Nursing Pain Management

Management of Selected Acute

Pain Problems

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Recall the definition of acute vs chronic pain.
– Acute pain
• Often duration 0-7 days
• Duration < 6 months
• Typically peripheral nociceptors involved
– Chronic pain
• Duration > 6 months
• Two types
– Chronic, nonmalignant pain
– Chronic, malignant pain (cancer)

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are frequent
causes of acute pain?
– Procedural – Painful wounds
– Post surgical – Painful medical
disorders (shingles,
– Orthopedic cardiac conditions,
– Phenomena after acute abdominal
amputation pain, acute
– Trauma exacerbation of
– Severe Burns chronic medical
conditions)
– Labor and delivery

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is procedural
pain?
– Acute pain caused by
stimulus of nociceptors
at the site of the local
intervention
– Short duration, may be
quite severe

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Give examples of painful procedures.
– Cardioversion, chest tube placement,
circumcision, dressing changes, lumbar
puncture, suturing of lacerations,
venipuncture, mechanical ventilation,
tissue biopsies, thoracentesis, etc

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Who is particularly vulnerable to
procedural pain?
– Infants and children
– Older adults
– Comatose or unconscious patients
– Cognitively impaired patients
– Patients with limited mobility
– Patients debilitated from a chronic disease
– Any patient with limited ability to speak for
themselves
PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are some pharmacologic approaches
to procedural pain?
– Local anesthetics and opioids – mainstay
– Benzodiazepines – anxiety
– NSAIDs
– General anesthetics – ketamine, propofol and
nitrous oxide

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is the purpose of
moderate sedation?
– To provide safe and
effective moderate
sedation and analgesia
for adults and children
during diagnostic and
therapeutic procedures

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How do you know when optimal
moderate sedation is achieved?
– Maintains consciousness
– Independently maintains his/her airway
– Retains protective reflexes (swallow, gag)
– Responds to physical and verbal commands
– Is not anxious or afraid
– Experiences acceptable pain relief
Continued on Next Slide

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How do you know when optimal
moderate sedation is achieved?
– Has minimal changes in vital signs
– Is cooperative during the procedure
– Has mild amnesia for the procedure
– Recovers to baseline status safely and promptly

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is the role of preemptive analgesia in
procedural pain?
– Minimizes alterations in synaptic function and
nociceptive processing within the spinal cord
dorsal horn , neuroendocrine responses and
sympathoadrenal activation
– Prevents “wind-up phenomenon” or central
sensitization
– Associated with reduced opioid requirements,
improved pain scores post procedure

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the causes
of post surgical pain?
– Tissue damage resulting
in the release of
neurotransmitters that
stimulate the A delta
and C nerve fibers
– These noxious stimuli
goes to the brain via the
spinal cord

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What influences the surgical pain
intensity, quality and duration?
– Site, nature and duration of the surgery
– Type and extent of the incision
• What are other influencing factors?
– Preoperative preparation
– Post operative complications
– Quality of post operative care

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What pain management techniques are
useful for post surgical pain?
– Pre-emptive analgesia
– Epidural analgesia
– Injection of local anesthetic into a wound at the
time of surgery
– Premedication (e.g. ketorolac in
hemorrhoidectomy or oral dextromethorphan in
tonsillectomy)
– Post op opioid analgesia

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Explain the causes of pain from orthopedic
injuries or surgeries. Both Acute and Chronic

– Nociceptive impulses occur as a result of the

disruption of tissue/bone/vessels/nerve in or near
the bone or joint
– Cell damage causes the release of bradykinin,
serotonin, prostaglandin and histamine causing
pain, inflammation, swelling and sensitization
– Pressure may increase in the fascial compartment
resulting in pain and potential ischemia

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the common treatments for
orthopedic pain?
– Combination of opioids and NSAIDs (inhibit
synthesis of prostaglandin)
– Ketamine – may be used for acute fractures when
the patient is unstable
– Propofol and fentanyl may be used during
reduction of fractures; moderate sedation
monitoring required
– Cortisone injection may be used for bursitis or
tendonitis

