Pain Management in Adults

Introduction

Although acute pain has a significant protective/warning function and can signal significant underlying pathologies, it is often a common cause for stress among patients. Timely nonjudgmental, and appropriate management of pain is an important responsibility of nurses, especially in the surgical unit.

Definition

Pain management refers to the process of administering interventions which alleviate or reduce the pain.

Purposes

• To alleviate/relieve pain and promote comfort.
• To promote cooperation of the patient for procedures.
• To improve functional ability and independence of the patient.
• To enhance the quality of life.
• To reduce stress.
• To promote coping.

Multidisciplinary Pain Management Team
Managing pain requires collaborative efforts of an interdisciplinary team comprising the following:

• Nurses.
• Physician/surgeon.
• Anesthesiologist.
• Pharmacist.
• Physiotherapist.
• Occupational therapist.
• Psychologist.
• Counselor.
• Psychiatrist.

Role of the Pain Management Nurse

• Pain assessment.
• Patient education.
• Healthcare collaboration.
• Compassion and cultural sensitivity.

Pain Management Strategies
This can be categorized as follows:

1. Pharmacological strategies.
2. Nonpharmacological strategies.

1) Pharmacological Strategies
Analgesics are preferred when acute pain is of moderate or severe intensity and cannot be controlled by nonpharmacological measures alone.

Types of Pain Medications

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and nonopioids.
• Opioids or narcotics.
• Adjuvants.

The World Health Organization (WHO) recommends a stepladder approach, also known as the analgesic ladder, which focuses on aligning proper analgesic with the intensity of pain.

• Nonopioids
  NSAIDs work in peripheral tissues. They are effective in managing mild to moderate pain.
• Aspirin: It can prolong the bleeding time and should be stopped at least a week before a patient undergoes any surgical procedure. It should never be given to children younger than 12 years due to the possibility of Reye’s syndrome. It may cause excessive anticoagulation if the patient is on warfarin.

• Paracetamol: It may have serious hepatotoxic side effects and possible renal toxicity with high dosages or with long-term use. Acetaminophen usage must be limited to 3 g/day.
• Celecoxib: It is a COX-2 inhibitor that has fewer GI side effects than COX-1 NSAIDs.

Action:

• They work by inhibiting the enzyme cyclooxygenase (COX), a chemical activated during tissue damage, resulting in decreased synthesis of prostaglandins, which stimulate nociceptors.
• Some of these completely block the synthesis of prostaglandins.
• All NSAIDs have anti-inflammatory (except for acetaminophen), analgesic, and antipyretic effects.

Side Effects:
Less severe side effects that some people may experience include the following:

• Indigestion and other gut complaints.
• Headaches.
• Dizziness.
• Drowsiness.

Rare adverse events associated with NSAIDs include problems with the following:

• Kidneys.
• Liver.
• Heart and circulation.

• Opioid Analgesics

These act on the opioid receptors and provide pain relief in patients with moderate to severe pain. They can be administered orally, transdermal, rectally, intravenously, intramuscularly, subcutaneously, patient-controlled analgesia (PCA) systems, or epidurally.

Types of Opioids:

• Weak opioid analgesics.
• Moderate or strong opioids: Sustained-release opioids (SROs or continuous-release or extended-release).
• Immediate-release opioids (IROs).
• Long-acting opioids.

Commonly used opioids are codeine, fentanyl, hydrocodone, hydromorphone, levorphanol, methadone, morphine, oxycodone, and tramadol.

Action:

These work by blocking the release of neurotransmitters involved in the processing of pain.

Side effects of opioids:

These include sedation, constipation, nausea and vomiting, pruritus, myoclonus, and respiratory depression.

• Adjuvants/Coanalgesics
  Adjuvants are medications that have been found to have independent analgesic effect or additive analgesic properties when administered with opioids. Coanalgesics are medications that are not classified as pain medication but have properties that may reduce pain alone or in combination with other analgesics. They may also relieve other discomforts, increase the effectiveness of pain medications, or reduce the pain medication’s side effects.
  
  Commonly used coanalgesics include the following:

• Antidepressants: These help in increasing pain relief, improving mood, and reducing excitability, for example, amitriptyline.

• Local anesthetics: These drugs block the transmission of pain signals and are used for pain in specific areas of nerve distribution.

• Others: These include anxiolytics, sedatives, and antispasmodics which are used to relieve other discomforts. Stimulants, laxatives, and antiemetics reduce the side effects of analgesics.

