Monserrat Fortunata

R. Angulo
Acting Nurse Clinician
MBOT /PACU
National University Hospital Singapore

OBJECTIVES

Define Pain and consequences of

pain
Understand pathophysiology of
pain
Understand various types of pain
Identify appropriate pain
assessment and techniques
Describe the basic pharmacology of
opiods

OBJECTIVES
.
Identify common side effects of opiods
Identify non pharmacologic
interventions useful in pain
management
Familiarize with the different types of
pain management
Gain a supplementary knowledge in
evidence based supporting
management of acute pain

An unpleasant sensory and

emotional
experience associated with
actual or potential tissue
IASP 1979
damage, or described
in

It facilitates accountability for

pain assessment and
management
(Chronic Pain Policy Coalition, 2007; ANZCA,
2005).

Cardiovascular Tachycardia, hypotension, Increase

myocardial O2 consumption, myocardial
ischemia
Respiratory

Atelectasis, sputum retention,

hypoxemia, pneumonia

GI

Decrease gastric & bowel motility, PONV

GU

Urinary retention

Metabolic

Increase catabolic hormones

MSK

Immobility, DVT, pulmonary embolism

Psychological

Anxiety, fear, insomnia

Long term

Chronic pain

4 Stages of
Pathophysiology of
Acute Pain :
TransductionTransduction a
stimulus is
converted into a
nerve signal at the
nociceptors
Transmission-pain
information is
transferred from
the peripheral to
the CNS

Pain Modulation-pain
information is
interpreted by many
neurochemical
mediators; can
exagerrate or reduce
reaction to pain;
psychologic factors
affect response to pain
PerceptionPerception awareness
of pain; associated
with specific area of
the body; influenced
by social and
environmental factors

Primary lesion or
dysfunction of the
nervous system

Tissue injury secondary

to trauma, incision,
disease or inflammation

pain we feel when o

internal organs are
damaged or injured
Caused by the activation of pain
receptors in body surface or

 ACUTE PAIN

begins suddenly and is usually sharp in qualit

serves as a warning of disease or a threat
to the body
CHRONIC PAIN

pain lasting for more than 3 months

persists despite the fact that the injury has he

C
O
L
D
S
P

- character
- onset
- location
- duration
- severity
- pattern
A alleviating/aggravating
factors

How does the pain affect ?

(e.g., sleep patterns, eating, activity,
mood and emotions, family, sexual
function, etc.)
Are you experiencing any other
symptoms?
(nausea, vomiting, itching,
constipation,etc)
Things to check

Non-stero
idal
antiinflamma
tory
drugs
(NSAIDS)
Acetamin
oph
en

Relaxation
Techniques
Psychotherapy

Narcotics
Localized
anesthetics

Biofeedback

Nerve blocks

Acupunc
t

ure

Physica
l
Therapy

Surgery

Behavior Modification

Electrical stimulatio

010 Numeric Pain Rating Sc

Categorical Rating Scale

- scale from 0 to 10 or to place a mark on a line indicating their level

of pain
- 0 indicates the absence of pain, while 10 represents the most
-intense
rate pain
aspossible
mild, moderate
or severe, which can indicate a
pain
.
potential disability
level

Wong-Baker Faces scale

Point to each face using the words to describe the pain

intensity.
Choose face that best describes own pain
and record the appropriate number.
Recommended for persons age 3 years and older

FLACC Scale
1
1
1
2
1
1
1
6
behavioral tool to measure pain in young children
designed for children between the ages of 2 months and 7 yrs
unable to communicate their pain

atients unable to provide a self-report of pain: scored 010 clinical obser

0

Face muscles
relaxed

Facial muscle
tension, frown,
grimace

Frequent to
constant frown,
clenched jaw

Face score:

Quiet, relaxed
appearance,
normal
movement

Occasional
restless
movement,
shifting position

Frequent
restless
movement may
include
extremities or
head

Restlessness
score:

Muscle
toneMuscle
tone *

Normal muscle
tone

Increased tone,
flexion of
fingers and
toes

Rigid tone

Muscle tone
score:

Vocalisation **

No abnormal
sounds

Occasional
moans, cries,
whimpers and
grunts

Frequent or
continuous
moans, cries,
whimpers or
grunts

Vocalisation
score:

Consolability

Content,
relaxed

Reassured by
touch,
distractible

Difficult to
comfort by
touch or talk

Consolability
score:

Face

Restlessness

Total

Assess above the

lesion injury. If hemip
Assess the unaffected

** cannot be measure
in patients with artifi
airways.

BEHAVIORAL RATING PAIN SCALE

- designed for use with non-verbal patients
unable to provide self-reports of pain.

Formal assessment tools available

but not necessarily useful in routine
clinical settings

Unique Pain Signature

Nonverbal Pain Indicators

Facial expressions (grimacing)

-Less obvious: slight frown, rapid
blinking, sad/frightened, any distortion
Vocalizations (crying, moaning, groaning)
-Less obvious: grunting, chanting, calling
out, noisy breathing, asking for help
Body movements (guarding)
-Less obvious: rigid, tense posture,
fidgeting, pacing, rocking, limping,
resistance to moving

PATIENT CONTROLLED
ANALGESIA

GRASEBY PCA PUMP

CADD LEGACY

PATIENT CONTROLLED ANALGESIA (PCA)

Patient self-administered analgesics

using a computerized pump

PCA
handset

pump delivers a specific dose at an

interval ordered by the
anesthetist.

ot re
n
s he
i
A .t r
C

If P ible othees
ss an tiv
o
p are rna
e
alt

 A fine catheter is inserted into the

epidural space
LA drugs , opioids, or sometimes
both are administered through the
catheter
Results in a loss ofsensation
including the sensation ofpain by
blocking the transmission of signals
throughnervesin or near thespinal
cord

Continuous epidural analgesia

Epidural
catheter with
the skin site marking

ADVANTAGES OF ECA
provide complete dynamic analgesia with a
combination of local anaesthetic and opiods
obtunds the stress response to major surgery
reduce the incidence of postoperative
pulmonary, thromboembolic and cardiac
complications
enhance the quality of patient recovery from
major surgery and shorten hospital stay
risk of serious complications from epidural
analgesia should be far outweighed

DISADVANTAGES OF ECA
causes respiratory depression

causes over sedation

catheterization may be needed
causes hypotension induced by
the drug.

Axillary Block

Brachial Plexus
Block

DISADVANTAGES OF NERVE BLOCK

mhon_nhette14@yahoo.com
monserrat_espinoza@nuhs.edu.sg