Pain Management For The Inpatient: Part I · person says it is, existing whenever he or she says it does.”10 Nurses must rely on the patient’s description of pain, as well as

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 1

Pain Management

For The Inpatient:

Part I

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor,

professor of academic medicine, and medical

author. He graduated from Ross University

School of Medicine and has completed his clinical clerkship training in various teaching

hospitals throughout New York, including King’s County Hospital Center and Brookdale

Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and

has served as a test prep tutor and instructor for Kaplan. He has developed several medical

courses and curricula for a variety of educational institutions. Dr. Jouria has also served on

multiple levels in the academic field including faculty member and Department Chair. Dr.

Jouria continues to serves as a Subject Matter Expert for several continuing education

organizations covering multiple basic medical sciences. He has also developed several

continuing medical education courses covering various topics in clinical medicine. Recently,

Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s

Department of Surgery to develop an e-module training series for trauma patient

management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy &

Physiology.

Abstract

Pain is an individualized concept that requires an equally individualized

solution. Every patient feels and responds to pain differently, and it is critical

that pain management strategies for inpatients be tailored to each specific

patient in order to provide adequate pain relief. A variety of analgesics and

alternative treatments are available to assist with pain management, and

nurses need to be familiar with these solutions for their patients’ benefit.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 0.5 hours (30 minutes).

Statement of Learning Need

Every person experiences pain differently. Nurses in the inpatient setting are

required to evaluate pain on an individual basis to determine the type of

medication and other therapies needed.

Course Purpose

To provide nursing professionals with knowledge of pain in the inpatient

setting, varied pain assessment tools and treatments.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 7/14/2018

Please take time to complete a self-assessment of knowledge, on

page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned

will be provided at the end of the course.


1. Which is an example of traumatic neuropathic pain?

a. Compartment syndrome

b. Diabetic neuropathy

c. Varicella zoster virus

d. Phantom limb pain

2. Which of the following is a true statement regarding pain

assessment?

a. Most patients overemphasize how much pain they are having.

b. Pain should be reassessed 5 minutes after providing pain

management measures.

c. Pain assessment is universally accepted as the “5th vital sign.”

d. The patient’s history, culture, and personality should all be included

as part of the pain assessment.

3. Which of the following is an example of a full agonist opioid?

a. Morphine

b. Buprenex

c. Elavil

d. Nubain

4. All of the following are common medications used with patient-

controlled analgesia except:

a. hydromorphone.

b. morphine.

c. codeine.

d. fentanyl.

5. Mind-body therapies for pain control include:

a. transcutaneous electrical nerve stimulation.

b. massage.

c. distraction.

d. acupressure.


Introduction

Pain is a personal, subjective experience that can only be described by the

person experiencing it. There is no physical method of measuring the quality

or intensity of pain; rather, the patient who is in pain is the only person who

can say how much something hurts. Pain is “whatever the experiencing

person says it is, existing whenever he or she says it does.”10 Nurses must

rely on the patient’s description of pain, as well as the patient’s report of the

success of pain relief measures. While it is the nurse’s responsibility to

provide pain relief for the inpatient experiencing pain, the patient is the only

one who must endure the situation that is causing pain, and is the one who

relies on the nurse to help manage his or her pain.

Types Of Pain

Pain differs for each person who is experiencing it. A specific type of pain

may only be a small amount of discomfort for one person, while pain in the

same location or from the same type of injury may be quite severe for

another patient. Pain may also be divided into acute and chronic types of

pain. The kind of pain the patient is experiencing affects assessment of the

patient’s condition and impacts pain treatment.

Acute pain occurs for a shorter duration and is classified as occurring for six

months or less. Acute pain may also only last for a few seconds or minutes

before resolving. Acute pain may be severe when the pain begins but often

resolves with time and treatment.4 Acute pain causes a stress response in

the affected person, such as an increased heart rate and rapid breathing, but

this response typically ends when the pain is resolved and the tissue has

healed.5 Examples of situations where a patient may experience acute pain

include surgery, burns, or cuts to the skin.


Chronic pain differs from acute pain in that it can last for a much longer

period of time, yet it may not be any more tolerable than acute pain

sensations. Chronic pain lasts for longer than six months, and if an injury

has caused the initial pain, the discomfort continues even after the initial

injury or condition has been treated.4 Chronic pain does not elicit a stress

response from the affected person because over time, the patient becomes

more accustomed to the pain. A patient may be admitted for treatment that

causes acute pain, yet already be suffering from chronic pain as well. A

patient may develop a physiologic stress response to the acute pain from

procedures or surgery, however, as the body’s response to chronic pain is

continuous and he or she may have adapted to it. Over time, chronic pain

can be very debilitating, resulting in other complications such as depression,

irritability, and difficulties with sleeping.5 Examples of conditions that may

result in chronic pain include pain from autoimmune disorders such as

arthritis, cancer pain, or low back pain.

Neuropathic Pain

Neuropathic pain occurs when a person experiences pain related to changes

in nerve fibers, usually resulting from a type of injury or disease process.

The person who experiences neuropathic pain may have no obvious injury,

but still has pain because of how his nerves impact the rest of his body.

Neuropathic pain causes damage to the nerve fibers, which continue to send

messages to pain centers throughout the body.1 Neuropathic pain may also

develop if the pain centers of the brain are damaged and do not receive

messages correctly.4

Neuropathic pain may be classified into different categories, depending on

whether co-existing conditions are present as well as how the pain has

developed. Traumatic neuropathic pain occurs when the nerves have been


injured as a result of some type of traumatic event. The injured nerves

continue to send incorrect pain signals to the brain, whether the injury to

the body healed or not. An example of traumatic neuropathic pain is

phantom limb pain, in which a person who has had an amputated limb

continues to feel pain in the missing extremity.2

Metabolic neuropathic pain occurs when a person experiences sensory pain

as a result of complex medical disorders that affect the metabolic system,

such as malnutrition or diabetes.2 One of the most common conditions

causing metabolic neuropathic pain is diabetic neuropathy. The patient with

diabetes may suffer from nerve damage as a result of uncontrolled blood

glucose levels, resulting in pain, numbness, burning, or tingling in the distal

extremities.

Infectious neuropathic pain develops from an infection in the body that

causes nerve damage and subsequently, chronic pain that may be constant

or intermittent. Examples of infections that can cause neuropathic pain

include post-herpetic neuralgia, caused by varicella zoster virus that causes

chickenpox and shingles; infection with Lyme disease or HIV, and Guillain-

Barré syndrome, which causes pain, weakness, and paralysis when it

develops after a viral infection.2

Autoimmune pain develops as a result of injury to the nerves from certain

autoimmune disorders that attack the body’s own cells. Chronic

inflammatory demyelinating polyneuropathy occurs when the myelin sheath

over the nerves becomes damaged, resulting in pain in the extremities.

