. Complications that may manifest in pain or other symptoms related to blunt chest or abdominal trauma include pneumothorax, rib fractures, pericardial tamponade, aortic tear, and intra-abdominal bleeding. The pain characteristics assessed in combination with other physical exam findings, such as quality of breath and heart sounds and a detailed abdominal exam will help to identify the cause of your patients pain and the potential for the development of other complications. Elizabeth: Given Elizabeths pain assessment, you can most likely surmise that Elizabeth is having some degree of pain upon coughing, probably due to pneumonia. A thorough history and physical exam provides you with the clues needed to create a tentative judgment about the patients pain source and will aid the physician in correctly diagnosing this patient. Benjamin: Increased pain, radiation, or changes in his abdominal exam are especially important for Benjamin and should be reported to his physician immediately. His initial complaints of periumbilical pain are still present, but you notice that he is now guarding his right lateral abdomen. When asked to cough or jump (which would elicit peritoneal irritation), Benjamin continues to cling to his mother and whimpers slightly. Correlating new physical exam findings will help to confirm the diagnosis of appendicitis or point the healthcare provider in another direction.
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Pain Management
Pharmacological treatment is largely determined based upon the type of pain the patient is experiencing. Determining whether the pain is nocioceptive or neuropathic in origin will allow the healthcare professional to accurately prescribe the right drug and administer it via the right route. In addition, the healthcare professional should assess whether the pain is somatic, visceral, acute, chronic, or any combination thereof. As mentioned previously, a large amount of pain experienced by hospitalized patients is either post-surgical or procedural. Also important to note is that hospitalized patients might already have a history of chronic pain; pain that they had before a procedure or surgery. Therefore, it is useful to discuss pain management in this context.
Understanding Opioids
Opioids are commonly administered through enteral and parenteral routes. Some may even be administered transdermally, subcutaneously, intrathecally, and epidurally. Around the clock oral dosing is the preferred mechanism for managing chronic pain. Alternatively, parenteral administration is usually a good choice for acute, surgical pain and breakthrough pain. Opioids can be divided into two main groups, mu-agonists and agonist-antagonists, based upon their mechanism of action. Mu-Opioid Agonist Mu-agonist opioids (also referred to as narcotics) are the most commonly used and include morphine, codeine, hydromorphone (Dilaudid), fentanyl, methadone, oxycodone, levorphanol, and meperidine (Demerol) (McCaffery & Pasero, 1999). These drugs are used most effectively in malignant, breakthrough, and acute pain, including surgical pain. Adverse effects of these opioids include constipation, nausea, vomiting, sedation, respiratory depression, and pruritus. These effects are usually visible in the opioid-naive patient and diminish as tolerance develops. Tolerance to constipation does not diminish; therefore an appropriate stool softener or bowel regimen should be prescribed concurrently with any opioids. The following table gives common dosages of common mu-opioid agonists. Drug Normal PO Dose Morphine 10-30 mg q 4 hours Fentanyl 5/mcg/kg 0.5-2.0 mg Hydromorphine 1-6 mg q 4-6 hours 2-4 mg q 4-6 hours Rectal Meperidine 50-150 mg q 3-4 hours 50-100 mg q 3-4 hours IM SC
1.0-2.0 mg/kg; Normal IV Dose Up to 0.1 mg/kg Other forms or routes Ext. release SC IM Rectal (Skidmore-Roth, 2002)
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Agonist-Antagonist Opioids Agonist-antagonist opioids are most appropriately used for acute, non-malignant pain and may be particularly helpful in nocioceptive (visceral or somatic) pain. Some examples of agonistantagonists are butorphanol (Stadol), Nalbuphine (Nubain), and Pentazocine (Talwin) (McCaffery & Pasero, 1999). Their side effects are limited. They also produce less analgesia and have a lower dependency potential than opioids. This group is not useful in the management of chronic pain. Agonist-antagonists displace opioids from their mu-receptor sites and often produce withdrawal reactions and further prevent adequate pain control in chronic pain sufferers (McKenry & Salermo, 2003). Therefore, they are contraindicated in patients taking long-term opioids or are physically dependant on opioids because they will displace the opioid at its binding site possibly leading to physical withdrawal symptoms (Skidmore-Roth, 2002).