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is compartment syndrome?
– An acute medical problem following injury or
surgery in which increased pressure (usually
caused by inflammation) within a confined space
(fascial compartment) in the body impairs blood
supply, leading to nerve damage and muscle
death without prompt treatment

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How do I recognize compartment syndrome?
Look for the 5 "P's"
– Pallor
– Paresthesia (altered sensation e.g.,( "pins & needles")
in the cutaneous nerves of the affected compartment
– Pulse deficit
– Paralysis
– Pain on passive extension of the compartment;
description is usually of deep, constant, and poorly
localized and is sometimes described as out of
proportion with the injury; aggravated by stretching the
muscle group within the compartment

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is the treatment for compartment
syndrome?
– Recognition a Must – See Five Ps!
– Fasciotomy (to allow the pressure to
return to normal)
– Chronic compartment syndrome in the lower leg
can be treated conservatively or surgically
• Conservative treatment includes rest, anti-
inflammatories, and stretching

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Describe post
amputation pain.
– Phantom pain is the
perceived pain in the
missing body part; stump
pain is localized at the side
of the amputation; phantom
limb is any sensation of the - Residual limb pain
missing limb except pain
occurs due to neuromas,
– Pain characteristics: circulatory impairment,
burning, cramping, tingling,
infection, tumor, or
shooting and “pins and
needles” wound
PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the treatment options and
outcomes for patient post amputation?
– Limit stump revisions to localized stump pathology
– Preoperative lumbar epidural blockade with
bupivacaine or morphine for 3 days preoperatively
decreases pain in the first year after surgery
– Ketamine – prevention of phantom limb pain
– Topical capsaicin cream – useful in decreasing
pain at amputation site

PEARLS review ©
Management of Selected
Acute Pain Problems
• What is the major concern in pain
management for the trauma
patient?
– Potential cardiorespiratory compromise
or hemodynamic instability
– Not an absolute contraindication for
opioid analgesia, however, meticulous
monitoring is required (especially in the
presence of hypovolemia)

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are some advantages of aggressive
pain control in trauma patients?
– Providing analgesia will help the patient to lie still
for diagnostic tests
– For patient with rib fractures, can reduce the need
for mechanical ventilation
– Periodic doses of midazolam and either ketamine
or fentanyl may be used with impact on
cardiovascular stability
– Moderate sedation techniques may be indicated for
pain relief during procedures (e.g. insertion of chest
tube)
PEARLS review ©
 Management of Selected
Acute Pain Problems
• Why are severe burns so painful?
– A delta and C fiber nociceptors activate the nerve
terminal causing sequential inflammatory
mediators and subsequently, peripheral
sensitization or primary hyperalgesia
– Hyperalgesia leads to spinal sensitization which is
neuropathic
– During healing, nerve regeneration and tissue
reinnervation occur – may result in a chronic pain
syndrome

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is the best approach in managing
pain in severe burns?
– IV opioid route a must
– Ketamine along with midazolam or propofol
provide superior analgesia than opioid alone; also
provides amnesia
– Patients have a baseline continuous pain with
acute exacerbations – preemptive analgesia is a
must
– Adjuvant analgesics: clonidine and
anticonvulsants may be useful

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are some
wounds so
painful?
– Granulation tissue
– Peripheral nerve
regenerate • Treatment includes:
– Hypersensitive to – Topical application of
stimuli due to local anesthetics
immature nerve buds – Opioid and adjuvant
analgesics

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are some painful medical disorders
that result in pain?
– Shingles
– Cardiac conditions
– Acute abdominal pain
– Acute exacerbation of chronic medical conditions

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are shingles?
– Shingles (herpes zoster) is an outbreak of rash or
blisters on the skin that is caused by the same virus
that causes chickenpox — the varicella-zoster virus.
– Signs include burning or tingling pain, or sometimes
numbness or itch, in one particular location on only one
side of the body (along the dermatomes); then a rash
of fluid-filled blisters appear after several days
– Shingles pain can be mild or intense.