Compressive pain is another type of neuropathic pain that results in physical

damage to the nerves as a result of stretching, pinching, or squeezing of the


nerve fibers. Examples of this type of pain include carpal tunnel syndrome

and compartment syndrome.2

Toxic causes of neuropathic pain result in damaged nerves due to exposure

of toxic substances. Chemicals such as lead, mercury, arsenic, thallium,

lithium, chemotherapy drugs; antibiotics, such as isoniazid and

metronidazole; and some cardiovascular medications, including captopril and

amiodarone can all cause neuropathic pain with exposure.3

Somatic Pain

Nociceptive pain occurs as a response to stimuli that are perceived by the

body as being painful. This type of pain stimulates the nociceptors in the

body, which are nerves that transmit signals in response to harmful or

noxious stimuli in the environment. Nociceptive pain is categorized as being

somatic pain or visceral pain.10

Somatic pain develops when the nerves send pain messages to the brain

because of cell injury to body areas containing connective tissue. Somatic

pain is pain that occurs in areas such as the bones, joints, muscles, or the

skin. It may be further classified as cutaneous somatic pain and deep

somatic pain.

Cutaneous pain often develops in superficial tissues and is less traumatic to

the body. It may be described as sharp or burning when the patient explains

it. Examples of injuries that can cause cutaneous somatic pain include skin

abrasions or lacerations. Deep somatic pain is often caused by trauma to

deeper tissues in the body, such as the bones or muscles; it may be caused

by trauma and the pain is usually much more intense. Examples of injuries

that can cause deeper somatic pain include broken bones or torn ligaments.4


Visceral Pain

Visceral pain occurs as pain affecting internal organs and tissues, such as

the heart, gastrointestinal system, or the kidneys.4 A person feels visceral

pain when nociceptive pain receptors in the organs respond to painful

stimuli.10 The pain may develop through part of a disease process, which

results in cramping or tissue spasms, or in ischemia development at the site.

Visceral pain may also occur as a result of injury, or through some type of

medical procedure, during which the organs and tissues are moved,

stretched, or manipulated, resulting in pain.9

Visceral pain may be difficult to localize and the pain may be initiated at one

point in the body but may radiate to another area of the body. When the

pain radiates, it may be difficult to determine the initial location of the pain

and whether an injury has occurred. Visceral pain is sometimes described as

cramping, squeezing, or a feeling of pressure.7 The intensity of the pain may

also vary, from mild and intermittent discomfort, to severe and agonizing

pain. Often, the person experiencing visceral pain may also suffer from a

feeling of doom or dread, wondering if the pain is a sign of something larger

that is life threatening.9 Because visceral pain is internal, it is difficult to see

the cause of the discomfort, which can be disturbing and frightening for the

affected patient.

Assessing Pain

Assessing the patient for pain is important for not only understanding how

much pain he is having and how to treat that pain, but it is also essential for

understanding how to care for the whole person. A patient in pain may also

have other complications and issues that need to be managed as part of his

or her care, such as difficulties with eating, problems with concentration, or


impaired mobility. The patient taking pain medications may develop

constipation. The location and the source of the pain can significantly impact

a patient’s abilities to perform tasks, such as activities of daily living.5 Pain

assessment is one aspect of assessing the patient’s total needs, including

physical, psychological, and emotional matters that may develop when

receiving care as an inpatient.

Some locations refer to pain assessment as the “5th vital sign,” naming it in

this method to state that assessing and responding to pain should be as

important as assessing blood pressure, heart rate, and other vital signs.

Some experts disagree about pain being the 5th vital sign, instead indicating

that other measures, such as oxygen saturations, should be in this position

instead. Regardless, pain assessment is crucial enough for the patient’s well

being that it should be given the same priority as other assessment tools,

such as assessment of vital signs.10

Pain assessment should occur at regular intervals in order to ensure that

adequate pain management is taking place. Pain should be assessed at

regular times during a nursing shift, such as during vital sign assessment.

Additionally, the patient’s pain should be assessed upon admission to the

facility or the unit, any time a procedure is performed that may produce

pain, whenever the patient reports changes in sensation or an increase in

pain, and 15 to 30 minutes after providing analgesia or adjuvant therapy to

determine its effectiveness.7

Many patients will not voice their pain, despite its presence and severity.

Some people do not want to be labeled as complaining, or they feel that

nurses are too busy to take time out to provide more medication or therapy

for pain. They may believe that pain is a normal part of hospitalization and


may not feel the need to vocalize it. There are people who feel that

expressing pain is too personal and they do not wish to share that part of

themselves, preferring to remain stoic. Finally, some patients do not notify

their nurses that they are having pain because they fear what the outcome

might be, such as potentially negative side effects of receiving narcotic

medications or possibly needing further tests.10 Because there are so many

reasons why patients may not talk about their pain, it is the nurse’s duty to

assess pain and ask the patient if he or she is experiencing discomfort so

that it can be managed.

How a patient perceives pain is affected by several factors that are particular

for each individual. A patient’s level of pain tolerance, cultural background,

expectations for pain management, and previous experiences with pain all

impact the patient’s responses to a current situation. These factors should

also be recognized as part of the pain assessment process because they

impact pain response.5 Two of the most common causes of unrelieved pain

among patients are inadequate pain assessment measures and failure to act

on patient reports of pain.

Adequate pain assessment involves determining the location, intensity, and

duration of the patient’s pain, relying on the patient’s use of words or

descriptions of discomfort felt. Providing adequate pain control then means

acting on how the patient has expressed pain to the nurse in order to

provide pain relief, as well as evaluating the effectiveness of therapy to

determine its success or whether further measures are necessary.6

Location

The location of the pain is described as where the patient is experiencing it.

This may or may not be the actual site of injury or illness that is causing the


pain. If the patient is experiencing pain that is radiating, he or she may feel

it at the source of the pain, as well as in the surrounding tissues. When a

patient experiences an injury such as an arm fracture, he or she may feel

pain at the site of the fracture, but may also have pain through the length of

the arm, near the site of the break. Alternatively, referred pain occurs when

the source of the pain is in one part of the body, but the patient feels pain in

a completely different area.10 An example of referred pain may be when a

patient is having a heart attack but is not having chest pain; instead, he or

she only feels pain along the jaw. Referred pain most commonly occurs in

situations where a patient is experiencing visceral pain.