Pentazocine 50-100 mg q 3-4 Not to exceed 600 mg/day IV 30 mg q 3 hours Not to exceed 600 mg/day IM & SC = 30 mg q 3 hours Not to exceed 360 Mg/day
Normal IV Dose
10-20 mg q 3-6 hours Not to exceed 160 mg/day IM & SQ = 0-20 Mg q 3-6 hours Not to exceed 160 mg/day
0.5-2.0 mg IV Every 3-4 hours IM = 1-4 mg q 3-4 hours Intranasal = 1 spray In 1 nostril q 3-4 hours Respiratory Depression Geriatrics give dose
Other
Respiratory Depression
Respiratory Depression
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Opioid Antagonists Opioid antagonists reverse the effects of opioid mu-agonists such as morphine, fentanyl, and meperidine. Naloxone (Narcan) is the primary opioid antagonist. Its main purpose is to rapidly reverse opioid induced-respiratory depression. The standard dose for naloxone is .4 mg diluted in 9 mls of IV fluid. It can be given as .4 mg every 2 minutes up to 4.0 mg. It onset is 1-2 minutes with a peak effect of 5-15 minutes. FYI Care must be taken in administering the right opioid for the right patient. For instance, meperidine is not used for chronic pain due to its ceiling effect and potential for accumulation of metabolites, which may lead to seizures. Propoxyphene (Darvon) is appropriate for short-term, non-malignant pain due to renal toxicity with long-term use. Transdermal fentanyl is not a good choice for acute, surgical pain as its peak effect is delayed (McCaffery & Pasero, 1999). It is however an excellent choice for chronic pain in individuals that cannot tolerate oral dosing, but must be applied over dry, non-edematous skin.
Elimination half-life is 90 minutes and duration of action is approximately 45 minutes. If this drug is given to opioid-dependant patients, it may result in severe physical withdrawal (American Pain Society, 1999; Skidmore & Roth, 2002).
Fentanyl (Duragesic)
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Doses of drugs in this chart are listed as compatible doses. For example 30 mg of oral morphine = 7.5 mg of oral hydromorphone = 1.5 mg of IV hydromorphone (McCaffery and Pasero, 1999).
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Tape your equianalgesic table to your clipboard or other easily accessible place. Know where to find your equianalgesic dose chart. Use a calculator Dont be afraid. It is easier than you think!
Converting from the OLD drug to the NEW drug 1. Calculate the total dose of the old opioid in a 24-hour period. 2. Set up the following ratio: mg old opioid Current mg of (old) in 24 hr. = mg new opioid X
Where X = mg of new opiod you are trying to calculate in a 24 hours period. 3. Divide the 24-hour dose of the new opioid to obtain the desired interval dose (e.g., q4th, q12h, etc.) 4. When converting from PO to IV, you may want to consider reducing the dose by one third to one half to accommodate for the first pass effect of oral agents through the liver. Since IV agents enter the bloodstream directly, a smaller initial dose is indicated.
For Example Elizabeth who been taking 30 mg of oxycontin q 4 hours PO can no longer swallow. You want to start a continuous IV morphine infusion at an equianalgesic dose.
1. 30 mg oxycontin q4h = 30 mg x 6 doses in a 24-hours period = 180 mg oxycontin in a 24-hour period. 2. Your equianalgesic dose table says that 30 mg PO oxycontin = 30 mg of oral morphine = 10 mg of IV morphine
30 mg PO Oxycontin 180 mg PO oxycodone/24 hrs X= 60 mg IV morphine in 24 hrs = 10mg IV morphine X mg IV morphine/24 hrs
3. The hourly infusion rate = 60 mg in 24 hrs = approximately 2.5 mg IV morphine per hour. 4. Since we are converting from PO to IV we should reduce the dose by 1/3 to to accommodate for the first pass effect of oral agents through the liver. 2.5 mg/hour /2 = 1.25 mg per hour 2.5 mg/hour /3 = 0.8333 = 2.5 0.833 = 1.67mg/hour New dose of IV Morphine should be between 1.25-1.67 mg/hour based upon your patients specific needs.