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How are shingles treated?
– Antiviral agent, acyclovir or famciclovir
– Tricyclic antidepressants
– NSAIDs – reduce inflammation
– Opioids – initially and short term
– Topical agents after lesions are healed such as
lidocaine (Lidoderm 5% patch) or capsaicin cream

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is the major concern for patients
with cardiac pain?
– Rapid assessment to determine cause and
determine if myocardial ischemia (MI) is occurring
– Treatment: Think MONA (Morphine, Oxygen,
Nitroglycerine, Aspirin)
– Goal: decrease oxygen consumption and demand
on the heart’s workload

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Explain the causes of acute
abdominal pain.
– Visceral disorders within the abdominal
cavity
– Muscle and systemic disorders
– Disorders in the chest – due to the
common distribution in the spinal cord with
the abdomen

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How is opioid analgesia managed for
these patients?
– Opioids have not been shown to obscure
findings
– Aids in physical exam relaxing the muscles
and improving palpation methods

PEARLS review ©
Management of Selected
Acute Pain Problems
• What are some examples
of acute exacerbation of
chronic medical
conditions?
– Pancreatitis
– Sickle cell disease
– AIDS
– Crohn's

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How can I recognize pancreatitis?
– Pain is visceral, deep and gnawing
– Commonly located in the upper abdomen to the
left of midline
– Often travels to the back, but may radiate to the
abdomen
– Pain decrease by leaning forward
– Pain increases with meals

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the treatment considerations in
pain management for the patient with
pancreatitis?
– Diet changes – high carbohydrate, low protein
– Titration of opioids with PCA
– All opioids cause some increase in the activity of
the sphincter of Odi/intrabiliary pressure
(meperidine seems to cause less affect)
– Octreotide may help decrease pain by suppression
of pancreatic secretions

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is sickle cell disease and how does it
present?
– Genetic disorder which is characterized by an
alteration from normal disc shaped hemoglobin to a
sickle shaped hemoglobin which are sticky and
clump together
– Vasoocclusive crisis result from the sickle shaped
hemoglobin clumping together resulting in blocked
blood flow, hypoxia, ischemia and infarction
– Locations: bone pain –back, chest, femur, hip, ribs,
knees; chest; abdomen; head
– Episodic painful crisis, widespread and migratory
PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the challenges in pain
management for the sickle cell patient?
– Crisis treatment: opioids (e.g. morphine,
hydromorphone), nonopioid and aggressive
hydration
– High risk for undertreatment of pain - ↑ with repeat
hospitalizations; pts often labeled as addicts
– Pts become angry and manipulative as health care
workers doubt their pain and accuse them of drug
seeking; we must believe the patient!
– Potential for organ failure, tissue damage and
chronic pain; aseptic necrosis of the femoral head or
vertebral collapse

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How is the treatment for pain for HIV/AIDS
patients complicated?
– Due to polypharmacy (various antiretroviral
agents) and high potential for drug to drug
interactions
– Multiple causes with different presentations:
infection, neuropathies, antiretroviral agents,
rheumatologic disorders, HIV related neoplasms
– Procedural pain – can be more painful the disease

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Describe Crohn’s disease and how it
presents?
– Chronic inflammatory bowel disease with frequent
bouts of remissions and relapses
– Pain characteristics: abdominal pain especially in
right lower quadrant, soreness, cramping; perianal
soreness
– Pain occurs after meals
– Associated symptoms: diarrhea
– Later in the illness: inflamed joints and arthritis

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the treatment options for Crohn's
disease patients?
– Management of underlying inflammation:
corticosteroids, aminoglycosides, antibiotics,
immunosuppressive drugs
– Opioids use cautiously due to potential for risk of a
toxic megacolon developing
– Dietary intake: low-residue foods and may need to
limit milk intake
– Surgery

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What pain medications can be given safely
during pregnancy?
– Main concern is maternal-placental-fetal drug
transfer; hence, if drug is more lipid soluble the
faster it crosses this barrier
– Acetaminophen is considered safe
– NSAIDs –short term management is probably safe
– Aspirin – drug of choice with rheumatoid arthritis