To determine where the patient is feeling pain, the nurse should ask the

patient to point to the place where it hurts, rather than only trying to

describe the area or region. A body diagram may also be useful for some

patients to point to affected areas in the picture and can be particularly

helpful if a patient is experiencing pain in more than one location.10 If the

patient has an injury that is apparent, such as a wound or contusion at a

specific site on the body, it would seem logical that this point is the location

of the patient’s pain. Despite having an obvious injury, the patient needs to

be the person to state where the pain is located. There may be more than

one location of pain, which could indicate another injury, or the patient may

be feeling pain associated with a different condition that is unrelated to the

obvious injury.

Duration

Duration refers to how long the patient has been experiencing the pain. It

may also explain if there are any factors that caused the pain. Knowing if

there are any precipitating factors can give the nurse a better idea of the

overall duration of the pain. A patient may have been participating in certain


activities that initially caused the pain; for example, he or she might have

been jogging to get some exercise and then developed chest pain. If the

patient jogs every morning, the clinician has a better idea of when the pain

started for the patient.

The patient may also know the specific time of when the pain started or be

able to tell the nurse exactly how long it has occurred. A description of pain

duration also includes whether the pain is constant or intermittent; if

intermittent, the patient should try to describe the intervals, such as the

length of time between episodes of pain. If the patient is currently between

pain intervals, he or she will need to explain how long it has been since a

painful episode occurred.10

Description

The nurse must pay careful attention to the type of words the patient uses

to describe pain. At times, it may be difficult for the patient to come up with

the words or appropriate description to explain the type, intensity, or

location of pain. There are some tools available that the nurse may use to

help the patient come up with the right words to describe the pain felt.

The OLD CARTS mnemonic can be used to help a patient to describe the

location and intensity of his or her pain. The mnemonic is used as:8

Onset: when did the pain start or how long has it been going on?

Localized: where is the pain?

Description: explain how the pain feels: burning, aching, sharp,

stabbing, throbbing

Characteristics: describe the pain’s intensity

Aggravating: is there anything that makes the pain worse?


Relief: what factors would improve the pain or provide pain relief?

What treatments have been done for the pain?

Time: how long have you had the pain and has it been constant or

intermittent?

Symptoms: has the pain had an impact on any other of your daily

activities, such as eating, sleeping, or mood?

A simpler method of describing pain intensity would be to ask the patient if

he or she is having pain and if the pain could be described as mild,

moderate, or severe. This pain assessment tool may need to be used in

conjunction with assessment of nonverbal symptoms that indicate pain

severity. In addition to using words to describe the pain, the patient may

also exhibit other non-verbal behaviors that indicate his discomfort.

Activities such as fidgeting or squirming, grimacing, crying, or guarding

painful sites are all indications that the patient may be experiencing pain.

Pain can also cause sleep disturbances, decreased self-esteem, diminished

social interactions, irritability, a lack of interest in eating, and confusion or

impaired thinking.4

In addition to assessing pain severity, location, and duration, part of the

pain assessment process is asking the patient what he or she understands

about the pain felt.10 A patient may be completely aware of why he or she is

having pain and understands the reasons for its existence; for example, a

patient who had surgery and who has pain at the surgical incision site may

completely understand the logic for why he or she is feeling pain in that

location.

Alternatively, some patients may not understand why they are having pain.

They may believe that they are experiencing pain because they did


something wrong, or, if they have referred pain, they may not understand

why the pain is not located at the source of the injury or illness. Asking a

patient what is known about his or her pain provides an opportunity for

education about how the body processes injuries or illness and may better

explain why some procedures or treatments are necessary.

Numerical Rating Scale

The numerical rating scale is one of the most commonly used methods for

assessing a patient’s pain. Because pain cannot be objectively measured but

instead relies on the patient’s own admission of pain level, this type of scale

can adequately explain the level of intensity the patient is experiencing in a

method that is easy to understand.

The numerical rating scale is appropriate to use for most adult inpatients

who are cognitively aware and who are awake to be able to respond. The

numerical rating scale asks the patient to rate pain on a scale of 0 to 10. A

score of 0 means the patient has no pain, while a score of 10 is the worst

pain imaginable. The patient gives a number somewhere on the scale to

describe his or her current level of pain.7

Some facilities assess a patient’s pain tolerance upon admission to the

facility by explaining the numeric rating scale and asking not only what the

patient’s current level of pain is, but also what number would be an

acceptable level of discomfort. For example, a patient may rate pain felt at a

‘7’ on the numeric rating scale, but may also say that the pain can be

tolerated that would be rated at a ‘2.’ For this patient, a level of pain

described as a ‘2’ may be quite tolerable, while some other patients may

tolerate pain classified as a ‘6’ and others may only be comfortable at a level

of ‘0.’ Understanding the patient’s tolerable level of pain can guide clinicians


to knowing whether pain management measures are working and whether

the nurse is keeping the patient comfortable.

Assessing Children Using FACES Rating Scale

Other assessment measures are available for some patients who cannot

speak but who are cognitively aware. The Wong-Baker FACES pain rating

scale has a series of faces with different expressions that may explain how

much pain a person is having. At one end of the scale, the equivalent of a ‘0’

on the numeric rating scale, the face is smiling and appears happy,

indicating no pain. Moving down the scale, the expressions of the faces

become progressively sadder or appear to be having more pain. At the

opposite end of the scale in the position of a ‘10’ on the numeric rating

scale, the face is crying and appears to be in significant pain. The patient

who cannot talk can use this type of scale to point to which face most closely

resembles the level of his or her pain. The Wong-Baker FACES scale may

also be used for children ages 3 and older.

Pain may be difficult to assess among patients who are cognitively impaired

and who have difficulty expressing their level of pain on a numerical scale.