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Another Example Diane, a status post MVA patient, has had satisfactory relief of pain with an IV hydromorphone infusion of 1 mg per hour. You want to send her home on an equianalgesic dose of sustained release oral morphine (MS Contin or OraMorph SR given q12h, or Kadian q day). 1. mg hydromorphone per hour = 24 mg IV hydromorphone in 24 hrs 2. Your equiananalgesic dose table says that 1.5 mg IV hydromorphone = 7.5 of oral hydromorphone = 30 mg of oral morphine. Make the dosage ratio:
1.5 mg IV hydromorphone 24 mg IV hydromorphone/24 hrs X = 480 mg PO morphine/24 hrs = 30 mg PO morphine X mg PO Morphine/24 hrs
3. q12h dose = 240 mg sustained-release morphine PO q12h 4. Since we are not converting from PO to IV reduction in the dose is not needed. Careful assessment of this patient is needed to ensure this dose is enough however, given liver and renal function. Now it is your turn Jerry is a 54-year-old male returning to the hospital 2 weeks after port placement for initial doses of chemotherapy. While receiving chemotherapy in the outpatient setting, he became significantly nauseated, with uncontrolled episodes of emesis. He is admitted to your facility for re-hydration, nausea and pain control. Calculate a satisfactory dose of IV morphine for Jerry to control his pain. At home, he had been taking 100 mg of MS Contin every 12 hours. Step 1: Calculate the total dose of the old opioid in a 24-hour period Step 2: Set up the following ratio
Mg old opioid Current mg of old in 24 hr = mg new opioid X
Where X = mg of new opioid you are trying to calculate in a 24 hour period. Step 3: Divide the 24-hour dose of the new opioid to obtain the desired interval dose (e.g., q4h, q12h, etc.)
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Answer:
1. Jerry has been taking 200mg of MS Contin in a 24-hour period. 2. 30 mg of PO morphine = 10 mg IV morphine Ratio:
10mg IV morphine X mg IV morphine/24 hrs = 30 mg PO morphine 200 mg PO morphine/24hrs
X = 66.6 mg IV morphine/24hrs
3. The q1hr dose of the IV morphine is 67 mg / 24 hours = 2.79 mg/hr 4. When converting from PO to IV, you may want to consider reducing the dose by 1/3 to to accommodate for the first pass effect of oral agents through the liver. Since IV agents enter the bloodstream directly, a smaller initial dose is indicated So, 2.8 mg / 2 = 1.4 mg/hour; 2.8 mg / 3 = .933; 2.8 .933 = 1.867 mg New IV dose should be between 1.4mg and 1.8 mg per hour IV.
The information above is for informational purposes only, and should be used solely as a reference. It should not be used as a substitute, or in lieu, of professional judgment. RN.com disclaims all warranties, express or implied, related to the contents of this tool. Always refer to specific facility medication guidelines/standards on medication administration.