Continued on next slide

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What pain medications can be given safely
during pregnancy?
– Opioid analgesics – morphine,hydromorphone,
fentanyl, methadone, oxycodone and hydrocodone
can be given safely short term
– Third trimester – hold off using aspirin and
NSAIDs due to delay in onset of labor and
increased potential for bleeding

PEARLS review ©
Management of Selected
Acute Pain Problems
• How do you treat back pain in
pregnancy?
– 1st and 2nd trimesters:
acetaminophen, short term use of
aspirin, ibuprophen or naproxen
– Pelvic tilt and muscle toning
exercises
– Massage
– Application of heat and cold
– If severe, may require treatment
with short-term opioid and physical
therapy
PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is the cause of labor and delivery
pain?
– Pressure on nerve endings
between the muscle fibers of
the body and the fundus of
the uterus
– First stage of labor – cervical dilation,
uterine segment dilation; pain along the T11 and
T12 nerve roots
– Second and third stage – pain from the body of the
uterus and distention of lower uterine segment;
distention of the outlet and perineum; location
S2,S3,S4
PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are some non-pharmacological
strategies used during labor?
– Breathing exercises
– Relaxation techniques
– Music therapy
– Distraction
– Family support

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How is treatment choices for labor
evaluated?
– Analgesic potency
– Side effects on mother
– Side effects on fetus and newborn
– Side effects on the forces of labor
• What is the most common method of
analgesia used to manage this pain?
– Epidural analgesia

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the six major Acute and Chronic
types of headaches?
– Migraine
– Tension-type
– Cluster
– Chronic daily headaches
– Analgesic rebound
headaches
– Occipital neuralgia

PEARLS review ©
Management of Selected
Acute Pain Problems
• What are the causes of
a migraine?
– Vasodilation
– Neurogenic inflammation
– Abnormal serotonin
metabolism

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the phases of a migraine?
– Premonitory phase
• Occurs hours or days before the headache,
changes in mood or behavior
– Main attack phase
• Consists of the headache; 15% of patients also
have an aura
– Resolution phase
• Spontaneous pain subsides, but other
symptoms are still present

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Describe an aura.
– Develop slowly over 5-20 min
– Usually last < 60 min
– S&S: vision changes -flashing
lights, zig-zag lines; sensory
changes – pins and needles
on face or limbs; motor
changes - muscle weakness,
language problems, dizziness

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the signs and symptoms
associated with a migraine?
– Pain has pulsating quality, moderate to severe
intensity, onset gradual then peaks then subsides
– Associated symptoms: photo sensitivity, nausea
and vomiting
– Adults – usually unilateral
– Children – bilateral, shorter duration

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Do migraines generally have triggers? Yes
– Triggers vary widely between individuals
– Possible triggers: alcohol, aspartame, barometric
pressure changes, cheese, chocolate, cigarette
smoke, estrogens, excessive or insufficient sleep,
head trauma, hunger, lights, medication overuse,
menstruation, monosodium glutamate, odors, oral
contraceptives, stress and worry, etc

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Discuss the treatments – Preventative medications
for migraines. • Beta blockers, calcium
– Avoid trigger agents channel blockers,
– Abortive measures clonidine,
antidepressants,
• Ergotamine, NSAIDs, neuroleptics,
dihydroergotamine, cyproheptadine,
triptans, isometheptene, Bellergal-S, Sandert
combination therapy of
aspirin, acetaminophen, – Complimentary measures
and caffeine, NSAIDs, • Biofeedback, cold
antiemetics, intranasal pack, behavior
lidocaine modification

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Explain the features of a tension-type
headache (TTH).
– Tension from any cause: muscle contraction,
stress or psychological tension
– Two types
• Episodic – attacks occur < 15 days/month or <
180 days/ year
• Chronic – attacks occur > 15 days/month or >
180 days/year

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Contrast the symptoms of a tension-type
headache with a migraine headache.
TTH Migraine
Bilateral Unilateral
Steady ache or squeezing Throbbing or pulsatile
pressure
Mild to moderate Moderate to severe
Not aggravated by physical Aggravated by routine physical
activity activity
Absence of associated Associated Symptoms
symptoms