During these situations, it is important to assess for visual signs of pain in

the patient and provide pain relief measures if the patient is showing

nonverbal cues that indicate pain, such as fidgeting, grimacing, crying,

moaning, being aggressive or disruptive, rocking, or pacing. Additionally,

physiological changes may also be present, even if the patient is unable to

state that he or she is in pain. Signs include an increased heart rate,

increased respiratory rate, increased blood pressure, dilated pupils, or

sweating.8


When assessing a very young child or infant who cannot describe his or her

pain, the nurse must use another form of pain assessment technique. There

are several types that have been developed for use in this population, when

giving a numeric score is not possible. Examples include the CRIES scale

(crying, requires oxygen, increased vital signs, expression, sleepless), the

Neonatal Facial Coding System (NFCS) or the Child Facial Coding System

(CFCS), and the FLACC (faces, legs, activity, cry, consolability) score.8

Beyond performing adequate pain assessments, it is important to provide

appropriate treatment based on what the patient says his or her pain level

is. It is not enough just to assess and document the patient’s pain;

treatment through medications and adjuvant therapies, based on the

patient’s reports of pain and provided at levels that are appropriate for

treating the amount of pain present are essential components of nursing

care to provide for pain relief.6

Pharmacotherapy

The concept of pain management means providing treatment for a patient’s

pain in order to eliminate the pain or reduce it to a level that is tolerable.10

In many inpatient situations, this is accomplished through the use of

pharmacotherapy. While the physician is the person to prescribe what

medications to give for pain relief as well as a schedule for when to give

them, the nurse must use clinical judgment to determine whether a type of

pain medication is effective or if it is causing adverse effects. In some cases

when a medication is to be given as needed instead of on a set schedule, the

nurse must use judgment about the appropriate times to give the

medication, as well as when to hold back from giving it, depending on the

patient’s condition.


Opioids

Opioids are medications given to provide pain relief by binding to certain

receptors in the spinal cord, which then blocks the perception of pain in the

brain. Opiates may be made of natural substances or they may be synthetic.

Opiates are not the same as narcotics, although the two terms may be used

interchangeably. Opioid medications are used specifically for pain control

because of their action, while narcotics may be used for other purposes

beyond pain relief.10

As nurses administer opioid medications for pain relief among patients, they

must understand the fine balance between providing enough to manage pain

while avoiding potential side effects of too much medication. In order to

provide safe care, the nurse must understand the power of opioids and give

enough to control pain while minimizing negative effects, such as sedation,

respiratory depression, or confusion, that may develop with these drugs.

Among hospitalized patients, opioid medications are the most common types

of drugs given to control pain.18

Opioid analgesics are powerful pain relievers that are often used for patients

who are suffering from significant pain. There are three types of opioids:

agonists, agonist-antagonists, and partial agonists. Full agonists work in a

manner similar to endorphins in the body, and increasing amounts of these

drugs continue to increase pain control and sedation levels. Examples of full

agonist opioid drugs include morphine, codeine, and hydromorphone.10

Agonist-antagonist analgesic medications work by blocking some nerve

receptor sites while stimulating other nerve receptor sites. If a patient is

already taking an opioid analgesic, an agonist-antagonist medication may

reduce its effectiveness. However, these drugs can be very effective for use


without other opioid medications in place. They do have a ceiling effect in

that giving higher or more frequent doses will not necessarily continue to

produce more pain relief. Examples of agonist-antagonist medications

include butorphanol tartrate (Stadol®) and nalbuphine hydrochloride

(Nubain®).10

Partial agonist medications, like agonist-antagonist medications, have a

ceiling effect and so their use is limited. However, these drugs may be used

when other opioid medications are not available or in cases when a patient is

unable to take other kinds of medications for pain relief. Partial agonist

medications work by blocking certain nerve receptor sites while binding to

others. An example of this medication is buprenorphrine (Buprenex®).10

There are several methods of delivery of opioid medications; and, the

selection of which method to administer is based on the patient’s condition

and the ease of taking the medication. The oral route is preferable among

patients who must take opioid medications on a long-term basis. It is the

easiest and cheapest method of administration and can be used among

patients who are conscious, have the ability to swallow, and who do not

have gastrointestinal issues that would preclude its action.20

Some patients who cannot take medication by mouth may receive drugs

through the rectal route. Both morphine and hydromorphone are available

as rectal suppositories. Not all patients tolerate this route, and it is not

usually considered as a first choice for most people. It should also not be

used among patients who have diarrhea or those with breakdown in or

around the anus and rectum. However, rectal administration of medications

can be effective for other patients who have limited alternative routes for

taking medication and the drugs are usually absorbed relatively quickly


through the intestinal mucosa. Fentanyl is available in the transdermal form;

this method involves placing a patch on the skin and the medication is slowly

absorbed. It can provide analgesia for up to 72 hours but it may take several

hours before effective analgesia levels are achieved.20

Other methods of administration of opioid medications that are more

invasive include subcutaneous, intramuscular, intravenous, and intraspinal.

Subcutaneous administration involves injecting the medication with a needle

into the subcutaneous fat under the surface of the skin. The injection can

only be given in certain locations, such as the abdomen or upper arm, where

the patient is more likely to have fatty tissue present, as compared to other

areas. The intramuscular route also involves injecting medication into the

patient, but the needle must be longer and the injection goes much deeper

into muscular tissue. Common areas used are the deltoid muscle of the

upper arm and the ventrogluteal muscle of the hip. Because this method of

administration can be quite painful for the patient, it is often avoided in

favor of other routes.20

Intravenous (IV) administration involves injecting medication directly into a

patient’s vein. The patient must first have an IV line in place. This route can

be quick and effective and can be used on patients who would otherwise

have difficulty taking medications in other methods, including patients who

are unconscious. The intraspinal method of administration involves injecting

medication into a catheter that has been placed in the epidural space of the

spine. This method may be used for patients who need long-term analgesia

and as an alternative to other routes.20

Patient-controlled analgesia (PCA) is a process that was developed to allow a

patient to have more control over pain by administering his or her own


doses of medication through a machine. The patient has an intravenous line

for fluids and medication administration and is connected to the PCA

machine. The machine contains a syringe with the prescribed medication in

it, which is set to deliver a specific amount of medication to the patient when

a button is pushed. Some settings offer a basal or continuous dose and the

patient can supplement the pain medicine when the need for more pain relief

occurs. Other situations the PCA is set up to give occasional doses of pain

medicine when the patient needs pain relief.

A PCA machine can reduce the need for the patient to depend on the nurse

for bringing pain medicine. At times, it may be difficult to answer call lights

and to bring medication in a timely manner, before pain becomes out of

control for the patient. With PCA, the patient can push a button to deliver

pain medicine when pain is felt, potentially stopping it before it worsens. The

machine is set to deliver only a certain amount per hour so that the patient

does not receive too much. It will lock out so that even if the patient

continues to push the button, he or she will not receive any more

medication. This safety feature prevents accidental overdosing of opioid

medications. Additionally, patients typically use PCA for themselves, without

someone else pushing the button for them. The safety in this feature is that

if the patient becomes sedated after receiving a bolus of medication, he or

she will not be able to receive more. The most common medications used

with PCA include morphine, fentanyl, and hydromorphone.19

The nurse is typically responsible for setting up the PCA and changing the

medication syringe when it becomes empty. Use of the PCA does not

eliminate the need for continued assessment and patient monitoring. The

nurse must still assess the patient’s level of pain to determine if the PCA is

providing adequate pain relief. If the nurse sets up the PCA, he or she


should check the settings with another nurse to determine that they are

correct and to avoid accidentally giving the patient too much opioid

medication.