NSAIDs have analgesic, antipyretic and anti-inflammatory effects. The adverse effects of NSAIDs include gastrointestinal dysfunction (nausea, vomiting, diarrhea, cramps, and gas), gastric ulcers, gastric bleeding, and interference with platelet aggregation. NSAIDS should be used with extreme caution in patients with a history of gastrointestinal bleeding or ulcers, those with low platelet counts, or those with renal insufficiency. Examples of commonly used NSAIDs include: aspirin, choline magnesium trisalicylate (Trilisate), ibuprofen (Motrin, Advil), ketoralac (Toradol), ketoprofen (Orudis), and naproxen (Naprosyn) (McKenry & Salermo, 2003; McCaffery & Pasero, 1999). 24
The following table represents commonly used non-opioid analgesics (AHCPR, 1992; Roth, 2002). Please note that all doses are approximate and the patients clinical condition must be taken into consideration prior to administration of these drugs. Commonly Used Non-Opioids Adult Dose Pediatric Dose Issues 650-975 mg q 4hr 10-15 mg/kg q 4 hr Acetaminophen does not have anti-inflammatory properties Contraindicated in liver failure or disease 650-975 mg q 4 hr 10-15 mg/dg q 4 Inhibits platelet hr aggregation 1000-1500 mg bid 25 mg/kg bid May have minimal antiplatelet activity Available as an oral liquid Available as several brand name and generic Available in oral suspension
400 mg q 4-6 hr
10 mg/kg q 6-8 hr
Ketoprofen(Orudis) Magnesium salicylate Naproxen (Naprosyn) Naproxen sodium (Anaprox) Ketorolac tromethamie (Toradol)
25-75 mg q 6-8 hr 650 mg q 4 hr 500 mg initial dose followed by 250 mg q 6-8 hr 550 mg initial does followed by 275 mg q 6-8 hr 30 or 60 mg IM/IV initial dose followed by 15 or 30 mg q 6 hr Oral dose following IM/IV dosage: 10 mg q 6-8 hr 5 mg/kg q 12hr Many brands and generic forms available Available as oral liquid
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COX-2 Inhibitors
COX-2 inhibitors were developed to reduce inflammation by selectively blocking the COX-2 enzyme. Blocking this enzyme halts the production of prostaglandins that cause the pain and swelling. The COX-2 inhibitors represent a new class of drugs that do not affect COX-1, but selectively block only COX-2. This selective action provides the benefits of reducing inflammation without irritating the stomach. The only COX-2 inhibitor that is now on the market is celecoxib (Celebrex). The analgesic efficacy of COX-2 selective inhibitors is comparable to non-selective NSAIDs such as naproxen, ibuprofen, and sulindac and seem to be of great value to people with arthritis. Vioxx, known generically as rofecoxib, was recalled in on October 1, 2004, in the largest prescription drug withdrawal in history. The withdrawal was prompted after a new study examining Vioxx's impact on bowel cancer found the drug caused an almost twofold increase in heart attacks and strokes. However, the controversy does not end there. The FDA asked Pfizer to withdraw Bextra (valdecoxib) from the market because the overall risk of heart disease and life-threatening skin reactions outweighed its therapeutic benefits. Celebrex is now the only Cox-2 drug on the market and it carries a very strong warning against cardiovascular and skin complications. One other Cox-2 inhibitor, lumiracoxib, has been made available outside of the U.S. and is being marketed under the name Prexige. As of 2007, the drug is still not approved for use in the U.S.
Adjuvant Analgesia
Adjuvants are drugs that are used to treat other disorders but also have analgesic properties. Adjuvants are most effective against neuropathic pain. They are generally grouped into antidepressants (amitriptyline [Elavil], desipramine [Norpramin], nortriptyline [Pamelor]), corticosteroids (dexamethasone [Decadron]), anticonvulsants (gabapentin [Neurontin], carbamazepine [Tegretol]), and psychostimulants (dextroamphetamine [Dexedrine] and methylphenidate [Ritalin]) (McKenry & Salermo, 2003). Almost all adjuvants can be given orally, however some may be given parenterally, transdermally, intrathecally, or epidurally. Most adjuvants have ceiling effects and must be titrated upward. A delayed response is common until the drug is at an effective dose and has reached its peak efficacy. Therefore, adjuvants are most commonly used in chronic pain (McKenry & Salermo, 2003; McCaffery & Pasero, 1999). Critical Thinking Tip: Anticonvulsants and antidepressants are best used to treat neuropathic, chronic pain. Titrate adjuvants upwards to achieve desired effect, keeping ceiling doses in mind.
