Foundations

• Age/developmental stage
• Gender
• Culture
• Meaning of pain
• Previous experience
• Attention
• Anxiety
• Fatigue
• Coping style
• Family and Social support

• Superficial
• Visceral
• Somatic: bones/muscles
• Radiating/referred
• Phantom: pain from an abscent source, ie amputated
• Psychogenic

Transitory exacerbation of pain that occurs on a background of otherwise stable pain in a patient receiving chronic opioid therapy. 

• The process by which information about tissue damage is conveyed to the central nervous system (CNS). Exactly how painful stimuli is perceived as pain is unclear. 
• There can be pain without nociception (e.g., phantom limb pain) and nociception without pain.

• 1) transduction: pain stimuli
• 2) transmission: pain signals transfered to brain
• 3) perception: signals interpreted as pain
• 4) modulation: down reg of response. 

• Definition
• Recognition
• Assessment
• Treatment
• Monitoring

• Assess and reassess
• Use methods appropriate to cognitive status & context 
• Assess intensity, relief, mood & side effects
• Use personal verbal report whenever possible 
• Document  in a visible place
• Expect accountability – staff, family, patient
• Elevate importance of pain management
• Engage patient & family/loved ones

• Requires effective patient advocacy that takes 
• Time 
• Patience 
• Courage
• Must establish:
• Trust 
• Rapport
• And communicate, “I believe you are in pain”
• Must identify pain and share information with health care team as well as family

• I want to discuss with you what  your pain means to you
• I am willing to stay with you even if I fail to help control your pain
• I f you cannot relate to me, I will try to find someone else for you. 

• Belief that failure of the patient to express pain equates with the absence of pain
• Patient fears
• Belief by older adults that pain is an inevitable consequence of aging
• Belief by the patient that caregivers know pain is present and are doing all they can to relieve it
• Lack awareness on the part of the patient that effective pain management is their right
• Fear that persistent use of PRN and IM medications will cause them addiction
• Fear of medication side effects/addiction
• Fear of being seen as a complainer
• Fear the meaning of the pain

says we MUST assess and treat

• Visual Analogue Scale (VAS)
• Numeric Rating Scale (NRS)
• Simple descriptor scale
• Wong-Baker Faces Pain
• Rating Scale

• To reach the pain number the pt states is tolerable. 
• Is subjective.  

• No single preferred assessment tool
• Individualize the tool for your patients
• Make sure the patient understands the scale
• Use the same scale with each assessment
• Familiarity with 2 tools is suggested
• Education of staff vital

• scored scale based on location and responses.
• Face
• Legs
• Activity 
• Cry
• Consolability 

• Inadequate pain assessment
• Concommitent pain from another source
• Better performance status
• High expectations for optimal management
• Old & Young
• Allergies
• Culture and traditions
• History of substance abuse(ETOH or drug)
• Chronic and preoperative pain history
• High anxiety about post-operative problems 

• Increased confusion
• Decreased decision-making skills
• Decreased communication 
• Combative behavior
• Impaired mobility 

• Establish a baseline
• Define a cause 
• Or not
• Sometimes don’t know the cause
• Select interventions
• Evaluate response to treatment 

• Cutaneous stimulation: 
• Based on “gate control” theory
• TENS-electrodes to override nerves. 
• PENS
• Acupuncture
• Acupressure
• Massage
• Use of heat and cold
• Contralateral stimulation
• Distraction
• Progressive muscle relaxation
• Guided imagery
• Hypnosis
• Therapeutic touch
• Humor
• Journaling

• On-Q pump
• Patient Controlled Analgesia (PCA)
• Epidural
• Regional Anesthesia
• Oral Medications
• Opiods
• Nonopiods 
• Adjuvants

• Gait Disturbances
• Falls
• Cognitive dysfunction 
• Agitation or restlessness
• Polypharmacy like use of 9 or more medications
• Increased nursing time

• Unreliable signs:
• Hypertension
• Tachycardia
• Diaphoresis
• Pupillary dilitation
• Sleep cycle changes
• Change in mood
• Resisting care
• Change in behavior
• Changes in ROM/ADL’s 

• Routine not PRN dosing
• Start low, go slow BUT GO!!!!
• Least invasive route
• Reassess frequently
• “He who write the narcotic, writes the cathartic”

• Preference for short acting or bolus opioids
• Reports that “nothing else helps”
• Multiple Prescribers:Multiple Pharmacies
• Noncompliance with other therapies
• Continued use despite adverse effects
• Loss of Control
• Not taking prescribed meds
• Repeatedly “running out” or “losing meds”