Non-opioids

Non-opioid analgesics are drugs that are typically used for mild to moderate

pain relief. These medications may be provided for patients by prescription

when in the hospital; they may also be bought over the counter. There is a

ceiling as to how much analgesia these medications can provide, so giving

more or repeating doses in an effort to increase comfort may not be

effective or safe.20

Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications such as

ibuprofen or aspirin. These drugs provide mild to moderate pain relief, they

reduce inflammation, and they can help to control high fever. Patients who

take these drugs may be at higher risk of bleeding, as they can have an

anticoagulant effect. Other side effects of NSAID use are gastrointestinal

irritation or bleeding and acute renal failure.20 NSAIDs work by blocking an

enzyme known as cyclooxygenase (COX), which is needed for creating

prostaglandins, the substances in the body that set off pain signals.

Cyclooxygenase may be classified as COX-1 or COX-2, and different

medications inhibit the different types. For example, aspirin and ibuprofen

are COX-1 inhibitors, while celecoxib (Celebrex®) is a COX-2 inhibitor.10

Acetaminophen is another non-opioid analgesic that is effective for reducing

mild to moderate pain and as a fever reducer. Tylenol® is an example of this

type of medication. Acetaminophen does not have anti-inflammatory effects,

but it also does not have the same type of adverse side effects that are


found with NSAIDs, such as an anticoagulant effect or gastrointestinal

bleeding.20

Adjuvants

Other medications may be combined with analgesics to provide more

effective pain control. Adjuvant medications, also called coanalgesics, are

those that are not designed for analgesia and when used alone, have other

purposes. However, when combined with opioid or non-opioid analgesics,

there can be a greater effect on pain relief.10 The World Health Organization

(WHO) has designed a pain control ladder to guide clinicians toward

choosing and administering medications for pain relief. The WHO

recommends combining medications such as adjuvants and opioid analgesics

to provide more effective relief than when using only one type of analgesic

at a time. Therefore, if possible, the patient can derive better pain relief

when the nurse administers medications in combination.21

Antidepressants may be used in combination with analgesics for better pain

control. Tricyclic antidepressants can affect how the body perceives pain by

interfering with the reuptake of the neurotransmitters serotonin and

norepinephrine in the brain. An example of a tricyclic antidepressant that

may be used as a coanalgesic is amitriptyline (Elavil®).10

Medications normally used as anticonvulsants may also be beneficial as

coanalgesics. Anticonvulsants may work well as adjuvant therapy because

they suppress neuron firing for seizure control, which may also be helpful for

some types of pain, particularly neuropathic pain. Examples of these types

of drugs include gabapentin and carbamazepine.25

Other drugs may also be used as adjuvant therapy in addition to analgesics

because their effects can reduce or eliminate other symptoms that are


commonly associated with pain. Corticosteroids may be administered with

analgesics to reduce swelling or inflammation that can develop and cause

pain in some conditions. Benzodiazepines, normally prescribed to manage

anxiety, depression, or insomnia, may also be given as part of pain

management. When combined with analgesics, benzodiazepines can help to

reduce muscle spasms and improve release of tension that may accompany

pain.25

Epidural Analgesia

Epidural analgesia involves administering medications for pain control into a

catheter that has been placed in the epidural space in the spinal column. The

epidural space lies between the meninges covering the spinal cord and the

walls of the vertebral canal. The space contains spinal nerves, as well as

blood vessels and adipose tissue. When it is cannulated and medication is

administered, pain control can be achieved because the medication can

quickly impact pain receptors in the nerves of the spinal cord, blocking pain

messages to the brain.

In some situations, a patient receives medication that also causes parts of

the body to become numb, in a process known as epidural anesthesia.

Epidural anesthesia is often provided for patients undergoing surgical

procedures, so that they can stay awake during the procedure but not

encounter pain; for instance, this process is frequently used during cesarean

sections. Providing analgesia through an epidural differs in that medications

are used for pain control but not necessarily to eliminate sensation

entirely.16

A physician or anesthesiologist must place the epidural catheter, but when it

is an indwelling catheter, the nurse is typically responsible for caring for the


patient while the catheter is in place. The medication may be provided

through a continuous infusion, through a bolus injection, or through a

patient-controlled module.16 Epidural analgesia can be used in many

different kinds of situations to manage pain, such as during or immediately

following surgery, after treatment for traumatic injuries, and to manage

chronic pain, such as among patients who have ongoing cancer-related pain,

back pain, or severe osteoporosis.17

An epidural catheter may be placed at various points along the spinal

column. The tip of the catheter can be positioned to affect specific nerves

along the spinal cord, each of which affects different areas of the body.

There is a risk of placing the catheter in a position that can block certain

nerves that will ultimately result in patient complications; for instance,

placing an epidural catheter too close to nerves that affect motor activity can

result in problems with muscle function or paralysis for the patient.16

Although it is the physician’s job to insert the epidural catheter and ensure

that it is in the correct place, the nurse may either assist the physician with

catheter placement or may care for the patient after the epidural is in

position. During the placement procedure, the nurse is responsible to assist

the physician and monitor the patient; and, if the patient has an adverse

reaction because of nerve stimulation, the nurse must act quickly to respond

and provide care. Additionally, when caring for a patient who has an

indwelling epidural catheter, the nurse must be aware of the potential risks

and complications of this placement as her or she makes decisions for

providing patient care, such as by moving the patient or providing help

during ambulation.


The most common opioid medications used for pain relief through epidural

analgesia are fentanyl, morphine, and hydromorphone. The type and

amount of analgesia given depend on the patient’s condition and needs for

pain relief. Some analgesics, such as fentanyl, have a rapid onset and

provide pain relief quickly for the patient, but may also wear off quickly.

Alternatively, a medication such as morphine may be given through an

epidural catheter and can take longer to start working, but its effects for

pain relief may last much longer.16

When caring for a patient who has an epidural for pain control, the nurse

must perform regular checks of vital signs, including frequent blood pressure

readings, as hypotension is a potential side effect of using this type of

treatment. The nurse should also ensure that the patient is receiving

adequate pain control. The physician may prescribe other analgesics to be

administered as needed in addition to the medication provided through the

epidural. Other nursing considerations that are part of caring for a patient

with an epidural are to monitor the insertion site to ensure patency. The

epidural catheter is typically covered with a dressing, taped, and secured

very well to the patient’s skin on the back. However, the nurse should check

the site as a regular part of assessment to ensure that it has not become

dislodged or moved in any way. The nurse should also determine if there are

any local reactions at the site, such as redness, swelling, or rash.