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Commonly Prescribed Adjuvants for Pain Drug Class Corticosteroids Antidepressants Drug Name Dexamethasone (Decadron) Amitriptyline (Elavil) Normal Adult Dose 4-16mg per day 25-150 mg qhs Comments May cause hyperglycemia Do not abruptly stop use. Titration upwards should occur every 3-5 days by 25 mg increments for desired dose. Titration upwards should occur every 3-5 days by 25 mg increments for desired dose. Imipramine is less sedating Maximum dose = 3600 mg/day
25-150 mg qhs
Anticonvulsants
Gabapentin (Neurontin)
300mg once daily Then 300mg twice a day, titrate to pain relief. Begin with 250mg TID and titrate.
Other routes such as intranasal, rectal, and topical are also effective for pain relief in certain conditions. Consider what is appropriate for your patient and the best drug for their needs when advocating pain management strategies.
Non-pharmacological Therapies
In addition to pharmacological therapies, non-pharmacological therapies can augment pain relief in all pain types. Heat, cold, massage, and repositioning in combination with acetaminophen or a NSAID may control mild pain. Other useful non-pharmacological measures include talking with a caregiver, relaxation, distraction, guided imagery, and changing the meaning of ones pain. Relaxation is an active process and requires concentration but has a direct physical and mental effect on how the patient perceives pain. Distraction and guided imagery allow the mind to concentrate on things other than the pain. Changing the meaning of pain counteracts the negative thoughts patients have about pain (Davis, 2000). Talking with a caregiver allows the patient to explore the meaning of their pain and may also provide distraction from the pain. Whichever nonpharmacological intervention is used to manage the patients pain, assessment of the effectiveness of these therapies must be based upon the patient self-report and re-assessment must occur.
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Critical Thinking Tip: Around-the-clock oral dosing is the most effective pain relief strategy in controlling chronic pain. Advocate for the patient using your knowledge of WHO ladders 3-Step Approach to Freedom from Cancer pain
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Special Populations
Treating pain in special populations is based upon individual assessment and knowledge of unique characteristics of these populations. Infants and children, the elderly, people from different cultures, and those with a prior history of substance abuse are most likely to experience inadequate pain control. Therefore, it is useful to discuss pain management in terms of the specific beliefs and actions of the healthcare provider toward these populations.
Consolability
Content, relaxed
Adapted from The FLACC: A behavioral scale for scoring postoperative pain in young children, by S. Merkel and others, 1997, Pediatric Nurse 23(3), p. 293-297.
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CRIES The CRIES tool has been well received by health professionals. The five parameters represented are below. The maximum score of 10 points is calculated in a similar manner as the Apgar score a score of four or more represents pain requiring intervention to reduce pain and maintain comfort. For example, a grimace, the facial expression most often associated with pain, gains a score of 1 but if associated with a grunt will be scored a 2. The scale is particularly useful for neonatal postoperative pain. Researchers concluded that CRIES postoperative pain assessment scale was a valid and reliable measure of postoperative pain in neonates 32 to 60 weeks gestation.
Crying Requires oxygen to maintain saturation greater than 95% Increased vital signs Expression Sleepless
(See Appendix A for the entire scale and scoring criteria) NIPS Neonatal/Infants Pain Scale has been used mostly in infants less than one year of age. Facial expression, cry, breathing pattern, arms, legs, and state of arousal are observed for one minute intervals before, during and after a procedure and a numeric score is assigned to each. A score >3 indicates pain. (See Appendix B for entire scale.) FACES Children or persons with cognitive impairment may better quantify their pain using a faces pain rating scale instead of a numeric scale. A faces pain scale allows the patient to express their pain using graphical representations of their pain instead of numbers. The Wong and Bakers Faces of Pain Scale is an alternative to the numerical scale (Wong, 1997).
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CHEOPS CHEOPS stands for Children's Hospital of Eastern Ontario Pain Scale. It is intended for children ages 1-7 yrs old. It assesses cry, facial expression, verbalization, torso movement, if child touches affected site, and position of legs. Very basically, a score >= 4 signifies pain. (See Appendix B for entire scale.)
