Editing Fundamentals of Nursing (section)

== Pain management ==

Pain is whatever the experiencing person says it is, existing whenever the person says it does. Self report is the gold standard. Vital signs may rise with acute pain but often normalize in chronic pain, so normal vital signs never disprove pain.

Classification:
* '''Acute''' pain has an identifiable cause and an expected resolution. '''Chronic''' or persistent pain continues beyond expected healing, generally longer than three months.
* '''Nociceptive''' pain arises from tissue damage and is somatic (sharp, well localized) or visceral (dull, cramping, poorly localized, often referred).
* '''Neuropathic''' pain arises from nerve damage and is described as burning, shooting, electric, or tingling. It responds better to adjuvants such as gabapentinoids and certain antidepressants than to opioids alone.
* '''Breakthrough''' pain is a transient flare over controlled baseline pain.
* '''Phantom limb''' pain is real neuropathic pain after amputation and must never be dismissed.

Assessment mnemonics: PQRST (provocation and palliation, quality, region and radiation, severity, timing) and OLDCART (onset, location, duration, characteristics, aggravating factors, relieving factors, treatment). Scales must match the patient: the 0 to 10 numeric rating scale for most adults, the Wong Baker FACES scale for children roughly three years and older, FLACC (face, legs, activity, cry, consolability) for infants and nonverbal children, and PAINAD or the Critical Care Pain Observation Tool for adults who cannot self report, such as those with advanced dementia or on mechanical ventilation.

Nonpharmacologic interventions: repositioning and splinting, heat for muscle spasm and stiffness, cold for acute injury, inflammation, and swelling, massage, distraction, guided imagery, relaxation breathing, music, and transcutaneous electrical nerve stimulation. Apply heat or cold with a barrier, limit application to roughly 15 to 20 minutes, and check the skin frequently, particularly in patients with impaired sensation.

Pharmacologic principles: use the least invasive effective route, dose around the clock rather than as needed for continuous pain, and medicate before pain becomes severe and before painful activities such as dressing changes or ambulation. For patient controlled analgesia, only the patient presses the button. Family members and staff must never press it for the patient, because the patient's own sedation is the built in safety mechanism.

Opioid adverse effects: constipation is the one effect to which tolerance does not develop, so start a bowel regimen with the opioid. Sedation reliably precedes respiratory depression, so a rising sedation score is the earliest and most useful warning sign. Naloxone reverses opioid induced respiratory depression, and the patient must be monitored afterward because naloxone has a shorter duration of action than many opioids. Pruritus, nausea, and urinary retention are also common. Physical dependence and tolerance are expected physiologic responses and are not the same as addiction.