Side effects of epidural analgesia are often associated with the catheter’s

effect on specific nerves, or are local reactions to having the catheter in

place in the body. With an epidural, the patient is at higher risk of vital sign

changes such as bradycardia, hypotension, and respiratory depression.

Opioid medications administered through the epidural may cause side effects

such as nausea and vomiting. Patients often complain of widespread itching,


and a rash may or may not develop. Finally, epidural placement puts the

patient at risk of a postdural headache, which is severe head pain associated

with leakage of fluid around the dura when the space is cannulated during

placement. Often, the pain is relieved when the patient lies down and

worsens when sitting or standing upright. The nurse must be aware of the

potential complications associated with epidural analgesia and work to

manage these effects if they do occur, such as by providing medication to

control undesirable side effects, monitoring vital signs and managing

negative changes, or assisting the physician with correcting complications.17

Nerve Block

A nerve block is a pain control measure that involves injecting medication

into a specific nerve in order to numb a certain part of the body.11 The nerve

block is performed prior to a procedure or treatment to cause the area to

become numb enough that the patient does not feel pain associated with

treatment or for a period of time afterward. Anesthesia providers typically

administer nerve blocks, but nurses are often responsible for caring for the

patients with the blocks to ensure adequate pain relief.

To place a nerve block, the anesthesia provider first locates the main nerve

associated with the injury or affected area. For example, if a patient is

having surgery on his forearm, the anesthesia provider locates the main

nerve affiliated with the area, which is often the brachial plexus nerve.12 To

find the correct location of the nerve, the clinician uses an ultrasound to look

for the right nerve under the skin using an ultrasound machine. When the

correct nerve is identified, the provider can then apply the medication for the

block.


Using an ultrasound to locate a nerve for a block is becoming increasingly

common practice before surgical procedures or as part of providing

analgesia. Depending on the location of the nerve to block, the anesthesia

provider may need to use different types of ultrasound transducers to locate

the nerve. For example, there are some nerves that run close to the surface

of the body, just under the skin. A provider would need to use a slightly

different ultrasound method to locate these nerves when compared to those

nerves that run very deep into the tissues.12

The nurse may assist the anesthesia provider with placing the nerve block.

The main role of the nurse is to monitor the patient during the procedure,

ensure that certain items such as the ultrasound transducer and needles or

syringes are kept sterile; and assist the provider with certain tasks, such as

opening packages or adjusting the ultrasound machine to improve the

image.12 Alternatively, the correct nerve can also be found through nerve

stimulation. The nerve stimulator contains an electrode and a needle; each

item contains a lead, one of which has a positive charge and one has a

negative charge. The electrode is attached to the patient and the other lead

is attached to the needle. Using the needle, the provider locates the affected

nerve, which responds by twitching. Once the affected muscles respond, the

provider knows he has found the nerve associated with that area and that is

the nerve to block.11,12 The nurse assisting the anesthesia provider may

need to hold the nerve stimulator and adjust the frequency of the machine

while the physician searches for the nerve. Adjusting the machine’s

frequency may cause the nerve to twitch faster or more slowly, allowing the

provider to properly isolate the correct nerve.12

A patient is often monitored while a nerve block is being placed, and may be

connected to a monitor that displays heart rate, respiratory rate, and oxygen


saturation levels, in addition to regular blood pressure readings. Because

administering the block can be somewhat painful for the patient, he or she

may need analgesia or sedation prior to the procedure.

A nerve block has several distinct advantages for pain control for a patient.

If a patient is undergoing a medical procedure that will be painful, the

anesthesia provider can administer a nerve block to numb the area; the

patient may then remain awake during the procedure, yet feel little to no

pain. Whether the patient remains awake depends on the patient’s condition

and the procedure being performed. In some cases, the patient may need

some sedation, despite having a nerve block in place, in order to remain

calm during the process. A nerve block will help to better control a patient’s

pain after a procedure because the site is numb and often remains so for up

to 24 hours afterward. Additionally, a nerve block reduces or eliminates the

need for general anesthesia because the patient does not need to recover

from feeling drowsy and sedated or having nausea or vomiting often

associated with some anesthetics.15

In many cases a nerve block is placed as a single-shot injection, in which the

anesthesiologist injects the medication into the nerve, which numbs the

affected tissue until the medication wears off. During the next 6 to 24 hours,

the patient may have little to no feeling in the affected area, but this

gradually returns, along with potential pain. There are some cases where a

nerve block provides continuous effects, known as a continuous peripheral

nerve catheter. When this is placed, a catheter that appears similar to a wire

is threaded next to the nerve. The other end of the catheter is connected to

an infuser that controls that rate at which medication is delivered to numb

the nerve.


The continuous catheter may be kept in place for several days after a

procedure, which allows a patient to have more time to heal from a

procedure before the medication wears off, as would be the case with a

single-shot injection. The continuous catheter may also reduce the amount

of opioids or non-opioid analgesics a patient needs for pain control. It can

also decrease the amount of time it takes for a patient to return to activities

of daily living. Continuous peripheral nerve blocks are not only used for

surgical procedures, but have also been implemented in treating some

patients with cancer pain, complex regional pain syndrome, or phantom limb

pain.14

A peripheral nerve block may not be appropriate as a form of pain relief for

every patient. A patient who has an injury at the site where the block should

be placed should not have a block because placement could cause further

injury at the site. Because nerve blocking involves penetrating the skin,

those who have clotting disorders should also be considered very carefully

for this procedure, as placing the block puts that patient at an increased risk

of bleeding. Those who have peripheral neuropathy should also not have

nerve blocks for pain control, as associated nerves may be damaged and the

patient may already be suffering from peripheral numbness, tingling, or

pain.12

Most nerve blocks are placed as peripheral blocks, in which they are

designed to control pain for one part of the body, such as an extremity. They

are most often used to control pain in procedures affecting the arms,

shoulders, knees, ankles, feet, or hips. There are other types of nerve blocks

that may be used for more central locations, such as abdominal incisions. In

these situations, one or more of the thoracic nerves, such as the intercostal

nerve, may be targeted to provide pain relief. Ultimately, although there are


other central blocks available, they are a little more rare than peripheral

blocks and the clinician may instead decide to use a different type of pain

control, such as through an epidural when these situations warrant the need

for anesthesia.13

Alternative Therapies

Other methods of pain management may be helpful when used in addition to

or in place of pharmacologic therapy. These methods may impact the body

through physical means or may use cognitive or behavioral therapy to help

the patient to manage pain through psychological measures.

