Pain Flashcards
Pain Assessment
Socrates
Pain history (acronym SOCRATES):
Site
Onset
Characteristics (e.g. aching, sharp, pulling)
Radiation – where the pain moves to
Associated factors (e.g. systemic symptoms)
Time – duration
Exacerbating and relieving factors (e.g. medications, movement, rest)
Severity
Causes of Pain
Nociceptive: Pain from tissue injury
* Somatic
(e.g. tumour invasion of bone, joint, muscle or connective tissue)
- Visceral
(e.g. bowel obstruction, liver infiltration or compression of vital organs)
Neuropathic: Pain from nerve injury
* Peripheral
(e.g. tumour compression of peripheral nerves)
- Central
(e.g. multiple sclerosis, stroke)
Management for Pain
WHO’s pain ladder can be used as a guide for both cancer pain and pain in life-limiting progressive non-cancer conditions (e.g. end stage organ failures or progressive neurological conditions).
*Some patients (e.g. those with severe incident pain) may benefit from interventional analgesia - contact the relevant Chronic Pain service (by anaesthetists) in your institution.
Step 1: For mild pain
Paracetamol 0.5-1g q.d.s.
NSAIDs: Ibuprofen 400mg t.d.s., Naproxen sodium 275-550mg b.d., Diclofenac 50mg b.d./t.d.s.
COX-2 inhibitors: Celecoxib 200mg b.d., Etoricoxib 60-120mg each morning
Step 2: For moderate pain, or if pain relief not achieved at maximum dose in Step 1
Start weak opioid: either Codeine 30-60mg t.d.s./q.d.s. or Tramadol 50-100mg t.d.s./q.d.s
Continue Paracetamol if it has been helpful, stop if pill burden is too much for patient.
Step 3: For severe pain, or if pain relief is not achieved at maximum dose in Step 2
Start a strong opioid (e.g. Morphine, Fentanyl, Oxycodone).
Special consideration for strong opioids
(What are the combinations that you can use?)
Renal & Liver
Opioids in renal failure
Caution is required when estimated creatinine clearance falls below 30ml/min, whether or not a patient is on dialysis
Fentanyl is recommended in moderate to severe renal impairment
Oxycodone and Tramadol can be used with caution
Codeine and Morphine should not be used unless mild renal impairment
Opioids in liver failure
Fentanyl is the opioid of choice in patients with moderate to severe liver failure or cirrhosis
Other opioids may be used with caution (by decreasing dose and frequency) and careful monitoring for side effects
Neuropathic pain
Neuropathic: Pain from nerve injury
Peripheral
(e.g. tumour compression of peripheral nerves)
Central
(e.g. multiple sclerosis, stroke)
Nociceptive Pain
Nociceptive: Pain from tissue injury
Somatic
(e.g. tumour invasion of bone, joint, muscle or connective tissue)
Visceral
(e.g. bowel obstruction, liver infiltration or compression of vital organs)
What are the common nursing considerations for palliative patients on opioids?
drugs to give in combination. & self-limiting s/s
1) Constipation –> Regular laxatives
2) N&V –> Haloperidol 0.5-1.5mg at bedtime
(Tolerance usually develops in about 1 week)
3) Sedation –> Reduce dose, usually mild & self-limiting.
(Tolerance usually develops in about 1 week or so)
4) Dry mouth –> Oral care
Adjuvant analgesics
Drugs with a primary indication other than pain, but have analgesic properties in some painful conditions.
Can play a complementary role to opioids and have opioid sparing effec
For Neuropathic Pain
* Antidepressants
(e.g. Amitriptyline, Nortriptyline, Duloxetine)
* Anticonvulsants
(e.g. Gabapentin or Pregabalin)
* Lignocaine patch
* Ketamine
Bone Pain
Bisphosphonates
Corticosteroids
Non-steroidal anti-inflammatory drugs (NSAIDs)
Colicky or Spasmodic Pain
Hyoscine Butylbromide
Muscle Cramps or spasm
Benzodiazepines
(e.g. Clonazepam or Midazolam)
How will acute pain be presented on the patient?
It may be acute in onset or worsening gradually to an intolerable level which requires immediate intervention
Often scored 7 or more in the numeric rating scale.
What are the considerations in acute pain nursing management?
What are the things you need to check?
1) Pain chart
2) Pain assessment/ history
3) Renal/ liver panel
4) Signs of opioid toxicity
5) Patient’s history with pain medications
List the pharmaco mgmt for acute pain
start off with strong opioids
+ add on adjuvants specific to clinical signs and symptoms. (check previous cards)
What is so bad about pethidine?
Pethidine has a toxic metabolite, Norpethidine, which accumulates when Pethidine is given regularly.
Particularly in renal impairment, Norpethidine causes tremors, multifocal clonus, agitation, and occasionally seizures.
Key notes in acute pain
1) >7
2) Reversible factors, e.g. ARU
3) The Checks in Nursing Management before suggesting drugs
2 things
1) P/t history with opioids
2) Pain Chart
3) Pain Assessment / history
4) Parenteral route (IV/SC)
5) Renal / Liver Panel
6) Signs of opioid toxicity (respiratory depression, pinpoint pupils, myoclonic jerks, hallucinations)
6) Breakthrough doses –> Continuous infusion
