1. Pain Management
Part II

2. Pain Intensity or Rating Scales
• Numbers
• Visual analogue
• Words
• Colors
• Faces
• Behavior / physiologic signs

3. Pain Intensity or Rating Scales
• Patient’s report of pain
– Single most important indicator of intensity
of pain
– Provider’s overrate or underrate pain
– Inaccuracy greater when patient’s pain is
severe

4. Pain Intensity or Rating Scales
• Pain intensity scales
• Easy and reliable
• Provide consistency in communication of
pain
• 0 – 10 range
• Word modifiers may help some apply

5. Pain Intensity or Rating Scales
• Effective Use
– Understand use of scale
– Educated about how information will be used
• Determine changes in condition
• Effectiveness of pain management interventions
– Ensures adequate pain management
achieved

6. Numeric Scale
0 1 2 3 4 5 6 7 8 9 10
No Pain Worst Pain

7. No Mild Moderate Severe Very Worst
Pain Severe

8. Visual-Analogue Scale*
No Pain Worst Pain
Usually 0-10 cm long line.
Placed either vertical or horizontal.

9. VAS: Coloured Analogue Scale
(Ref: McGrath, PA, et al: Pain, 1996.)

10. Wong-Baker FACES
Pain Rating Scale
0 2 4 6 8 10

11. Sample of Child’s FACES Pain Rating Scale

12. Photographic/
Numeric Pain Scale
• Oucher scale
(Beyer)
• White child,
3 year-old
male

13. Photographic/
Numeric Pain
Scale, cont.
• Oucher scale
(Beyer)
• Black child,
school age,
male

14. Photographic/
Numeric Pain
Scale, cont.
• Oucher scale
(Beyer)
• Hispanic
child, school
age, male

15. Cultural Preference for Scales
100 African-American children with SCD
rated preference of 3 scales:
• FACES -- 56%
• Black Oucher -- 26%
• VAS -- 18%
• Validity was strongest for FACES, then
Oucher and VAS
Ref: Luffy R: Pediatric Nursing, Jan 2003.

16. Pain Intensity or Rating Scales
• Wong-Baker FACES Pain Rating Scale
– Children
– Elderly with impairments
• Cognition
• Communication
– People who do not speak English
• Includes number scale in relation to each
expression

17. Pain Intensity or Rating Scales
• When a scale can’t be used
– Rely on observation of behavior
– Rely on physiologic signs
– Use input of significant others
• Parents/caregivers
• Help interpret observations

18. Nonverbal responses to pain
• Facial expression
• Vocalizations like moaning and groaning
or crying and screaming
• Immobilization of the body or body part
• Purposeless body movements
• Behavioral changes such as confusion
and restlessness
• Rhythmic body movements or rubbing

20. QUESTT
• Question the patient
• Use pain rating scale
• Evaluate behavior and physiologic
signs
• Secure family’s involvement
• Take cause of pain into account
• Take action and assess effectiveness

21. Comprehensive Pain History
• COLDERR
– Character
– Onset
– Location
– Duration
– Exacerbation
– Relief
– Radiation

22. Characteristics of Pain
• Quality
– What does it feel like
– Record patient’s words that he describes
– Provides information useful in diagnosing
cause of pain
• Intensity
– Important to obtain estimate of intensity
– Evaluate effectiveness of treatment

23. Characteristics of Pain
• Aggravating and Alleviating Factors
– Include behaviors or activities that influence pain
– Helps in care planning
• Associated Manifestations
– Impact on ADLs
• Sleep, work, activities
• Appetite, mood, sexual function, recreational activities
– Pain is fatiguing
• Longer experience pain the greater the fatigue
• Stress response of pain continues in sleep
– Physiological consequences
• Pain more severe in morning

24. Characteristics of Pain
• Meaning of Pain
– Soldier vs civilian
• Objective Data
– Physiologic
• Activates sympathetic nervous system
– ↑ HR, RR, BP,
– Diaphoresis, pallor, muscle tension, dilated
pupils
• Chronic pain shows adaptation

25. Characteristics of Pain
• Behavioral
– Crying, moaning
– Rubbing site, restlessness
– Distorted posture, clenched fists, guarding
– Frowning, grimacing
• Speaks of discomfort
• Restless
• Afraid to move

26. Characteristics of Pain
• Location
– Point to place in body
– Ask if more than one site
– Radiates, deep, superficial
• Onset, Duration
– How long existed
– Triggers
– Patterns – worse am, pm, getting up, etc.