Nonpharmacologic therapies for pain control can help to relieve pain by

making the patient more comfortable and changing the way the body

perceives pain. Some types of nonpharmacologic measures that may be

used for pain control include massage, heat or cold therapy, and

transcutaneous electrical nerve stimulation. Massage involves kneading or

manipulating the muscles and tissues under the skin to promote relaxation

and stress relief. Pain can cause the muscles to contract and tighten, which

can cause further pain and tension for the patient. The massage practitioner

rubs and manipulates the muscles in various parts of the body, most

commonly the back, shoulders, arms, and legs. This results in improved

circulation to the tissues and greater relaxation and tension release.10

Inpatients in the hospital setting may also experience greater amounts of

anxiety and loss of sleep due to the situation causing the hospitalization or

the environment. Massage has been shown to help improve sleep among

these patients and to reduce tension that can contribute to anxiety.22

Improving sleep and anxiety can further supplement pain control measures.


Heat or cold therapy involves that application of warm or cold packs to

various sites on the body and may be used in areas where a patient is

feeling pain. This process may also include other measures such as warm

baths, heating pads, or ice massage. Application of these measures can help

with pain relief by assisting the body with tissue repair. Heat therapy

increases circulation to the affected site, which can increase range of

motion, improve joint stiffness, and relax the muscles. Alternatively, cold

therapy reduces the amount of blood flow to a site and may reduce swelling

of injured tissues. By decreasing circulation to an affected area, cold therapy

can also reduce inflammation.23

Transcutaneous electrical nerve stimulation (TENS) sends a small electrical

current to impact the nerves associated with pain for the patient. A TENS

unit is an electrical machine that has patches that are placed over the area

where the patient is experiencing pain. The machine sends the electrical

current through the electrode, which stimulates the fibers that regulate the

nociceptive impulses that send pain messages. TENS may also cause an

increase in release of endorphins, which can also help the patient to feel

better.10

In addition to physical activities that can improve pain relief, there are some

mind-body exercises that the patient can learn, which can change how he

responds to pain. These measures do not always relieve pain, but rather

help the patient to manage his body and his response to the pain. Pain can

cause the affected person to experience increased feelings of stress,

depression, or anxiety, which may further compound the feelings of pain.

Using mind-body techniques may help to regulate emotional responses to

pain and diminish these additional factors.24


Distraction is the process of focusing on some other aspect besides the pain.

When concentrating on something else, a distracted patient may be unaware

of the pain. Distraction can be used with visual methods, such as watching

television or reading a book; auditory measures, such as listening to music,

or physical distraction, such as massage, deep breathing, or moving

rhythmically.10

Other examples of mind-body techniques that can help with pain control

include relaxation, mindfulness, biofeedback, and cognitive-behavioral

therapy. Relaxation techniques help the muscles to relax, reducing tension

and producing an opposite effect of the fight-or-flight response.24 Relaxation

techniques such as progressive muscle relaxation, in which the patient

actively concentrates on tensing and then relaxing certain muscle groups, as

well as laughter as a form of relaxation therapy can improve a patient’s

mood and how he responds to pain. These methods have also been shown to

reduce inflammation and make the brain respond more to endorphins.24

Mindfulness is a form of distraction in that the patient focuses on other

aspects beyond the pain. Mindfulness involves control of thoughts to focus

on awareness of being as well as cultivating an attitude of acceptance. This

practice can also reduce the amount of emotional reaction that often goes

along with pain, helping the patient to focus on life and activity around the

pain.24

Biofeedback involves using thoughts to control certain body functions; for

example, biofeedback might involve using thought processes to slow a

racing heart rate. Biofeedback requires focus of attention toward making a

change in the body. A patient may watch certain measurements of body

functions, such as a blood pressure reading or heart rate monitor, and then


relax and focus the mind to change these functions. It is a process of

relaxation that can provide pain relief when a patient is in a relaxed state

and learning to control the sympathetic nervous system, thereby reducing

stress and tension that can contribute to pain.24

Summary

Pain continues to be a mechanism that drives people to seek treatment,

undergo procedures, or learn techniques to find ways to manage it. Because

so many hospital inpatients experience pain, understanding ways of

managing it and recognizing signs of its escalation should be a core

component of nursing care. Because pain is a personal, subjective

experience, the person experiencing it should be the one describing it. Pain

is whatever the person with pain describes it to be. Nurses must rely on the

patient’s description of pain, either verbally or through the aid of a pain

assessment tool, as well as the patient’s report of the success of pain relief

measures.

Please take time to help NurseCe4Less.com course planners evaluate

the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing

feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.


1. Which is an example of traumatic neuropathic pain?

a. Compartment syndrome

b. Diabetic neuropathy

c. Varicella zoster virus

d. Phantom limb pain

2. Which of the following is a true statement regarding pain

assessment?

a. Most patients overemphasize how much pain they are having.

b. Pain should be reassessed 5 minutes after providing pain

management measures.

c. Pain assessment is universally accepted as the “5th vital sign.”

d. The patient’s history, culture, and personality should all be included

as part of the pain assessment.

3. A patient is diagnosed with an acute myocardial infarction. He

has not had chest pain at all but instead only feels pain in his

jaw. Which type of pain is this example of?

a. Referred pain

b. Receptive pain

c. Radiating pain

d. Random pain

4. The “O” in the OLD CARTS mnemonic for assessing pain stands

for:

a. obtuse.

b. onset.

c. oxygen.

d. operate.


5. Which of the following is an example of a full agonist opioid?

a. Morphine

b. Buprenex

c. Elavil

d. Nubain

6. All of the following are common medications used with patient-

controlled analgesia except:

a. hydromorphone.

b. morphine.

c. codeine.

d. fentanyl.

7. Which of the following is a disadvantage of using

acetaminophen for pain control?

a. It has an anti-platelet effect and can cause excessive bleeding

b. It does not have anti-inflammatory properties

c. It has no ceiling effect and requires large doses on a regular basis

d. It can cause stomach irritation and bleeding

8. Which statement is true regarding epidural analgesia?

a. Epidural analgesia involves giving medication to control pain and to

block sensation in certain motor nerves.

b. Epidural analgesia is typically only used for patients undergoing

surgical procedures.

c. The epidural catheter is placed so that its tip lies between the

intravertebral space and the lowest layer of the dermis.

d. The patient who receives epidural analgesia is at risk of

hypotension, bradycardia, and respiratory depression.


