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[Fr. peine, fr L. poena, a fine, a penalty, punishment] As defined by the International Association for the Study of Pain, an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Pain includes the perception of an uncomfortable stimulus and the response to that perception. About half of those who seek medical help do so because their primary complaint is pain. Pain may arise in nearly any organ system and may have different characteristics in each system. Acute pain occurs with an injury or illness; is often accompanied by anxiety, diaphoresis, nausea, and changes in vital signs (such as tachycardia or hypertension); and ends after the stimulus is removed or the organ heals. Chronic or persistent pain lasts beyond the normal healing period. Musculoskeletal pain is often exacerbated by movement and may be accompanied by swollen joints or muscle spasm. Myofascial pain is marked by trigger-point tenderness. Visceral pain is often diffuse or vaguely localized, but pain from the lining of body cavities is often localized precisely, very intense, and sensitive to palpation or movement. Nerve pain usually stings or burns; it may be described as numbness, tingling, or shooting sensations. Colicky pain fluctuates in intensity from severe to mild and usually occurs in waves. Referred pain results when an injury or disease occurs in one body part but is felt in another. Several factors influence the experience of pain, such as the nature of the injury or illness causing the symptom, the physical and emotional health of the patient, the acuity or chronicity of the symptom, the social milieu and/or cultural upbringing of the patient, neurochemistry, memory, and personality. SEE TABLE: Usual Adult Doses and Intervals of Drugs for Relief of Pain
SYMPTOMS Many clinicians use the mnemonic COLDER to aid the diagnosis of painful diseases. They will ask the patient to describe the Character, Onset, Location, and Duration of their painful symptoms, the features that Exacerbate or Relieve it. For example, the pain of pleurisy is typically sharp in character, acute in onset, located along the chest wall, and long-lasting; it is exacerbated by deep breathing or coughing and is relieved by analgesics or by holding still. By contrast, the pain of myocardial ischemia is usually dull or heavy, gradual in onset, located substernally, may be exacerbated by activity (but not by taking a breath or coughing), and relieved by nitroglycerin.
In 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, since 2007 called The Joint Commission,) issued standards of pain management , began surveying for compliance in 2001, and in 2004 added patient-safety goals; thus most U.S. health care facilities have devised policies and procedures that require pain-intensity rating as a routine part of care (the fifth vital sign). Pain intensity is usually assessed on a numerical scale, in which 0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 to 10 = severe pain. However, obtaining a numerical rating of pain intensity is possible only if the patient can provide this report of the pain being experienced, which infants, children, the critically ill, and cognitively impaired usually are unable to do. The Wong-Baker FACES Pain Rating Scale, which uses visual representations of smiles or grimaces to depict the level of pain a patient feels, was developed for pediatric use and has been used successfully in other patient populations.
PATIENT CARE Health care professionals must be aware that pain in nonverbal patients can easily be overlooked; they must make a conscious effort to ensure that pain in these patients is assessed and treated. Observing subtle behaviors and being sensitive to contextual clues are two methods that health care professionals use to determine when nonverbal patients are in pain. When this judgment is made, a trial of pain-relieving medication may be used. The responses of the patient and any complications of treatment should be carefully observed and appropriate changes made in dosing or the type of analgesic drug as indicated.
Because pain is subjective, sympathy is an important part of relieving it. In addition to administering analgesics, health care professionals should use a wide range of techniques to help alleviate pain, including local application of cold and heat, tactile stimulation, relaxation techniques, diversion, and active listening.
Usual Adult Doses and Intervals of Drugs for Relief of Pain
Nonopioid Analgesics
Generic Name
Dose, mg*
Interval
Comments
Acetylsalicylic acid
325-650
4-24 hr
Enteric-coated preparations available
Acetaminophen
650
4 hr
Avoid in liver failure
Ibuprofen
400-800
4-8 hr
Available without prescription
Indomethacin
25-75
8 hr
Gastrointestinal and kidney side effects common
Naproxen
250-500
12 hr
Delayed effects may be due to long half-life
Ketorolac
15-60 IM
4-6 hr
Similar to ibuprofen but more potent
Opioid Analgesics
Generic Name
Parenteral Dose (mg)
PO Dose (mg)
Comments
Codeine
30-60 every 4 hr
30-60 every 4 hr
Nausea common
Hydromorphone
1-2 every 4 hr
2-4 every 4 hr
Shorter acting than morphine sulfate
Levorphanol
2 every 6-8 hr
4 every 6 hr
Longer acting than morphine sulfate; absorbed well PO
Methadone
10-100
6-24 hr
Delayed sedation due to long half-life
Meperidine
25-100
300 every 4 hr
Poorly absorbed PO; normeperidine is a toxic metabolite
Morphine
10 every 4 hr
60 every 4 hr
Morphine, sustained release
30-90
60-180 2 or 3 times daily
Oxycodone
—
5-10 every 4-6 hr
Usually available with acetaminophen or aspirin
Sites of Referred Pain
Organ of Origin
Location Felt
Head
External or middle ear
Nose & sinuses
Teeth, gums,
Throat, tonsils
Parotid gland, TMJ joint
Thorax
Diaphragm
Shoulder, upper abdomen
Heart
Upper chest, L shoulder, inside L arm, L jaw
Abdomen
Stomach & spleen
L upper abdomen
Duodenum
Upper abdomen, R shoulder
Stomach & spleen
L upper abdomen
Stomach & spleen
L upper abdomen
Stomach & spleen
L upper abdomen
Colon
Lower abdomen
Appendix
Periumbilical and R lower abdomen
Pelvis
Appendix
Periumbilical and R lower abdomen
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