27. Nurse’s Role
Patient Advocate
• Primary Concern-Comfort

28. Practice Guidelines
• Establish a trusting relationship
• Consider client’s ability and willingness to
participate
• Use a variety of pain relief measures
• Provide pain relief before pain is severe
• Use pain relief measures the client believe
are effective
• Align pain relief measures with report of
pain severity

29. Practice Guidelines
• Encourage client to try ineffective
measures again before abandoning
• Maintain unbiased attitude about what
may relieve pain
• Keep trying
• Prevent harm
• Educate client and caregiver about pain

30. Barriers to Effective Treatment
• Lack of knowledge of the adverse effects
of pain
• Misinformation regarding the use of
analgesics
• Misconceptions about pain
• May not report pain
• Fear of becoming addicted

31. Pharmacologic Interventions
• Opioids (narcotics)
• Nonopioids/nonsteroidal anti-inflammatory
drugs (NSAIDS)
• Co-analgesic drugs

32. Opioids (Narcotics)
• Full agonists
– No ceiling on analgesia
– Dosage can be steadily increased to relieve
pain
– morphine, oxycodone, hydromorphone

33. NSAIDS
• Vary little in analgesic potency
– vary in anti-inflammatory effects, metabolism,
excretions, and side effects
• Have a ceiling effect
• Narrow therapeutic index
• acetaminophen, ibuprofen, aspirin

34. Coanalgesic Drugs
• Antidepressants
• Anticonvulsants
• Local anesthetics
• Others

35. WHO Ladder Step
Approach for Cancer Pain Control

36. Rational Polypharmacy
• Evolved from WHO three step approach
• Demands health professionals be aware
of all ingredients of medications that
alleviate pain
• Use combinations to reduce the need for
high doses of any one medication
• Maximize pain control with a minimum of
side effects or toxicity
• Combined with multimodal therapy (e.g.
nondrug approaches)

37. Oral Administration
• Preferred because of ease of
administration
• Duration of action is often only 4 to 8
hours
• Must awaken during night for
medication
• Long-acting preparations developed
• May need rescue dose of immediate-
release medication

38. Transdermal Administration
• Transmucosa and Transnasal
– Enters blood immediately
– Onset of action is rapid
• Transdermal
– Delivers relatively stable plasma drug level
– Noninvasive

39. Rectal
• Useful for clients with dysphagia or
nausea/vomiting

40. Medication Administration
• Intramuscular
– Should be avoided
– Variable absorption
– Unpredictable onset of action and peak effect
– Tissue damage
• Intravenous
– Provides rapid and effective relief with few
side effects

42. Intraspinal
• Provides superior analgesia with less medication used

43. PCA
• Patient-controlled
analgesia
– Minimizes peaks of
sedation and
valleys of pain that
occur with prn
dosing
– Electronic infusion
pump
– Safety mechanisms

44. Cognitive-Behavioral
(Mind-Body)
• Providing comfort
• Eliciting relaxation
response
• Repatterning thinking
• Facilitating coping
with emotions

45. Body Interventions
• Reducing pain triggers
• Massage
• Applying heat or ice
• Electric stimulation (TENS)
• Positioning and bracing (selective
immobilization)
• Acupressure
• Diet and nutritional supplements
• Exercise and pacing activities
• Invasive interventions (e.g. blocks)
• Sleep hygiene

46. Mind Interventions
• Relaxation and imagery
• Self-hypnosis
• Pain diary and journal writing
• Distracting attention
• Re-pattern thinking
• Attitude adjustment
• Reducing fear, anxiety, stress, sadness,
and helplessness
• Providing information about pain

47. Spirit Interventions
• Prayer
• Meditation
• Self-reflection
• Meaningful rituals
• Energy work (therapeutic touch,
Reiki)
• Spiritual healing

48. Social Interaction
• Functional restoration
• Improved communication
• Family therapy
• Problem-solving
• Vocational training
• Volunteering
• Support groups