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  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
  • More About:

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    Site Index
    Back to Table of Contents
    Part I: Principles of Pain Management

    General Principles Pain Pathophysiology Pharmacologic Approaches to Pain Management

    General Principles

    General Principles of Pain Assessment

    • The process of pain management starts with adequate assessment of the pain
    • The absence of appropriate assessment is the leading reason for poor pain management
    • A comprehensive pain assessment addresses the pain's:

    Pain assessment is discussed in detail in Module 3: Whole Patient Assessment


    General Principles of Pain Management

    A comprehensive pain management strategy includes:

    • Use of appropriate interventions
      • Pharmacologic
      • Nonpharmacologic
    • Education of the patient, family, and all caregivers about the plan
    • Ongoing assessment of treatment outcomes
    • Regular review of the plan of care
    • Use of other members of the interdisciplinary team, including:
      • Nurses
      • Social workers
      • Pharmacists
      • Chaplains
      • Physiotherapists
      • Occupational therapists
      • Child life specialists
    • Flexibility is essential—successful plans are tailored to the individual patient and family
    • Willingness to ask for help from colleagues with more expertise when the plan is not effective at controlling the patient’s pain


    Pain Pathophysiology

    Acute vs. Chronic Pain

    Acute pain

    • Is usually related to an easily identified event or condition
    • Usually resolves within a period of days or weeks
    • Is usually nociceptive

    Chronic pain

    • May or may not be related to an easily identified pathophysiologic phenomenon
    • May be multifactorial
    • May be present for an indeterminate period


    Nociceptive Pain

    • Nociceptive pain is presumed to involve:
      • Direct stimulation of intact mechanical, chemical, or thermal nociceptors
      • Transmission of electrical signals along normally functioning nerves
    • It can be subdivided into 2 subgroups:
      1. Somatic pain
        • Involves skin, soft tissue, muscle, and bone
        • Due to stimulation of the somatic nervous system
        • Patients may describe this as sharp, aching, and/or throbbing pain that is easily localized

      2. Visceral pain
        • Involves cardiac, lung, GI and GU tracts
        • Results from stimulation of the autonomic nervous system
        • Patients may find this pain difficult to describe or localize
    • Nociceptive pain generally responds well to opioids and/or coanalgesics


    Neuropathic Pain

    • Neuropathic pain is presumed to result from disordered function of the peripheral or central nervous system (CNS) due to any of many potential causes, including:
      • Compression
      • Transection
      • Infiltration
      • Ischemia
      • Metabolic injury
    • There are varied subtypes, including:
      • Those sustained by peripheral processes (e.g., painful neuroma)
      • Those sustained by CNS processes (e.g., phantom pain)
      • Complex regional pain syndromes (previously referred to as causalgia or reflex sympathetic dystrophies)
    • These pains can also be classified by syndrome (e.g., malignant plexopathy, painful polyneuropathy, phantom pain, postherpetic neuropathy, etc)
    • Patients tend to describe neuropathic pain with words like burning, tingling, numbness, shooting, stabbing, or electric-like feelings
    • The intensity of pain involved may exceed observable injury
    • Although neuropathic pain may respond well to opioids, adjuvant analgesics (tricyclic antidepressants, anticonvulsants, antiarrhythmics, etc) are often required in combination with opioids to achieve adequate relief


    Additional Information about Pain Pathophysiology

    • Acute and chronic pain may be conceptualized as either nociceptive or neuropathic in origin
    • A broad description of the predominating pain pathophysiology can usually be inferred through:
      • Patient description
      • Physical findings
      • Results of laboratory tests and imaging studies
    • The International Association for the Study of Pain (IASP) has published precise definitions and made them available on their web site http://www.iasp-pain.org
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