• Choose a category
• All
• Classic-Fiction

6 Give each pain site a numerical value according to the key to pain intensity or the pain scale and note time recorded. To indicate the intensity of the pain at each site (Turk and Okifuji 1999, E).

7 Record any analgesia given and note route and dose. To monitor efficacy of prescribed analgesia (Twycross and Wilcock 2001, R5).

Postprocedure

8 Record any significant activities that are likely to influence the patient’s pain. Extra pharmacological or non-pharmacological interventions might be indicated (Disorbio et al. 2006, E; Turk and Okifuji 1999, E).

Pain management

Evidence-based approaches

Management of chronic pain

The control of pain is directed by the ‘analgesic ladder’, which was presented by the World Health Organization (WHO) in 1996 (Figure 9.12). Pharmacological intervention begins on the first step of the ladder and proceeds upwards as and when the pain reaches a higher level and the current analgesia is no longer effective. Analgesia should be administered ‘around the clock’ (ATC) to enable chronic persistent pain to be controlled.

Figure 9.12 The analgesic ladder.

It is important to remember that the patient will experience different types of pain due to different aetiological and physiological changes. It is important to make an assessment of each pain separately, since the pain may need to be managed in a different manner and one analgesic intervention will rarely be sufficient. Often the best practice is to combine the baseline analgesia with an appropriate adjuvant treatment in order to achieve maximum pain control (Table 9.2). It is also important to utilize non-pharmacological interventions at all stages of the treatment plan.

Table 9.2 The use of adjuvant drugs (co-analgesics)

Type Use Examples

NSAIDs Bone pain

Muscular pain

Inflammation

Visceral pain Diclofenac

Naproxen

Ibuprofen

Steroids Pressure

Bone pain

Inflammation

Raised intracranial pressure Dexametasone

Prednisolone

Tricyclic antidepressants

Anticonvulsants Neuropathic pain Amitriptyline

Sodium valproate

Carbamazepine

Gabapentin

Pregabalin

Antibiotics Infection Flucloxacillin

Trimethoprim

Benzodiazepines Anxiety Diazepam

Clonazepam

Antispasmodics Spasms Baclofen

Bisphosphonates Bone pain Sodium clodronate

Disodium pamidronate

Zoledronic acid

Oral administration of therapeutic interventions may not always be appropriate. In chronic cancer pain the European Association of Palliative Care (EAPC) recommends that if patients can no longer manage the oral route, the preferred alternative route is subcutaneous, which is simple and less painful than the intramuscular route (Hanks et al. 2001). In rare circumstances when rapid titration of analgesia is required, the intravenous route may also be used if patients have established intravenous access.

Accurate ongoing assessment is imperative for efficient and effective pain control.

Management of acute pain following surgery

Since nurses, surgeons, anaesthetists, pain specialists, pharmacists and physiotherapists are all involved in the management of surgical pain, teamwork is essential. Professionals must reach clear agreement as to their individual roles so that patients receive the best possible care from preadmission through to discharge (Audit Commission 1997).

A wide variety of pharmacological and non-pharmacological techniques are available for the management of surgical pain. The following basic principles apply to their use (Box 9.13).

Box 9.13 Principles of surgical pain management

Tailor the treatments to:

(a) meet individual needs

(b) prevent pain, rather than allowing it to become established.

Whenever possible, choose the simplest and safest techniques to achieve the desired level of pain relief (McQuay et al. 1997).

Use the WHO analgesic ladder (see Figure 9.12) to select the most appropriate analgesics for mild, moderate and severe acute pain.

Choose the most appropriate route for giving analgesia.

Combine techniques to provide balanced analgesia and enhance overall pain control (Kehlet 1997).

Ensure patients receive regular