9. Which of the following is an advantage of using a peripheral

nerve block for pain control?

a. The patient will be able to sleep throughout the surgical procedure

b. The affected site may remain numb up to 24 hours after a

procedure

c. The patient will not need any supplemental analgesia with a

successful nerve block

d. The affected site will heal faster with a nerve block than if general

anesthesia were used

10. Mind-body therapies for pain control include:

a. transcutaneous electrical nerve stimulation.

b. massage.

c. distraction.

d. acupressure.

Correct Answers:

1. D

2. D

3. A

4. B

5. A

6. C

7. B

8. D

9. B

10. C


References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. Bennett, M. I. (Ed.). (2010). Neuropathic pain (2nd ed.). New York, NY:

Oxford University Press, Inc.

2. Lema, M. J. (2014). Types of neuropathic pain. Retrieved from

http://www.neuropathy.org/site/News2?id=7775

3. Shields, Jr. R. W. (2014). Peripheral neuropathy. Retrieved from

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement

/neurology/peripheral-neuropathy/

4. Timby, B. K., Smith, N. E. (2014). Introductory medical-surgical nursing.

(11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins

5. Wilson, S. F., Giddens, J. F. (2012). Health assessment for nursing

practice (5th ed.). St. Louis, MO: Elsevier Mosby

6. Pasero, C., McCaffery, M. (2011). Pain assessment and pharmacologic

management. St. Louis, MO: Elsevier Mosby

7. Davis, A., Thomas, D. (2013). Pain assessment and management in the

adult patient. Retrieved from http://www.ceufast.com/course/pain-

assessment-and-management/

8. Lee, K. L., Lee, H., Cruz-Oliver, C. M. (Eds.). (2013, Feb.). Pain

assessment in persons with cognitive impairment. Retrieved from

http://emedicine.medscape.com/article/2113960-overview#aw2aab6b2

9. Shippee-Rice, R. V., Fetzer, S. J., Long, J. V. (2012). Gerioperative

nursing care: Principles and practices in surgical care of the older adult.

New York, NY: Springer Publishing

http://www.neuropathy.org/site/News2?id=7775

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/peripheral-neuropathy/

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/peripheral-neuropathy/

http://www.ceufast.com/course/pain-assessment-and-management/

http://www.ceufast.com/course/pain-assessment-and-management/

http://emedicine.medscape.com/article/2113960-overview#aw2aab6b2


10. Kozier, B. J., Erb, G., Berman, A. J., Snyder, S., Buck, M., Yiu, L,

Leeseberg Stamler, L. (2013). Fundamentals of Canadian nursing:

Concepts, process, and practice (3rd ed.). Ontario, Canada: Pearson

Education Canada

11. FOAA Anesthesia Services. (n.d.). Peripheral nerve blocks. Retrieved

from https://www.foaa.net/peripheralnerveblocks.html

12. Moos, D. D. (2011, Sep.) Understanding peripheral nerve blocks. OR

Nurse, 5(5), 24-32. doi: 10.1097/01.ORN.0000403415.90130.ba

13. Kumar, C. M., Bellamy, M. (Eds.). (2007). Gastrointestinal and colorectal

anesthesia. New York, NY: Informa Healthcare USA, Inc.

14. Aguirre, J., Del Moral, A., Cobo, I., Borgeat, A., Blumenthal, S. (2012).

The role of continuous peripheral nerve blocks. Anesthesiology Research

and Practice 2012: 560879. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385590/

15. The University of Arizona. (2008). A patient’s guide to peripheral nerve

blocks. Retrieved from

http://anesth.medicine.arizona.edu/system/files/pdfs/Nerve-Block-

Broch.pdf

16. Sawhney, M. (2012). Epidural anesthesia: What nurses need to know.

Nursing, 42(8), 36-41. Retrieved from

http://journals.lww.com/nursing/Fulltext/2012/08000/Epidural_analgesi

a__What_nurses_need_to_know.15.aspx

17. Halm, M. A. (2012, Apr.). Epidural analgesia update. Retrieved from

http://www.netce.com/coursecontent.php?courseid=818

18. Jarzyna, D., et al. (2011, Sep.). American Society for Pain Management

nursing guidelines on monitoring for opioid-induced sedation and

respiratory depression. Pain Management Nursing, 12(3), 118-145.

https://www.foaa.net/peripheralnerveblocks.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385590/

http://anesth.medicine.arizona.edu/system/files/pdfs/Nerve-Block-Broch.pdf

http://anesth.medicine.arizona.edu/system/files/pdfs/Nerve-Block-Broch.pdf

http://journals.lww.com/nursing/Fulltext/2012/08000/Epidural_analgesia__What_nurses_need_to_know.15.aspx

http://journals.lww.com/nursing/Fulltext/2012/08000/Epidural_analgesia__What_nurses_need_to_know.15.aspx

http://www.netce.com/coursecontent.php?courseid=818


19. Mann, A. (n.d.). Patient-controlled analgesia. Retrieved from

http://nursing.advanceweb.com/article/patient-controlled-

analgesia.aspx

20. Lehne, R. A. (2013). Pharmacology for nursing care (8th ed.). St. Louis,

MO: Elsevier Saunders

21. Cardiff University. (n.d.). WHO analgesic ladder. Retrieved from

http://www.paincommunitycentre.org/article/who-analgesic-ladder-0

22. Adams, R., White, B., Beckett, C. (2010). The effects of massage

therapy on pain management in the acute care setting. International

Journal of Therapeutic Massage and Bodywork, 3(1), 4-11.

23. University of Rochester Medical Center. (n.d.). When to use hot and cold

therapy. Retrieved from

http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentType

ID=1&ContentID=4483

24. Hassed, C. (2013, Mar.). Mind-body therapies: Use in chronic pain

management. Australian Family Physician, 42(3), 112-117. Retrieved

from http://www.racgp.org.au/afp/2013/march/mind-body-therapies/

25. Bennett, P. N., Brown, M. J., Sharma, P. (2012). Clinical pharmacology

(11th ed.). New York, NY: Elsevier

http://nursing.advanceweb.com/article/patient-controlled-analgesia.aspx

http://nursing.advanceweb.com/article/patient-controlled-analgesia.aspx

http://www.paincommunitycentre.org/article/who-analgesic-ladder-0

http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=1&ContentID=4483

http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=1&ContentID=4483

http://www.racgp.org.au/afp/2013/march/mind-body-therapies/

Documents

Pain Management For The Inpatient: Part I · person says it is, existing whenever he or she says it does.”10 Nurses must rely on the patient’s description of pain, as well as