Critical Thinking Tip: No matter what scale your institution uses, it is important to try to get a self-report from the child first. Children older than 3 years old can often give an accurate self-report. If a self-report is not possible, then one of the aforementioned scales can be used or another scale. Be sure you use the scale appropriate to the age you are trying to assess and you understand how to score and what the score means.
The Elderly
The elderly are also at risk for the under-treatment of pain. This is largely because of their inability or reluctance to report pain and healthcare professionals fear of overdosing this type of patient. The elderly may also have varying levels of cognitive impairment. Careful assessment of the cognitively impaired elder through observable indicators and family information about their loved ones pain is very useful in recognizing pain in the elderly (see section on Cognitively Impaired). When providing opioids for pain control, the key is to start at a low dose and titrate upward until a desired effect is reached. Renal dysfunction in the elderly may also inhibit adequate pain management. Therefore, monitoring of appropriate laboratory values is indicated.
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Culture Issues
People from different cultures experience pain largely based on their meaning of pain. Be aware of your own cultural uniqueness and seek to accept the distinct perspectives of others. Be cognizant of your approach to the patient, including the use of non-verbal communication styles. The patients comfort with eye contact, various body postures, amount of physical space, and appropriateness of touch are individual to various cultures. It is often difficult for you to be knowledgeable about all of the possible cultural norms of patients; however, you can be alert to the patients verbal and non-verbal cues. A careful approach to the patient in these instances will often set the stage for successful pain management.
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Conclusion
In conclusion, pain is a multifaceted symptom that must be accurately assessed to be managed successfully. Healthcare professionals must actively participate in continuing to learn about new theories and techniques in pain management. Barriers must be addressed at the patient, provider and system level. A thorough patient history and assessment should be conducted for all existing and new pain; recognizing that the patient is the best equipped to describe the pain. Successful pain control is often achieved by providing both pharmacological and non-pharmacological therapies. Finally, healthcare professionals must be aware of those at risk for under-treatment of pain and current strategies in managing pain. Pain is a universal affliction and all healthcare providers must take initiative to appropriately manage pain and alleviate suffering.
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Appendix A
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Appendix B
Pain Assessment Tools Neonatal/Infant Pain Scale (NIPS) (Recommended for children less than 1 year old) - A score greater than 3 indicates pain. Pain Assessment Facial Expression 0 Relaxed Muscles 1 Grimace Cry 0 No Cry 1 Whimper 2 Vigorous Cry Quiet, not crying Mild moaning, intermittent Loud scream; rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidence by obvious mouth and facial movement). Usual pattern for this infant Restful face, neutral expression Tight facial muscles; furrowed brow, chin, jaw, (negative facial expressionnose, mouth, and brow) Score
Breathing Patterns 0 Relaxed 1 Change in Breathing Indrawing, irregular, faster than usual; gagging; breath holding Arms 0 Relaxed/Restrained 1 Flexed/Extended Legs 0 Relaxed/Restrained 1 Flexed/Extended State of Arousal 0 Sleeping/Awake 1 Fussy Quiet, peaceful sleeping or alert random leg movement Alert, restless, and thrashing No muscular rigidity; occasional random leg movement Tense, straight legs; rigid and/or rapid extension, flexion No muscular rigidity; occasional random movements of arms Tense, straight legs; rigid and/or rapid extension, flexion
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1 Body (not limbs) is at rest; torso is inactive 2 Body is in motion in a shifting or serpentine fashion 2 Body is arched or rigid 2 Body is shuddering or shaking involuntarily 2 Child is in a vertical or upright position 2 Body is restrained 1 Child is not touching or grabbing at wound 2 Child is reaching for but not touching wound 2 Child is gently touching wound or wound area 2 Child is grabbing vigorously at wound 2 Childs arms are restrained 1 Legs may be in any position but are relaxed; includes gentle swimming or separate-like movements 2 Definitive uneasy or restless movements in the legs and/or striking out with foot or feet 2 Legs tensed and/or pulled up tightly to body and kept there 2 Standing, crouching, or kneeling 2 Childs legs are being held down
(2005). Retrieved September 10, 2005 from
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