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is the treatment for tension-
type headaches?
– Relaxation techniques, biofeedback
– Tricyclic antidepressants
– Analgesics: NSAIDs, acetaminophen
– Cognitive-behavioral pain therapy
– Physical therapy: myofascial release
techniques, craniosacral techniques,
ergonomic evaluation

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the features of a cluster
headache?
– Headache marked by prominent cranial autonomic
symptoms such as eye watering or nasal stuffiness, facial
flushing, miosis, ptosis
– Duration: 15-30 min to 2-3 hours
– Pain: intense, often described as like a “poker in my eye”
– Location: unilateral, orbital, suborbital or temporal
– Frequency: episodic, occurs in groups, happens over
weeks or months, then followed by long absences of the
symptoms
PEARLS review ©
 Management of Selected
Acute Pain Problems
• What are the strategies for managing
cluster headaches?
– Medication principles: 1. start acute treatment
early in the cluster; 2. continue drugs until pain
free > 2 weeks; 3. taper the drugs off; 4. restart
drugs at the beginning of next cluster
– Acute treatment – O2, dihydroergotamine, triptans,
intranasal lidocaine, ergotamine
– Prophylactic measures if not contraindicated –
methysergide, lithium carbonate, corticosteroids,
calcium channel blockers, sodium valproate

PEARLS review ©
 Management of Selected
Acute Pain Problems
• What type of headache is described as “I
have headaches more days than not”?
– Chronic daily headaches
– Causes: trauma, anxiety, stress, depression,
medications use/disuse, caffeine
– Strategy: detoxification from daily medications to
determine headache pattern and rule out rebound
headache; once type of headache determine treat
accordingly

PEARLS review ©
 Management of Selected
Acute Pain Problems
• Why do analgesic
rebound
headaches occur?
Headache,
Medication
Headache,
More medication – Withdrawal from
frequently used
meds or substances
– Pain: frontal h/a,
pressure, stabbing,
worse on awakening
Headache,
more medication
– Treatment: similar to
chronic daily h/a
Vicious cycle
PEARLS review ©
 Management of Selected
Acute Pain Problems
• What is occipital neuralgia?
– Recurrent, episodic pain in the area of occipital
nerves (C2- C3)
– Often due to nerve entrapment
– Pain: intense then dull, radiates along the nerve,
occipital tender spots, scalp paresthesia,
radiating pain to ipsilateral eye with palpation
– Treatment: physical therapy, occipital nerve block
with local anesthesia, NSAIDs, anticonvulsants

PEARLS review ©
 Management of Selected
Acute Pain Problems
• How can you summarize basic headache
pain management?
– Mild, intermittent
• Acetaminophen, NSAIDs
– Moderate, intermittent
• NSAID Combinations, Midrin
– Severe, intermittent
• 5-HT2 Agonists Ergotamine derivatives

PEARLS review ©
 Management of Selected
Acute Pain Problems
• We have highlighted some common acute
pain problems in this module
• Obviously many acute pain problems are
also chronic and many chronic pain
problems can have acute episodes

PEARLS review ©
 Bibliography
• American Pain Society (2006) Pain: Current understanding of Assessment,
Management and Treatments retrieved February 15, 2007 from
http://www.ampainsoc.org/ce/enduring.htm
• American Society of Pain Management Nursing (2005) Pain management nursing:
scope and standards of practice. Maryland: American Nurses Association.
• ASPMN Position Statement: Pain Management in Patients with Addictive Disease
(2002) retrieved January 10, 2007 from
http://www.aspmn.org/Organization/documents/addictions_9pt.pdf
• Kanner, R. (2003) Pain management secrets. (2nd ed) Philadelphia: Hanley & Belfus,
Inc.
• McCaffery M. & Pasero, C. (1999) Pain: Clinical manual (2nd ed). St. Louis: Mosby.
• Melzack R. Evolution of pain theories and the neuromatrix. Program and abstracts of
the 21st Annual Scientific Meeting of the American Pain Society; March 14-17, 2002;
Baltimore, Maryland. Abstract 102.
• St. Marie, Barbara (2002). Core curriculum for pain management nursing,
Philadelphia: W.B. Saunders Company.

PEARLS review ©