Precautions for patients taking analgesics are the following:

• Do not self-medicate especially during pregnancy as it may harm the fetus.
• Special attention must be given to the elderly and debilitated adults as the risk of side effects may be more.
• Do not overdose even if pain does not subside completely.
• Do not take multiple painkillers without professional consultation.
• Avoid taking pain killers for nonmedical purposes.
• Take the advice of healthcare professionals if any existing comorbidities are present.

2. Nonpharmacological Strategies

• Basic comfort measures: These include proper positioning with appropriate comfort devices such as pillows, cotton rings, backrest, and cardiac table; providing therapeutic environment; avoiding sudden movement; and reducing painful stimuli within the environment.

• Distraction: It is an effective and simple intervention which involves diverting the patient’s focus away from the pain. The stimuli prevent the transmission of sensory pain impulses to the brain as per the theory of closing the pain gates. This involves but is not limited to activities such as describing photos, telling jokes, and playing games to engage the patient.

• Music therapy: It is also a popular pain control measure which distracts the patient who is enjoying one’s favorite music from the thought of pain.

• Hot application: It involves the placement of a heating pad or hot water bottle on the painful body part. This causes vasodilation and relieves pain and discomfort by stimulating the closure of pain gates and the release of endorphins.
• Precaution: The patient must not lie directly on the heat source to avoid the risk of burns and the skin over this area must be reassessed frequently for any possible skin injury.

• Cold application: An ice pack or ice cap can be used to produce vasoconstriction which reduces blood flow to the area, numbs the nerve sensation, relieves pain and inflammation, for any and promotes healing.
• Precaution: The nurse must reassess the site for any injury and discontinue the procedure if the patient feels numbness, aching, or burning.

• Mindful meditation: It is an ancient practice which involves the practice of being aware of the present and focusing on one’s own inner processes. It is believed to help control pain and reduce anxiety, depression, stress, and many other physical symptoms by reducing pain sensitivity.

• Visualization meditation/guided imagery: It is an intervention which involves the nurse sitting near the patient and speaking quietly, helping the patient to concentrate on the description to create a calming and relaxing image in his or her mind.
• Breathwork meditation: It involves the use of breathing exercises to change one’s breathing pattern and relax the mind.

• Body scan meditation: The person is trained to focus on his or her body from top to bottom aiming to notice everything about one’s body, and relaxing as the scanning process is taking place.

• Massage: It is a touch stimulation technique to soothe the muscles and promote relaxation and sleep. This triggers the release of endorphins and blocks the transmission of pain impulses.

• Acupressure: It is a traditional Chinese modality that involves the application of pressure to certain points in the body.
• Purpose: It aims to restore the flow of energy and balance through the body.
• Method: Press firmly and use an up-and-down or circular movement for several minutes. Stop/ease the pressure if the motion causes worsening pain/discomfort.
• Precaution: Some points should not be stimulated in pregnant women as they might stimulate labor.
• Acupuncture: It is also a traditional Chinese modality that involves the insertion of small needles into the skin at specific points.
• Purpose: It aims to help stimulate endorphin release and trigger pain-relieving changes in the brain for patients with complicated or chronic pain.
• Method: The needles are left in place for 10-30 minutes at a time while the patient rests and are then removed. The treatment is repeated several times.
• Precaution: This should be performed in a safe manner and only by a licensed practitioner.

• Aromatherapy: It is an ancient therapeutic modality that involves the use of essential oils which are absorbed through the skin or inhaled through the nose.
• Purpose: To reduce pain, nausea, muscle tension, anxiety, and depression.

• Biofeedback: It is a type of behavioral therapy that is taught to the patient over several weeks and allows him or her to visualize physiological responses and eventually control them. This technique is beneficial for persons with headaches or muscle tension.

• Cognitive behavior therapy (CBT): It is a form of psychological therapy which can help a person to learn to change how one thinks, and in turn how one feels or behaves in response to pain. This is commonly used for chronic pain management. It includes Reiki, spiritually guided approaches, emotional counseling, hypnosis, biofeedback, meditation, and relaxation techniques.

• Contralateral stimulation: It involves stimulating the skin in the area opposite to the painful area. This technique is applied when the painful area cannot be touched.

• Transcutaneous electrical nerve stimulation (TENS): This technique uses a special device that produces a mild electrical current through the skin via external electrodes. The intensity of the buzzing or tingling sensation which it produces can be controlled by the patient in response to the level of pain.
• Precaution: Hair removal may be necessary, if needed, before applying the electrodes in areas with excess body hair.

• Exercises: Low-intensity exercises, such as tai chi and yoga, can also help to relax, relieve stress, and promote comfort.
• Precaution: Certain patients may need immobilization of specific joints for a particular period to prevent disturbing the affected/operated area until it is stabilized.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

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