i bc27f85be50b71b1 (276 page)

VI

Pain Management

Jaime C. Paz

In t.he acute care setting, physical therapists encounter patients who

are experiencing pain for a variety of reasons, most commonly from

surgical intervention. This appendix provides information on tools to

evaluate and manage pain that can facilitate the therapist's ability to

provide care for a patient.

Evaluation

The subjective complaint of pain is often difficult to objectify in the

clinical setting. However, an effective pain treatment plan depends on

an accurate evaluation of the pat.ient's pain,l.2 Each evaluation

requires a complere physical and diagnostic examination of the

patient's pain. The goal for evaluation should be toward individualization while maintaining consistency among patients. To assist with this process, various pain rating rools have been developed. Table

VI-l describes some of the pain rating tools that are used in the acute

care setting, with the visual analogue and numeric raring scales being

the mOst commonly used.I•3,4

877

878 ACUTE. CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table VI-l. Pain Assessment Tools

Tool

Description

Verbal descriptor scales

The patient describes pain by choosing from a list

of adjectives representing gradations of pain

intensiry.

Numeric rating scale

The patient picks a number from 0 to 10 to rate

his or her pain, with 0 indicating no pain, and

10 indicating the worst pain possible.

Visual analog scales

Line scale

The patient marks his or her pain intensiry on a

10-cm line, with one end labeled "no pain,"

and the other end labeled "worst pain

possible. "

Faces scale

The patient chooses one of six faces, portrayed on

a scale that depicts graduated levels of distress,

to represent his or her pain level.

Pain diary

A daily log is kept by the patient denOting pain

severity, by using the numeric rating scale,

during activities of daily living.

Medication and alcohol use (if out of the hospital), along with emotional responses, are also

helpful pieces of information to record.

Sources: Data from KP Kirrelberger, AA leBel, 0 Sorsook. Assessmem of Pain. In 0

Sorsook, AA LeBel, B McPeek (cds). The Massachusc:rts Genc:ral Hospital Handbook

of Pain Management. BoslOn: Little Brown, 1996;27; and Carey Sj, Turpin C, Smith J,

et al. Improving pain management in an acute care setting: the Crawford Long Hospital

of Emory Universiry experience. Orthop Nurs 1997; 16(4}:29.

Clinical Tip

•

The validiry of these scales may be improved by asking

the patient about his or her current level of pain, rather

than asking the patient to speculate about "usual" or

"previous" levels of pain.5

•

The patient's self-reporting of pain is the most accurate indicator of the existence or intensity of his or her pain, or both.6

APPENDIX VI: PAIN MANAGE...\1ENT 879

• Be sensitive and respectful to how different cultures perceive pain, as certain cultures may be very stoic about their

pain, whereas others are very demonstrative.

Physical Therapy Considerations for Pain Evaluation

•

Be aware of the nonverbal indicators of pain, such as behavior

changes, facial expressions, and body language, in patients who

have an impaired ability to communicate their pain, as with an

unconscious patient or an adult with dementia.

•

Monitoring vital signs during the pain evaluation may provide

insight into the sympathetic tone of the patient, which can be indicative of their level of pain. This can be performed easily in the intensive care setting, because the patient'S hemodynamic status is

being continuously monitored.

• The physical therapist should recognize when the patient is

weaning from pain medication (e.g., transitioning from intravenous to oral administration), as the patient may complain of increased pain with a concurrent reduced activity tolerance during

this time period.

• To optimize consistency in the health care team, the physical

therapist should use the same pain rating tool as the medical-surgical team to determine adequacy of pain management.

•

Often the best way to communicate the adequacy of a patient's

pain management to the nurses or physicians is in terms of the

patient'S abiliry to complete a given task or activity (e.g., the

patient is effectively coughing and clearing secretions).

Management

Nonsteroidal anti-inflammatOry drugs (Table VI-2) and systemic opioids (Table Vl-3) are the most common pharmacologic agents prescribed for postOperative pain. Aspirin and acetaminophen (Tylenol) are also common medications prescribed for pain relief and are categorized as non-narcotic analgesic and antipyretic drugs.7·8 Alterna-

880 ACtrrE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Table VI-2. Nonsteroidal Anti-Inflammatory Drugs

Indications:

Used as the sole therapy for mild to moderate pain

For patients with osteoarthritis, rheumatoid arthritis, and dysmenorrhea

Used in combination with opioids for moderate postoperative pain, especially

when weaning from stronger medications

Useful in children younger than 6 mos of age

Contraindicated in patienes undergoing anticoagulation therapy, with peptic

ulcer disease, or with gastritis

Mechanism of action:

Accomplish analgesia by inhibiting prostaglandin synthesis, which leads to antiinflammatory effects (Prostaglandin is a potent pain-producing chemical.) A useful alternative or adjunct to opioid therapy

General side effeces:

Platelet dysfunction and gastritis, nausea, abdominal pain, anorexia,

dizziness, and drowsiness

Severe reactions include nephrowxicity (dysuria, hematuria) and cholesratic

hepatitis

Medications: Generic name (trade name)

Celecoxib (Celebrex)

Diclofenac potassium (Caraflam)

Diclofenac sodium (Voltaren, Voltarol)

Erodolac (Lodine, Lodine XL)

Fenoprofen calcium (Fenopron, Nalfon)

F1urbiprofen (Ansaid, Apo-Flurbiprofen, Froben, Ocufen, Opthalmic)

Ibuprofen (Morrin, Advil. Excedrin, Medipren, Nuprin, Pamprin, Nurofen,

Pedia Profen, Rafen, Saleto-200, 400, and 600, Trendar)

Indomethacin (Apo-Indomethacin, (ndocin)

Ketoprofen (Actron, Apo-Keto, Novo-Keto, Orudis, Rhodis)

Ketorolac tromethamine (Toradol)

Nabumerone (Relafen, Relifex)

Naproxen (Naprosyn)

Naproxen sodium (Aleve)

Oxaprozin (Daypro)

Piroxicam (Apo-Piroxicam, Feldene, Novo-Pirocam, Pirox)

Rofecoxib (Vioxx)

Sulindac (Adin, Apo-Sulin, elinoril, Novo-Sundae, Saldac)

Tolme,in (Tolectin)

Sources: Data from JC B3lbnryne. D Borsook. PostOperative l)ain. In D Borsook, AA

LeBel, B McPeek (eds), The Massachuserts General Hospitall-l3ndbook of Pain Managemenr. Boston: Linle, Brown, 1996;247; Nursing 2001 Drug Handbook (21st ed).

Springhouse, PA: Springhouse Corporation, 2001 ;346-367; and L Skidmore-Roth (ed).

Mosby's Nursing Drug Reference. Sr. Louis: Mosby, 200 1;56-57,924.