Tag: PQRST pain assessment

Acute pain is characterised by a quick onset which may be severe, yet lasts for a shorter period of time when compared to chronic pain. Acute postoperative pain should be managed in the best way possible so as to restore or improve the patient’s quality of life, reduce morbidity, facilitate a quick recovery, leading to an early postoperative discharge.

Pain should be classified as acute, chronic or acute-on-chronic, nociceptive, neuropathic or inflammatory. Classification of pain helps in patient assessment as well as treatment.

Acute Pain:

• immediate onset eg. cut or injury
• usually lasts less than 3 to 6 months
• can act as a warning
• usually easier to treat
• usually has an end

Chronic Pain:

• lasts relatively longer than acute pain (more than 3 to 6 months)
• has no purpose
• can lead to pain behaviours
• is very difficult to treat

Nociceptive Pain:

• caused as a result of an injury eg. bruising, inflammation, fractures, burns
• includes post-surgery cuts/wounds

Neuropathic Pain:

• results from a nerve trauma
• may include components of cancer pain, phantom limb pain, pinched nerve (eg. carpal tunnel)
• may manifest as widespread nerve damage a.k.a. peripheral neuropathy which is frequently caused by diabetes mellitus

Nociceptive Pain:

Nociceptive pain can be divided into two categories, both of which involve nociceptors, which are the pain-detecting receptors which can be found in the body.

• SOMATIC PAIN – a sign of tissue damage which may be either superficial or deep (bones, joints, skin, muscle, connective tissue etc). This type of pain is usually described as throbbing, aching and localised.
• VISCERAL PAIN – originates from inner organs within the body (eg. angina). This type of pain is usually described as dull and is not usually localised.

Why Pain Relief?

1. BASIC HUMAN RIGHT
2. PAIN & SUFFERING REDUCTION = restore quality of life
3. QUICKER RECOVERY – early discharge = lower cost & less sick leave
4. REDUCING RISK OF DEVELOPING PERSISTENT PAIN
5. ENHANCING PATIENT SATISFACTION

Acute Postoperative Pain

Factors influencing acute postoperative pain include:

• lack of patient education
• fear of analgesia and associated complications
• inaccurate pain assessment leading to inaccurate pain management
• lack of human resources

Inefficient postoperative pain relief reduces rehabilitation and functional outcome:

poor pain management = patient immobilisation = longer hospital stay = increased cost of patient care = increased chronic pain development risk = long term disabilities and complications

Complications arising from poor pain management include:

• increased risk of deep vein thrombosis (DVT)
• increased risk of pulmonary embolism (PE)
• increased risk of respiratory problems (eg. pneumonia & hypoxaemia)
• increased risk of cardiac complications
• increased heart rate and blood pressure
• increased gastrointestinal (GI) symptoms (eg. paralytic ileus & anastomotic failure)
• increased risk of muscoskeletal symptoms (eg. muscle spasms & immobility)
• increased immunological risks (eg. infection, delayed wound healing, pressure sores)
• increased psychological risks (eg. anxiety, depression, fatigue, fear & insomnia)

The Nurse’s Role in Acute Postoperative Pain Management

ASSESS = correct preoperative and postoperative pain assessment using the available pain assessment tools such as SOCRATES and Pain Severity Assessment Tool

ADMINISTER = correct administration of safe and effective analgesics

EDUCATE = teach patient about helpful therapies including therapeutic therapy eg. position change

COMMUNICATE = best communication practice includes the patient, caregivers and healthcare professionals

REASSESS = monitor pain level and severity to identify patient improvement or deterioration

DOCUMENT = documentation of all pain management methods used

Pain Assessment Mnemonic: SOCRATES

PQRST Pain Assessment Tool

Pain Severity Assessment Tool

Patient History

• Current Pain Medication – seek accuracy regarding drug name, dose, frequency, route and duration
• Medical History – look for possible drug interactions, allergies and intolerances to certain medications (eg. in patients with renal disease avoid morphine and NSAIDS; in patients with cardiovascular disease check if patient is on any anti-coagulants / avoid NSAIDs)

IMPORTANT: Always treat each patient as a unique individual:

• don’t assume – every individual has a different perspective
• evaluate – monitor for painkillers side effects
• check for interactions – keep a list of the patient’s drugs for interaction monitoring
• respect religious and cultural considerations – do not judge, respect and empathise; be aware of specific patient needs and beliefs, and explain treatment need within a holistic context

Effective Pain Management

• regular pain intensity assessment
• provide written instructions
• balance analgesia administration (oral, IM, IV and patient controlled analgesia PCA)
• include alternative methods of pain control
• educate patient and/or family about pharmaceutical pain management
• continuous training of medical and nursing staff

PCA – Patient Controlled Analgesia refers to analgesia administered through a pump. It contains a syringe prefilled with pain medication which is connected directly to the patient’s IV line. This pump can be set to deliver a small constant flow of pain medication through a bolus.

Postoperative Pain Control Plan

1. Identify patient queries
2. Dispel myths
3. Address patient concerns including those about opioid use and addictions
4. Address fear of tolerance
5. Age-related pain expectation

Multimodal Analgesia

• NSAIDs (non-steroidal anti-inflammatory drugs)
• Opioids (have effects similar to those of morphine)
• Anticonvulsants (suppress the excessive rapid firing of neurons during seizures)
• Antidepressants (used to treat major depressive disorder, some anxiety disorders, some chronic pain conditions, and to help manage some addictions eg. valium and amitriptyline – may cause drowsiness leading to an increased risk of falling)
• Non-pharmaceuticals (eg. heat reduces pain and muscle spasms; ice reduces swelling, pain and tissue damage; physiotherapy and occupational therapy improve mobility and decrease pain)

Common Painkillers

• Paracetamol – headaches, muscle aches, arthritis, backaches, toothache, cold and fever
• Voltaren, Diclofenac and Catafast – NSAIDs
• Codeine – opioid/narcotic used for pain and as a cough suppressant
• Pethidine – opioid used frequently as a postoperative analgesic
• Morphine – opioid pain medication
• Tramodol – narcotic that treats moderate to severe pain
• Tapentadol and Palexia – opioid/narcotic used to treat moderate to severe pain
• Lyrica and Pragiola (Pregabalin) – antiepileptic drug
• Gabapentin – antiepileptic drug

Opioids Adverse Effects may include:

• respiratory depression and sedation
• nausea and vomiting
• allergies
• confusion and delirium especially in the elderly
• constipation

The more medications are being taken by the patient (polypharmacy), the higher the risk for adverse effects. Always educate your patient about possible side effects.

Below you can find a collection of videos that can help provide a more visual approach to acute postoperative pain.

Pain meaning and classification

Nociceptive Pain

Inflammatory Pain

Neuropathic Pain

Physiological Types of Pain

Holistic pain management

Pharmacological Pain Management

Patient Controlled Analgesia (PCA)

Rectal Sheath Catheter

non-pharmacological Alternative therapy

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Manipal Hospital, 2will physiotherapy & pain management clinic, MjSylvesterMD, CHEO, Dominic Cliff and CareChannel.

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